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Answer the question based on the following context: Giant cell arteritis (GCA) of the breast is one of the less recognized variants of this vasculitis and may represent an isolated finding or a manifestation of a more widespread disease. We present the case of a 74-year-old woman with malaise and a 14-day persistent fever, reaching 38 degrees C. There was a bilateral, painless and mobile axillary lymphadenopathy and a slight tenderness over the medial and lateral upper quadrants of her left breast, as well as an independent palpable tender mass in the upper outer quadrant of the same breast measuring 2 cm in its greatest diameter. Constitutional symptoms, anemia and an elevated erythrocyte sedimentation rate suggestive of polymyalgia rheumatica were also present. An invasive ductal carcinoma of the breast with coincidental pathologic findings of GCA in the same biopsy specimen was revealed. In this case, arteritis was limited to the breast and presented with diffuse breast tenderness. No other artery was involved by GCA. All arteritis-related symptoms disappeared after the removal of the tumor.

Question: Giant cell arteritis of the breast and breast cancer: paraneoplastic manifestation or concomitant disease?

There is a relationship between cancer, particularly breast cancer, and GCA of the same organ, but the real nature of this association still remains unknown.

Answer the question based on the following context: The aim of this study was to determine if nurses, using patient-centered care (PCC), affect patient satisfaction, perceptions of nursing care, and quality outcomes. The Institute of Medicine proposed PCC as 1 of 6 national quality aims, whereas the Centers for Medicare and Medicaid Services highlighted integration of PCC as 1 of 12 actions for quality improvement. A total of 116 patients were randomized into an intervention (PCC) or control group. Patients who were to receive PCC were called before admission and cared for by nurses who trained to administer/practice PCC. Control patients received usual care. Both groups completed questionnaires and received postdischarge calls. Length of stay, falls, infections, and adverse events were measured to assess quality of care. No significant differences were found between groups for length of stay, infection, falls, postoperative complications, quality of care, satisfaction level, or perceptions of nursing care.

Question: Can nurses impact patient outcomes using a patient-centered care model?

Patient-centered care did not affect patient's level of satisfaction or quality of care. However, findings yielded clinically relevant results regarding patient/staff responses.

Answer the question based on the following context: To systematically evaluate the presumption that the healthy middle ear becomes colonized with organisms via the patent eustachian tube using modern microbiologic techniques. Sterile saline washings were obtained from the middle ear of patients in a prospective fashion. Tertiary/quaternary referral centers. Pediatric and adult patients undergoing cochlear implantation surgery.INTERVENTION(S): Standard bacterial and viral cultures, and nucleic acid amplification techniques.MAIN OUTCOME MEASURE(S): Identification of organisms. Specimens were obtained from 13 children and 9 adults. No organisms were identified in any of the specimens, either through standard culture or PCR testing.

Question: Is the healthy middle ear a normally sterile site?

The presumption that the healthy middle ear is colonized by bacteria from the nasopharynx is unsubstantiated.

Answer the question based on the following context: Diethylstilbestrol (DES) is a well-known, non-steroidal estrogen with high affinity to the estrogen receptor (ER). Labeled DES would be a useful tool for therapy of ER-positive mammary carcinomas and their metastases. Particularly with Auger emitters, high cytotoxic potential combined with only slight side effects can be expected. DES was labeled by a new method with higher yield and specific activity than former methods. Cytotoxic effects on MCF-7 (human, Caucasian, breast, adenocarcinoma) cells, were tested in relation to radioactivity concentration applied and location of decay. Different iodine isotopes ((123)I, (125)I, (131)I) bound to DES or in the form of iodide were compared with regard to induction of intracellular DNA (deoxyribonucleic acid) fragmentation, and decrease of viability. For this purpose the 'Cell Death Detection Enzyme-Linked ImmunoSorbent Assay (ELISA)' and the water soluble tetrazolium salt WST-1 were used. The radiation protective effects of the radical scavenger vitamin C were also tested. The experiments showed a significantly lower viability of cells exposed to the Auger emitters than those with the beta-emitter (131)I. All nuclides induced intracellular DNA fragments. The maximum amount of intracellular DNA fragments was different for all nuclides: (131)I-DES<(125)I-DES<(123)I-DES. With isotopes in the form of iodide, no increase of intracellular DNA fragmentation could be detected. Vitamin C reduced intracellular DNA fragmentation significantly, which points to an induction mechanism mainly via free radicals.

Question: Diethylstilbestrol (DES) labeled with Auger emitters: potential radiopharmaceutical for therapy of estrogen receptor-positive tumors and their metastases?

Labeled DES is a promising compound with high cytotoxic potential for treatment of ER-positive mamma carcinomas and their metastases.

Answer the question based on the following context: The aim of this prospective study was to assess the diagnostic benefit of taking a kidney-ureter-bladder (KUB) radiograph in an upright position during routine intravenous urography (IVU). Between February 2005 and September 2007, 170 consecutive patients were included in the study. A basal IVU exam consisted of pre-contrast supine KUB, post-contrast supine KUB at the 7th and 15th minutes, and supine pelvic radiographs with full bladder and post-voiding. When needed, additional compression and/or oblique radiographs were taken. In this study, for all patients, a post-contrast 15th minute upright KUB radiograph was added to IVU. Two consecutive radiographs taken at the 15th minute postcontrast in supine and upright positions were evaluated by consensus of 2 radiologists. Primary benefits were improved filling and emptying of the collecting system, and secondary benefits were nephroptosis and ascertaining diagnosis of phlebolith. Of 170 patients, 337 kidneys and collecting systems (n = 168 right; n = 169 left) were examined. Improved filling, emptying of the collecting system, nephroptosis, ascertaining diagnosis of phleboliths were detected with the rates of 12.5%, 44.2%, 8.3%, and 3.2%, respectively. Improved filling was significant in the presence of hydronephrosis (P<0.05) and ureterolithiasis (P<0.05) on both sides. There was a positive correlation between both improved filling and presence of hydronephrosis, and improved filling and presence of ureterolithiasis. Emptying was significant in collecting systems that had no visible pathology on IVU (P<0.05) on either side.

Question: Does an extra kidney-ureter-bladder radiograph taken in the upright position during routine intravenous urography provide diagnostic benefit?

Upright KUB radiographs provide supplementary data about urine flow in terms of improved filling and emptying of the collecting system.

Answer the question based on the following context: The diagnosis of myelodysplastic syndromes (MDS) is mainly based on morphology and cytogenetic analysis. Several efforts to analyze MDS by flow cytometry have been reported in adults. These studies have focused on the identification of abnormalities in the maturation pathway of antigen expression of myelo-monocytic cells, and characterization of blast populations. Therefore, phenotype has been proposed as a diagnostic and prognostic criterion tool for adult MDS. The current article provides data concerning the blast phenotype in pediatric MDS. We evaluated by multiparameter flow cytometry 26 MDS pediatric patients with more than 2% of blast cells at bone marrow morphological examination (17 de novo MDS and 9 secondary MDS) and 145 pediatric de novo acute myeloid leukemia (AML) cases (M3 excluded). As control group, 12 healthy age-matched donors for allogenic bone marrow transplantation (BMD) and 6 regenerating bone marrow samples, collected from children with acute lymphoblastic leukemia (ALL) in remission after induction chemotherapy, were studied. We identified a blast immunophenotype typically expressed in most MDS cases and a strong correlation between CD7 expression and poor outcome. CD34+ compartment in MDS bone marrow was also analyzed: a significant decrease of B-cell precursors was detected in MDS patients independent of age.

Question: Advanced pediatric myelodysplastic syndromes: can immunophenotypic characterization of blast cells be a diagnostic and prognostic tool?

Our data suggest that the blasts phenotypic features can constitute a diagnostic and prognostic tool also for pediatric MDS.

Answer the question based on the following context: To characterise the nature and impact of World Youth Day (WYD) 2008 on emergency department (ED) presentations at key hospitals. Retrospective analysis of WYD pilgrims presenting to the EDs of St Vincent's Hospital and Sydney Hospital, 9-23 July 2008. Frequency of pilgrim ED presentations; presenting complaint, Australasian Triage Scale category, diagnosis, admission to hospital and demographic characteristics. 191 pilgrims presented at the two EDs during the study period, comprising 7.8% of all visits to these EDs. Pilgrims had a median age of 22 years, and most were international visitors. The female-to-male ratio was 1.7 : 1. The most common diagnoses were lower limb strain or sprain, infections, and acute asthma. Pilgrims presented with less severe illnesses (with lower triage scores), and were less likely to be admitted to hospital than other patients.

Question: World Youth Day 2008: did it stress Sydney hospitals?

The pilgrim caseload was small, and these presentations were less acute and less likely to result in admission than non-pilgrim presentations. Thus, the overall impact on the hospitals was very small.

Answer the question based on the following context: To determine the association, if any, between male-pattern hair loss (baldness) and serum 25-hydroxyvitamin D (25-OHD) levels. A cross-sectional study of 296 healthy middle-aged and older men. Degree of baldness was independently assessed by two researchers using the Hamilton-Norwood scale and serum 25-OHD was measured in all men. Classification of the degree of baldness by the two researchers showed a high level of agreement (kappa = 0.93). Forty-eight per cent of men had no hair loss or mild frontotemporal recession, 15% had predominant vertex loss, and 37% had significant scalp and vertex loss. After data were adjusted for potential confounding factors - including age, month of 25-OHD measurement, exercise levels, use of sunscreen, skin type and frequency of outdoor hat wearing - no significant differences in 25-OHD levels between these groups was detected (P = 0.60).

Question: Does degree of baldness influence vitamin D status?

The degree of baldness does not appear to influence serum 25-OHD levels. The high prevalence of baldness in older men does not explain sex differences in 25-OHD levels. Other novel hypotheses are required to help determine whether baldness serves any physiological purpose.

Answer the question based on the following context: We have previously reported a chronic acid reflux esophagitis model using Japanese Wistar male (JWM) rats. The aim of this study is to discuss unexpected differences encountered within the same species bred in different countries. In JWM rats via a midline laparotomy the limiting ridge of the stomach was ligated and the duodenum was covered with a small piece of an 18 Fr. catheter. We subsequently tried to reproduce the same model using American Wistar male (AWM) and subsequently with female (AWF) rats. The 3-wk survival rate of AWM rats (30%) was significantly lower than for JWM rats (90%) due to differences in growth curve and eating behaviors. On the other hand, the growth curve of AWF rats was similar to JWM rats. Still, the 3-wk survival rate was only 40% mainly due to different eating patterns. Since then we have modified our postoperative care to include restricted access to food and other objects and have achieved a 3-wk survival of 80%, which is the same as JWM rats.

Question: American and Japanese rats of the same species: are they same?

Growth curve and eating behavior of rats from different countries exhibit significant differences even within the same species. It is important that such differences be taken into account when reproducing animal models created elsewhere.

Answer the question based on the following context: To examine whether participants with the most behavioral goals to achieve were more likely to meet more goals than those given fewer goals. Eight hundred ten participants were randomly assigned to advice-only, established guidelines for blood pressure control (reduced sodium, increased physical activity), or established guidelines plus the DASH diet (increased fruits, vegetables, low-fat dairy, reduced fat). At 6 months, 11.7% of Advice-Only, 19.3% of Established, and 44.6% of Established plus DASH met at least 3 goals (P<0.0001). At 18 months, 33.5% of Established plus DASH met at least 3 goals.

Question: Can individuals meet multiple physical activity and dietary behavior goals?

Those with the most goals to achieve reached the most goals.

Answer the question based on the following context: Attached tissue from the explanted or removed titanium implants was examined by transmission electron microscopy and histopathological analysis. Attached tissue from both implants showed the presence of keratinocytes at the titanium implant and living bone interface. This was confirmed by histopathological analysis. In one case, there was frank keratinocyte proliferation, which had led to osseointegration failure; in the other case, such proliferation was present but not so advanced.

Question: Can keratinocytes cause failure of osseointegration?

These findings suggest that, in the cases reported, keratinocytes implanted between the titanium and the living bone, leading to disruption of osseointegration.

Answer the question based on the following context: To determine if omission of the Center for Epidemiologic Studies Depression Scale (CES-D) items that assess the somatic symptoms of depression improves the psychometric properties of the scale and utility of the CES-D diagnosis of depression for predicting four adverse obstetrical outcomes that have been tentatively linked to maternal depression. A cohort of 1684 13-21-year-old participants in an adolescent-oriented maternity program completed the CES-D at enrollment. Chi-square analyses were used to compare the predictive capacity of depression diagnosed by the full CES-D and the 14-item non-somatic subscale of the CES-D. The reliability and construct validity of the two scales were also compared. Removing the somatic component of the CES-D decreased the proportion of adolescents who met screening criteria for depression. However, it did not improve the psychometric properties of the scale. The reliability (Cronbach alpha: 0.87) and construct validity (depressed adolescents were significantly more psychologically stressed and had poorer social support) of the two scales were equivalent. Regardless of the scale used, adolescent mothers who were depressed in the second and third trimesters were at increased risk for inadequate weight gain and both small for gestational age fetuses and preterm delivery (ORs 1.6-1.8). The differences in case definition and predictive capacity were most evident when the CES-D was administered during the first trimester. However, overall effect sizes were nearly identical with the two scales.

Question: Depression, weight gain, and low birth weight adolescent delivery: do somatic symptoms strengthen or weaken the relationship?

Removing the somatic component does not improve the psychometric properties of the CES-D or the predictive capacity of the CES-D diagnosis of depression for three sentinel obstetrical outcomes. This information should be reassuring to researchers and clinicians as most studies of the causes and consequences of maternal depression during and after pregnancy use the full CES-D scale.

Answer the question based on the following context: To test the feasibility of a brief, clinic-based, behavioral intervention designed to foster the adoption of three protective behaviors among adolescent females testing positive for any of 13 oncogenic strains of HPV. This feasibility study also included non-statistical comparisons of risk behaviors assessed at follow-up. A non-randomized clinical trial. Twenty-eight sexually active, 17-23-year-old females were recruited from a hospital-based adolescent medicine clinic. Adolescents testing positive for HPV received a physician-delivered intervention designed to emphasize the association of high-risk HPV with cervical cancer and to promote protective behaviors. Those testing negative for HPV did not receive intervention. Several indicators were used including sexual risk behaviors, intent for subsequent Pap testing, intent to quit smoking, and intent to be vaccinated against HPV. Those testing positive (39.3%) received the intervention. Recruitment and retention rates were high. In comparing the two groups after a 30-day follow-up period, modest differences, favoring the intervention, were observed. At follow-up, teens testing positive reported lower levels of risk taking behavior, greater intent to return for next Pap testing, greater intent to quit smoking (if applicable), and greater intent to be vaccinated against HPV.

Question: Does knowing about an HPV infection influence behavior change?

Overall, the findings suggest that a larger study is indeed feasible and may produce meaningful differences between groups. Although the source (i.e., testing positive vs. the receipt of intervention) of these differences cannot be determined, findings suggests that further investigation of a testing/behavioral intervention regarding HPV and cervical cancer prevention for adolescent females may be warranted.

Answer the question based on the following context: Dietary restrictions to control serum phosphorus, which are routinely recommended to persons with chronic kidney disease, are usually associated with a reduction in protein intake. This may lead to protein-energy wasting and poor survival. We aimed to ascertain whether a decline in serum phosphorus and a concomitant decline in protein intake are associated with an increase in the risk of death. In a 3-y study (7/2001-6/2004) of 30 075 prevalent maintenance hemodialysis (MHD) patients, we examined changes in serum phosphorus and in normalized protein nitrogen appearance (nPNA), a surrogate of dietary protein intake, during the first 6 mo and the subsequent mortality. Four groups of MHD patients were defined on the basis of the direction of the changes in serum phosphorus and nPNA. Baseline phosphorus had a J-shaped association with mortality, whereas higher baseline nPNA was linearly associated with greater survival. Compared with MHD patients whose serum phosphorus and nPNA both rose over 6 mo, those whose serum phosphorus decreased but whose nPNA increased had greater survival, with a case mix-adjusted death risk ratio of 0.90 (95% confidence limits: 0.86, 0.95; P<0.001), whereas those whose phosphorus increased but whose nPNA decreased or those whose phosphorus and nPNA both decreased had worse mortality with a risk ratio of 1.11 (1.05,1.17; P<0.001) and 1.06 (1.01,1.12; P = 0.02), respectively.

Question: Is controlling phosphorus by decreasing dietary protein intake beneficial or harmful in persons with chronic kidney disease?

The risk of controlling serum phosphorus by restricting dietary protein intake may outweigh the benefit of controlled phosphorus and may lead to greater mortality. Additional studies including randomized controlled trials should examine whether nondietary control of phosphorus or restriction of nonprotein sources of phosphorus is safer and more effective.

Answer the question based on the following context: To assess current attitudes towards the national patient survey programme in England, establish the extent to which survey results are used and identify barriers and incentives for using them. Qualitative interviews with hospital staff responsible for implementing the patient surveys (survey leads). National Health Service (NHS) hospital organisations (trusts) in England. Twenty-four patient survey leads for NHS trusts. Perceptions of the patient surveys were mainly positive and were reported to be improving. Interviewees welcomed the surveys' regular repetition and thought the questionnaires, survey methods and reporting of results, particularly inter-organisational benchmark charts, were of a good standard. The survey results were widely used in action planning and were thought to support organisational patient-centredness. There was variation in the extent to which trusts disseminated survey findings to patients, the public, staff and their board members. The most common barrier to using results was difficulty engaging clinicians because survey findings were not sufficiently specific to specialties, departments or wards. Limited statistical expertise and concerns that the surveys only covered a short time frame also contributed to some scepticism. Other perceived barriers included a lack of knowledge of effective interventions, and limited time and resources. Actual and potential incentives for using survey findings included giving the results higher weightings in the performance management system, financial targets, Payment by Results (PbR), Patient Choice, a patient-centred culture, leadership by senior members of the organisation, and boosting staff morale by disseminating positive survey findings.

Question: Do patient surveys work?

The national patient surveys are viewed positively, their repetition being an important factor in their success. The results could be used more effectively if they were more specific to smaller units.

Answer the question based on the following context: Repairing contour defects is a challenge in plastic surgery. Different filling materials have been used with inadequate results and complications. The autologous fat transfer is the standard technique at the moment, but adipose tissue reserves are limited. The aim of our study was to compare in vivo on an animal model, preadipocytes cultured in a collagen scaffold versus adipose tissue transferred by the usual surgical technique. In order to compare adipocytes resulting from the differentiation of preadipocytes with those of purified adipose tissue, we implanted them in 10 nude mice. The preadipocytes were implanted using a collagen scaffold as intermediary and the adipose tissue following the plastic surgery protocol described by SR Coleman. After 8 weeks, tissue fragments were explanted and analysed after staining with HPS, Oil Red O and labelling with human anti-vimentin antibodies. The scaffold seeded with preadipocytes had the macroscopic appearance of adipose tissue with peripheral neovascularisation. The preadipocytes had been transformed into mature adipocytes. Purified adipose tissue also presented peripheral neovascularisation. Numerous mature adipocytes were found. There was an abundant murine extracellular matrix since anti-vimentin labelling was negative.

Question: Does adipose tissue cultured with collagen matrix and preadipocytes give comparable results to the standard technique in plastic surgery?

This experimental study showed that adipose tissue engineering is feasible and gives comparable results to fat grafting. It allows a better understanding of the sequence of events following the transfer of adipose tissue. It provides not only volume but also undeniable stimulation, leading to significant thickening of the extracellular matrix.

Answer the question based on the following context: The blood based interferon-gamma release assays (IGRA) for the diagnosis of tuberculosis do not discriminate between active TB disease and latent TB infection (LTBI). The search for distinguishing biomarkers therefore continues, as the accurate diagnosis of tuberculosis is particularly challenging in children. IFN-gamma-inducible protein 10 (IP-10/CXCL10) has recently been evaluated as a marker for active TB in adults with promising results.AIM: To investigate this new biomarker for active TB and LTBI in paediatrics. We measured IP-10 levels using ELISA in supernatants of whole blood samples stimulated with TB-specific-antigens and negative control antigen. IP-10 is produced in high levels following mycobacterial antigen stimulation in active TB (n = 17) and LTBI (n = 16) compared to controls (n = 16) and to IFN-gamma. The baseline levels of IP-10 are increased in active TB and in LTBI, but there is no significant difference of stimulated levels of IP-10 between active TB and LTBI.

Question: Is IP-10 a better biomarker for active and latent tuberculosis in children than IFNgamma?

IP-10 is a biomarker for tuberculosis in children. However like IFNgamma, IP-10 also does not distinguish between active TB and LTBI.

Answer the question based on the following context: This study describes the long-term outcome of 163 patients with stable mild to moderate heart failure (NYHA II-III), who already were enrolled in a heart failure clinic and now were randomized to continued follow-up in the heart failure (HF) clinic or else to usual care (UC). The primary outcome was unplanned hospitalisations and death, the secondary endpoints were pharmacological therapy, NYHA class, six-minute-walking distances and NT-pro BNP level. At the end of follow-up we found no significant differences in total number of hospitalisation (p = 0.2) or mortality (16% vs. 16%) between the two groups. Patients in the HF clinic cohort achieved a significantly better NYHA score (p<0.01), significantly longer walking-distances (p = 0.04) and received a significantly higher dose of angiotensin-converting enzyme inhibitors (p<0.001) and beta-blockers (p<0.001). No significant difference was found on the level of NT-pro BNP (p = 0.4).

Question: Are there long-term benefits in following stable heart failure patients in a heart failure clinic?

Patients with mild to moderate HF may benefit from long-term follow-up in a HF clinic in terms of pharmacological therapy and functional status, but we found no significant impact on unplanned hospitalisations or death.

Answer the question based on the following context: Since partographs were introduced into obstetric practice, more than 50 years ago, the appearance of cervicographs as their central section has not been significantly changed. The aims of this article are to assess whether the current characteristics of cervicographs represent the optimal solution with regard to the rules for plotting data and to suggest what that optimal solution might be. The literature was searched for papers containing reproductions of cervicographs to review their characteristics. According to the general rules for plotting data, values of three most important characteristics of cervicographs were defined. The characteristics of the majority of available cervicographs are: a dilatation scale smallest division 1 cm, a time scale smallest division 1 h and 1 cm/h dilatation rate line inclination less than 45 degrees. The optimal characteristics of cervicographs are: a dilatation scale smallest division 2 cm, a time scale smallest division 5 min and 1 cm/h dilatation rate line inclination of 45 degrees.

Question: Could the central part of the partograph, the cervicograph be improved?

The scale divisions on the proposed cervicograph form are in predefined relation to the accuracy of the measurements made. This enables improved portrayal of labour.

Answer the question based on the following context: The aim of the study was to evaluate the effects of different access methods for the treatment of pyloric stenosis (PS). Since 2001, we have operated on children with PS using three different access methods: classic right upper quadrant transverse incision (TI), incision on the superior umbilical fold (UI) and laparoscopic (L). We reviewed the records of these children with special emphasis on the number and characteristics of complications, operative time, and length of stay (LOS). We identified 256 patients (212 M, 44 F) with a mean age of 36 days. 138 procedures were performed using TI, 18 with UI and 100 laparoscopically. The mean operative time for patients with TI was 35.9 +/- 8.6 min, and for those with UI 31.8 +/- 9.3 min. Patients in the L group had a mean operative time of 29.8 +/- 11 min. Although the operative time for TI was significantly greater than that of L, the differences between the TI and UI groups and between UI and L groups did not reach statistical significance. For the TI, UI and L groups, the mean overall LOS was 3.22 +/- 0.3 days, 3.39 +/- 0.4 days and 2.94 +/- 0.2 days, and the mean postoperative LOS was 1.52 +/- 0.1 days, 1.44 +/- 0.2 days, and 1.56 +/- 0.1 days, respectively. No significant difference in LOS was found. One patient from each group had a wound infection. While three of four perforations occurred in the L group and the fourth was in the TI group, the difference in rates of perforation among the groups did not achieve statistical significance. The perforation during open surgery was typical, occurring on the duodenal end during spreading of the pyloric muscle. The perforations in the L group were atypical: one was a grasper injury to the duodenum; another was on the gastric end of the pyloric incision and the third occurred not during spreading of the pyloric muscle but during the cutting of it. The pylorus was relatively small in this particular case (12 mm in length).

Question: Access to the hypertrophic pylorus: does it make a difference to the patient?

While the operative time of laparoscopic repair for PS is less than in either of the open approaches, laparoscopic surgery may increase the risk for atypical injuries to the bowel. Therefore, proper attention should be paid to dissection of the structures and the selection of laparoscopic instruments. Incision on the superior umbilical fold is a reasonable alternative access for the treatment of PS.

Answer the question based on the following context: Gallbladder carcinoma (GBC) is a highly aggressive neoplasm that arises in the background of gall stones and inflammation. Anti-inflammatory cytokine interleukin-10 (IL-10) gene polymorphisms have been associated with susceptibility to various inflammatory diseases and cancers.AIM: of the study The aim of the present study was to investigate whether IL-10-819C/T polymorphism is associated with GBC susceptibility. The study subjects comprised 124 GBC patients, 135 patients with symptomatic gallstone disease, and 200 healthy subjects. Genomic DNA was extracted from blood leukocytes and IL-10-819C/T gene polymorphism was analyzed by polymerase chain reaction-restriction fragment length polymorphism. Frequency distributions of IL-10-819C/T genotypes were similar in GBC, gallstone patients, and healthy subjects. However, after stratification on the basis of sex, in male GBC patients, the TT genotype of IL-10-819C/T polymorphism showed an approximately sevenfold risk (p value = 0.038; odds ratio = 6.58; 95% confidence interval = 1.11-39.11) in the presence of gall stones when compared with gallstone patients.

Question: Is IL-10-819C/T gene polymorphism modulating the risk of gallbladder disease in north Indian population?

These results suggest that interplay of sex hormones and IL-10-819C/T polymorphism may lead to the susceptibility of gallstone-mediated gallbladder carcinogenesis.

Answer the question based on the following context: To investigate the long-term effect of continuous insulin infusion for glucose control on cerebral metabolism in aneurysmal subarachnoid hemorrhage (SAH) patients. Prospective, nonrandomized study of 31 SAH patients in the ICU (52 +/- 10 years, WFNS Grade 2.9 +/- 1.6). A microdialysis catheter was inserted into the vascular territory of the aneurysm. Metabolic changes during 4 days after onset of insulin infusion were analyzed. Blood glucose levels>140 mg/dL after clinical stabilization were treated with intravenous insulin. 24 patients were treated with intravenous insulin. Though no insulin-induced hypoglycemia occurred, cerebral glucose decreased on days 1-4 after insulin onset without reaching critical levels. Glycerol, a marker of membrane degradation, showed a reversible increase on day 1 while the lactate/pyruvate ratio remained stable and glutamate even decreased indicating absence of severe cerebral crisis following insulin infusion and excluding ischemia as a cause for cerebral glucose depletion.

Question: Is continuous insulin treatment safe in aneurysmal subarachnoid hemorrhage?

Concerning cerebral metabolism, long-term continuous insulin infusion appears to be safe as long as cerebral glucose levels do not fall below the physiological range. In view of the high incidence of hyperglycemia and need for insulin treatment, future studies on the effect of insulin on cerebral metabolism in SAH patients are desirable.

Answer the question based on the following context: To analyse changes in clinical indications for community antibiotic prescribing for children in the UK between 1996 and 2006 and relate these findings to the new NICE guidelines for the treatment of upper respiratory tract infections in children. Retrospective cohort study. The IMS Health Mediplus database was used to obtain annual antibiotic prescribing rates and associated clinical indications in 0-18-year-old patients between 1 January 1996 and 31 December 2006 in the UK. Antibiotic prescribing declined by 24% between 1996 and 2000 but increased again by 10% during 2003-2006. Respiratory tract infection was the most common indication for which an antibiotic was prescribed, followed by "abnormal signs and symptoms", ear and skin infections. Antibiotic prescriptions for respiratory tract infections have decreased by 31% (p<0.01) mainly because of reduced prescribing for lower respiratory tract infections (56% decline, p<0.001) and specific upper respiratory tract infections including tonsillitis/pharyngitis (48% decline, p<0.001) and otitis (46% decline, p<0.001). Prescribing for non-specific upper respiratory tract infection increased fourfold (p<0.001). Prescribing for "abnormal signs and symptoms" increased significantly since 2001 (40% increase, p<0.001).

Question: Changes in clinical indications for community antibiotic prescribing for children in the UK from 1996 to 2006: will the new NICE prescribing guidance on upper respiratory tract infections just be ignored?

There has been a marked decrease in community antibiotic prescribing linked to lower respiratory tract infection, tonsillitis, pharyngitis and otitis. Overall prescribing is now increasing again but is associated with non-specific upper respiratory tract infection diagnoses. General practitioners may be avoiding using diagnoses where formal guidance suggests antibiotic prescribing is not indicated. The new NICE guidance on upper respiratory tract infections is at risk of being ignored.

Answer the question based on the following context: This report investigates epidemiologically whether exposure to silica is associated with lung cancer risks in individuals without silicosis. We searched the PubMed reference data base from 1966 through 1/2007 for reports of lung cancer in silica-exposed persons without and with silicosis. To explore heterogeneity between studies, a multi-stage strategy was employed. First, fixed-effect summaries (FES) and corresponding 95% confidence intervals (CI) for various combinations of studies were calculated, weighting individual results by their precision. The homogeneity of the contributing results was examined using chi(2) statistics. Where there was evidence of substantial heterogeneity, the CI around the FES was increased to take account of the between-study variability. Random-effect summaries and their CI for identical combinations of studies were also computed. Meta regression was used to explore interactions with covariates. To draw comparisons, parallel analyses were performed for non-silicotics and for silicotics. The persistence of a significant link between silicosis and lung cancer since the characterisation in 1997 of silica as a human carcinogen [our estimates of lung cancer relative risks (RR) exceeded unity in each of 38 eligible studies of silicotics published until 1/2007, averaging 2.1 in analyses based on both fixed and random effect models (95% CI = (2.0-2.3) and (1.9-2.3), respectively)] does not resolve our study question, namely whether exposure to silica levels below those required to induce silicosis are carcinogenic. Importantly, our detailed examination of 11 studies of lung cancer in silica-exposed individuals without silicosis included only three with data allowing adjustment for smoking habits. They yielded a pooled RR estimate of 1.0 [95% CI = (0.8-1.3)]. The other eight studies, with no adjustment for smoking habits, suggested a marginally elevated risk of lung cancer [RR = 1.2; 95% CI (1.1-1.4)], but with significant heterogeneity between studies (P approximately 0.05).

Question: Is exposure to silica associated with lung cancer in the absence of silicosis?

Necessary further research should concentrate on silica exposures both above and below those that induce silicosis, so that the shape of the exposure-response relationship may be identified, with adjustments for likely confounding factors including silicosis. Time-dependent information on silicosis and on silica dust is required as well as the application of methods like G-estimation to answer the important public health question: Is silicosis a necessary condition for the elevation of silica-associated lung cancer risks?

Answer the question based on the following context: Older patients experience a higher prevalence of pain, including cancer pain, than other age groups and tend to receive poorer pain management. The reasons for unnecessary suffering resulting from pain among older patients are not well understood. This study aimed to identify barriers to cancer pain management for older patients living at home and to compare these with a younger control group. Patients newly referred to community-based palliative care services were interviewed about their pain and related issues. Data included pain impact (BPI), mood (HAD), health (EuroQol), and barriers to reporting of pain and analgesic use (Barriers Questionnaire). Fifty-eight patients aged 75 or over and 32 people aged 60 or under were interviewed. Both groups reported that beliefs about the use of analgesics was the greatest barrier to effective pain management. Older patients reported that beliefs about the use of analgesics and communicating with medical staff were significantly more important barriers to pain management than for younger patients. Overall, factors such as communication with medical staff and fatalism were ranked lower than barriers related to medication. Younger patients reported significantly greater sleep disturbance due to pain and greater anxiety.

Question: Cancer pain management at home (II): does age influence attitudes towards pain and analgesia?

Older age appears to influence attitudes towards pain and analgesia. Factors such as poorer knowledge about taking analgesia, reluctance to communicate with medical staff, poorer performance status, and being more likely to live alone suggest that older patients may require greater support in the management of their cancer pain than younger patients. Targeted interventions are needed to test this proposition.

Answer the question based on the following context: Roux-en-Y gastric bypass (RYGBP) either laparoscopic or open has been increasingly employed in the treatment of patients with morbid obesity. Laparoscopic approach is believed to be superior over open approach in terms of shorter hospital stay and easier recovery. We aimed to assess feasibility and safety of open RYGBP with short stay in comparison with laparoscopic RYGBP. One hundred and ninety consecutive patients were assigned to open (n=103) or laparoscopic (n=87) RYGBP. The first 20 patients of the laparoscopic arm were excluded due to procedure learning curve. Patients were treated by a multidisciplinary team focused on successfully RYGBP with short stay (1 day). Short stay was reached by 90% of patients operated with open approach and 81% by laparoscopy (P=0.070). Discharge in the second day was reached by 97% of patients in both groups. Procedure length [(median (IQR)] was faster for open RYGBP [103 (70-180 min) vs. 169 (105-248 min); P<0.0001]. Thirty-day readmission rate was similar between groups (3% vs. 7%; P=0.266). There was no death in either group.

Question: Hospital discharge in the day following open Roux-en-Y gastric bypass: is it feasible and safe?

Short stay (1 day) following open gastric bypass was a feasible and safe procedure. This approach might have economic impact and might increase patient acceptance for open RYGBP.

Answer the question based on the following context: In healthy individuals, blood pressure (BP) decreases, or "dips", during sleep. Ethnicity and high daytime blood pressure level are known markers of nondipping status. The literature on psychological markers of nondipping is scant but suggests that anger/hostility and chronic stress may be contributors to nondipping. We have investigated this phenomenon in drug-free hypertensives who participated in a clinical trial and supplied extensive demographic, psychological, and biological risk factor data after medication washout prior to any treatment. Sixty-two patients were available for analysis (n = 30 nondippers). While most studies focus only on systolic BP nondipping, we explicitly studied both systolic and diastolic BP dipping as outcomes given that both have prognostic value. Hierarchical multiple regression revealed that predictor variables in total accounted for 38% of variance in systolic blood pressure dipping and 44% of variance in diastolic blood pressure dipping. A significant positive predictor was alcohol consumption (beta = 0.37, t = 2.8, p = 0.007) for systolic BP and beta = 0.43, t = 3.7, p = 0.001 for diastolic BP), and an anger diffusion preference was also a positive predictor (beta = 0.42, t = 2.7, p = 0.01) for systolic BP dipping. No measure of trait negative affect reached significance as a predictor for systolic or diastolic BP dipping.

Question: Can psychological factors account for a lack of nocturnal blood pressure dipping?

These findings suggest that for a better understanding of the nondipping phenomenon, behavioral risk factors are important, and anger response styles may also be worthy of further study. Furthermore, anger coping preferences may be as important, or even more so, than levels of negative affect.

Answer the question based on the following context: Disperse dyes (DDs) are the most common sensitizers among textile dyes, but there is little knowledge of the clinical relevance of positive patch test reactions. To investigate if patient-reported textile-related skin problems can be explained by contact allergy to eight different DDs and/or to chemically related substances, by occupation or by atopic constitution, and if the skin problems are influenced by age or sex. A questionnaire on textile-related skin problems was answered by 858 of 982 consecutively patch tested patients in Malmö, Sweden and in Leuven, Belgium. The baseline series used for patch testing was supplemented with a textile dye mix (TDM) consisting of the eight DDs and with the separate dyes. The association between textile-related skin problems and contact allergy to the DDs and other risk factors was investigated using multiple logistic regression analysis. Eighteen per cent of the patients suspected textiles as a cause of their skin problems. Atopic constitution and female sex were risk factors for skin reactions. Synthetic materials were the most common textiles to give skin problems. A significant association was found between self-reported textile-related skin problems and contact allergy to para-phenylenediamine (PPD) [adjusted odds ratio (OR) 2.1; 95% confidence interval (CI) 1.0-4.3]. A similar, but more imprecise, adjusted OR was found for TDM (OR 1.9; 95% CI 0.57-5.6). Contact allergy to black rubber mix was too rare to be evaluated.

Question: Is contact allergy to disperse dyes and related substances associated with textile dermatitis?

Contact allergy to PPD was a more prevalent indicator for skin reactions to textiles than the TDM used in this study.

Answer the question based on the following context: Tobacco smoking is known to influence various inflammatory skin diseases and an association between tobacco smoking and hand eczema has been proposed in some studies. To examine a possible association between reported current tobacco smoking and the occurrence of hand eczema. Previously collected questionnaire data on the occurrence of hand eczema in three occupational cohorts and corresponding controls from the general population were studied. The questionnaires used included questions on 1-year prevalence of hand eczema and questions on smoking habits. For one occupational group, hairdressers and their controls, information on amount of smoking was obtained. Information on age, sex and history of atopy was also available. In total, answers regarding smoking and hand eczema were obtained from 13,452 individuals. Out of 3493 smokers, 437 (12.5%) reported hand eczema compared with 1294 out of 9959 nonsmokers (13.0%) (P = 0.51). With regard to the number of cigarettes smoked, 22.6% of the hairdressers smoking more than 10 cigarettes per day reported hand eczema compared with 17.4% of those smoking 0-10 cigarettes per day (P = 0.01). Corresponding figures for the controls were 14.5% and 11.7%, respectively (P = 0.06).

Question: Does tobacco smoking influence the occurrence of hand eczema?

No clear association was found between 1-year prevalence of hand eczema and smoking. Heavy smoking, more than 10 cigarettes per day, may give a slightly increased risk of hand eczema. Further studies with information on the amount of tobacco consumption and on possible confounders are needed to evaluate smoking as a risk factor for hand eczema.

Answer the question based on the following context: To investigate whether prematurity has an independent influence on the response to GH treatment in short, small for gestational age (SGA) children. A longitudinal 3-year GH study. A total of 392 prepubertal non-GH-deficient, short SGA children, comprising 138 preterm (<36 weeks) and 254 term (>or= 36 weeks) children. Height, weight, head circumference, skinfolds and serum IGF-I and IGFBP-3 levels were measured before start of GH treatment and after 6 months, 1, 2 and 3 years of treatment. Preterm short SGA children were significantly lighter and shorter at birth after correction for gestational age than term short SGA children (P<0.001). At start of GH treatment, preterm children were significantly shorter than term children when height was corrected for target height (TH). Preterm children were also significantly leaner as shown by a lower body mass index (BMI) standard deviation score (SDS) and a lower sum of four skinfolds SDS. Prematurity had no influence on childhood IGF-I and IGFBP-3 levels. The response to GH treatment was similar for preterm and term SGA children.

Question: Does preterm birth influence the response to growth hormone treatment in short, small for gestational age children?

Within a population of short SGA children, prematurity is associated with a smaller size for gestational age and a shorter height corrected for TH and leaner phenotype in childhood. The response to GH treatment is similar for preterm and term short SGA children.

Answer the question based on the following context: Atrial fibrillation (AF) is associated with increased mortality and a higher complication rate postmyocardial infarction (MI), but the exact mechanisms are unknown. We investigated whether AF predisposes to ventricular arrhythmia in postmyocardial infarct patients, thereby accounting for increased mortality. Five hundred consecutive patients admitted to our coronary care unit with acute MI were monitored for in-hospital arrhythmias. Detailed information was also compiled on past history, co-morbidities, electrolyte disturbances, drug therapies, and ejection fraction. Mortality data were collected for an average of 5.5 years. The results have shown that the incidence of ventricular fibrillation (VF) is much greater in patients presenting with AF (P=0.03) and multivariate analysis has shown that AF is independently associated with the development of VF. This association occurs principally in patients who are admitted with AF (P=0.01) rather than those who develop it during their admission, although these patients are also at mildly increased risk. The increased incidence of VF does account for increased mortality in the AF patients but does not explain all of their excess risk. There was no association between AF and ventricular tachycardia (VT); P=0.50.

Question: Does atrial fibrillation beget ventricular fibrillation in patients with acute myocardial infarction?

In conclusion, AF on admission to the hospital with acute MI is associated with an increased risk of VF and subsequent mortality.

Answer the question based on the following context: Smoking may be a major problem in chronic low back pain (LBP) patients. The goal of this study was to determine whether smoking status affected multidisciplinary pain facility treatment outcome. As part of a grant study, chronic LBP patients identified themselves as either current smokers (N = 81) or current nonsmokers (N = 140), and were compared by chi-square for employment status at 1, 6, 12, and 24 months after multidisciplinary pain facility treatment. Smokers who were unemployed at each time interval were then compared with employed smokers for a large number of assessment scales and clinical variables of interest by chi-square or Student's t-test. The significant independent variables from these analyses were then utilized in a logistic regression to determine predictors for smoker nonemployment. Pain facility. Current smokers were less likely to be employed at each follow-up time point. Pain levels over the previous 24 hours predicted employment status for current smokers at 1-, 12-, and 24-month follow-up, while worker compensation status predicted employment status at 6 months.

Question: Does smoking status affect multidisciplinary pain facility treatment outcome?

Current smoking status appears to be associated with poorer treatment outcome after multidisciplinary pain facility treatment. Return to work within smokers is predicted by pain and worker compensation status. Pain facilities should target current smokers with significant perceived pain for close treatment monitoring in an attempt to improve treatment outcome.

Answer the question based on the following context: Research addressing sexual health or STD risk among lesbian and bisexual college women is scarce. Data on 29,952 sexually active females aged 18-24 who completed the 2006 National College Health Assessment were examined to assess differences in sexual risk factors and recent STD incidence by sexual orientation. Comparisons were analyzed at the bivariate level and through multivariate logistic regression. Bisexual students were the most likely to have had an STD during the past year (9%); lesbians were the least likely (2%). However, lesbians were also the least likely to have had a routine gynecologic examination (46%, compared with 64-73% of others). Among students who had had multiple partners in the past year, those who had had partners of both sexes were more likely to have had an STD (16%) than were students who had had only male partners (9%) or only female partners (6%). Students who had binged on alcohol the last time they partied, had had multiple partners or had had a routine gynecologic examination in the past year, had been tested for HIV or had not used condoms at last vaginal intercourse were at increased odds of having had an STD (odds ratios, 1.3-4.0).

Question: STDs among sexually active female college students: does sexual orientation make a difference?

Sexual health programs targeting female college students, regardless of sexual orientation, must focus on behavioral risks associated with STDs. In addition, the importance of regular gynecologic exams should be emphasized, especially among lesbians. Further research is needed on risk-taking among female college students who are sexually active with both sexes.

Answer the question based on the following context: Activated T cells present in psoriatic plaques play a key role in the pathogenesis of psoriasis. CCR7 on T cells plays a crucial role in native immune response and formation of secondary lymphoid organ. To determine whether differential expression and functions of the CCR7 occur in psoriasis patients in China, we examined CCR7 on T cells from normal and psoriasis subjects. Skin specimens and T cells from 33 patients and 22 healthy controls were analyzed by immunohistology, flow cytometry, and RT-PCR. Patients with psoriasis had a skewed distribution of T lymphocytes, with an increased level of CCR7+ T lymphocytes compared to healthy controls (P<0.01) By flow cytometry, it was found that CCR7 was selectively, frequently, and functionally expressed on CD4+ (20.5+/-6.8%)but not on CD8+ (9.5+/-3.4%) T cells from patients with psoriasis, whereas this phenomenon was not seen in normal subjects. Through RT-PCR it was also found that CCR7 was highly expressed on T cells in patients with psoriasis than in healthy controls in the level of gene.

Question: Is CCR7 a potential target for biologic therapy in psoriasis?

Patients with psoriasis had a skewed distribution of T lymphocytes, with an increased level of CCR7+ T lymphocytes compared to healthy controls. CD4+ CCR7+ T cells had abnormal expression, which might induce protraction and persistence of psoriasis.

Answer the question based on the following context: To assess the cytologic criteria for distinguishing neoplastic from nonneoplastic follicular cell and Hürthle cell thyroid lesions. Ten previously described and commonly used cytologic criteria were evaluated and graded on a 0-4 scale in a consecutive series of thyroid fine needle aspirations (FNAs) reported as follicular or Hürthle cell neoplasms or lesions. Scoring was compared to subsequent surgical outcome. A total of 93 (57fo llicular cell and 36 Hühle cell) cases was analyzed. No individual cytologic feature was helpful in distinguishing benign neoplarms from malignancy in either category (p>0.05), but 4 or more coexistent cytologic features in combination were identified in 50.0% of follicular neoplasms, 13.6% of Hürthle cell neoplasms and none of the nonneoplastic lesions. An unexpected number (13 of 93, 14.0%) of unrecognized papillary carcinomas, some of follicular subtype, was encountered.

Question: Follicular and Hürthle cell lesions of the thyroid: can inconclusive results be minimized?

In this series, the indeterminate thyroid FNA category could have been reduced by diagnosis of samples with 4 or more of the studied criteria as definite follicular (50% of cases) or Hürthle cell (13.6% of cases) neoplasms and by more astute recognition of papillary carcinomas (14.0% of cases), which blend into this category, often as a result of less-than-optimal sampling or preservation.

Answer the question based on the following context: To correlate the simple triage and rapid treatment (START) colors to trauma injury severity scores (ISS). Six volunteer healthcare providers unfamiliar with START were trained to triage. Each chart was designated a START color by a volunteer healthcare provider and the "expert" trainer. The colors and corresponding ISS were recorded. Level I trauma center at a suburban tertiary care hospital. One hundred charts of patients at least 65 years old who appear in Christiana Hospital's Trauma Registry were randomly chosen for the study, and 98 charts with complete data were included.MAIN OUTCOME MEASURE(S): Cohen's Kappa score measures the level of agreement between the "volunteer" and "expert" reviewers. Pearson correlation determines the association between the START colors and mean ISS. The Cohen's Kappa score between the volunteer and expert reviewers was 0.9915, indicating a highly significant agreement between the reviewers on the triage category of the patients. The mean ISS for each color was as follows: green = 11, yellow = 12, red = 20, black = 24. The mean ISS increases as the acuity of the triage category increases, with a Pearson correlation of 0.969.

Question: Does the simple triage and rapid treatment method appropriately triage patients based on trauma injury severity score?

The START method is a simple technique used to triage quickly a large number of patients. Healthcare providers can undergo just-in-time training to learn this technique and use it effectively. The START colors also imply a correlation with the trauma ISS, with higher ISS more likely to be triaged "red" or "black."

Answer the question based on the following context: Previous experimental and laboratory studies have implicated antibodies against Hu proteins (anti-Hu) as a potential marker for small cell lung cancer (SCLC); there are no estimates of the association between anti-Hu and SCLC using a population-based design. We used stored plasma specimens to evaluate anti-Hu reactivity in relationship to small cell lung cancer in a population-based case-control study. Using Western Blot analysis, we measured anti-Hu reactivity against recombinant Hu family member, HuD, in plasma samples from 41 SCLC cases and 79 controls individually matched for age, race, sex, and smoking status (never, past, current). We analyzed the association between anti-Hu reactivity and SCLC using conditional logistic regression. Anti-Hu reactivity was associated with SCLC, both before and after adjustment for amount of smoking. We observed a smoking-adjusted odds ratio of 3.2 (95% confidence interval from 0.98 to 13.4) comparing subjects above 1800 units (the lower limit of the second tertile of the distribution among antibody positive controls) to subjects with lower reactivity. We also found suggestive evidence in follow-up of our cases that anti-Hu above 1800 units was related to longer-term survival from SCLC. The present research is the first report of anti-Hu reactivity and SCLC in a population-based study.

Question: Low level anti-Hu reactivity: A risk marker for small cell lung cancer?

Given the suggestive evidence in this study, prospective analyses to examine whether anti-Hu reactivity might predict risk of developing SCLC, or whether anti-Hu reactivity could serve as an early marker for SCLC, may be warranted.

Answer the question based on the following context: To investigate whether a computer-aided detection (CAD) system could act as an arbitrator of discordant double-reading opinions, replacing the need for an independent third film reader. The mammograms of the 240 women that underwent arbitration by an independent third reader were identified from the 16,629 women attending our screening centre between July 2003 and April 2004. Mammograms of the arbitration cases were digitized and analysed by a CAD system. To assess the ability of CAD to act as the arbitrator, the site of the CAD prompts was retrospectively compared to the site of any abnormality noted by the original film readers. If a CAD prompt was placed on a region marked by one of the film readers then the decision of CAD as the arbitrator was that the women should be recalled for further assessment. If no mark was placed then the region was considered low risk and the decision was not to recall. The decision of CAD as the arbitrator was retrospectively compared with the original recall decision of the independent third reader. There were 21 cancer cases in the group of women undergoing arbitration, diagnosed both at the original screening episode and subsequently. The independent third reader recalled 15/18 (83%) of the cancers that corresponded with the arbitrated lesion. CAD as the arbitrator would have recalled 16/18 (89%) of the cancers that corresponded to the arbitrated lesion. CAD acting as the arbitrator would have resulted in a significant increase in normal women being recalled to assessment in the arbitration group (P<0.001). The extra 50 recalls would have potentially increased the overall recall rate to assessment from 3.1 to 3.4%; a relative increase of 10%.

Question: Does computer-aided detection have a role in the arbitration of discordant double-reading opinions in a breast-screening programme?

The main effect of CAD acting as an arbitrator of discordant double-reading opinions is to increase the recall rate, significantly above what is found when arbitration is performed by an independent third reader. Using CAD as an arbitrator may be an option to deal with discordant double-reading opinions when no other method of consensus or arbitration is available.

Answer the question based on the following context: Ten consecutive children who had supraglottic penetration while swallowing barium were evaluated as part of a video fluoroscopic feeding study. All fluoroscopic studies were performed with a pulse rate of 30 frames/s. Frame by frame analysis was performed of the first episode of penetration in each patient to determine on how many image frames the penetration could be detected. Supraglottic penetration occurred very rapidly. In seven of the 10 patients, full-depth penetration was only seen on one image frame. In no patient was the full-depth penetration seen in greater than two imaging frames.

Question: Can we use pulsed fluoroscopy to decrease the radiation dose during video fluoroscopic feeding studies in children?

Decreasing the fluoroscopic pulse rate cannot be used as a method of decreasing radiation dose during performance of video fluoroscopic studies because it will potentially result in non-detection of episodes of supraglottic penetration of liquid barium.

Answer the question based on the following context: The objective of the study was to determine the relationship between fetal fibronectin (fFN) testing prior to ultrasound-indicated cerclage and obstetric outcome. Singleton pregnancies between 18 and 24 weeks' gestation with an ultrasound-diagnosed short cervix (<25 mm) and funneling (>25%) of the chorioamniotic membranes into the endocervical canal were analyzed. The fFN testing was performed and patients were randomized to cerclage or no-cerclage. Groups were stratified by fFN result. Cerclage patients were compared with no-cerclage patients. The primary outcome was delivery prior to 35 weeks' gestation. Spontaneous preterm birth prior to 35 weeks' gestation occurred in 15 (44.1%) fFN-positive-cerclage patients and 16 (55.2%) fFN-positive no-cerclage patients (P = .45). Similarly, it occurred in 16 (17.8%) fFN-negative cerclage patients and 11 (17%) fFN-no-cerclage patients (P = .99).

Question: Fetal fibronectin testing in patients with short cervix in the midtrimester: can it identify optimal candidates for ultrasound-indicated cerclage?

fFN did not identify optimal candidates for cerclage. However, fFN testing before an ultrasound-indicated cerclage aids in counseling patients, anticipating the outcome of pregnancies complicated by cervical shortening.

Answer the question based on the following context: To evaluate decisions selecting patients for anti-retroviral treatment (ART) in Uganda. We held 39 semi-structured interviews with 41 health professionals holding various selection roles and 5 focus groups with 47 HIV/AIDS patients in diverse ART programs. Decisions were evaluated using accountability for reasonableness (A4R). A4R considers a decision fair when those whom it affects can know the decision and its complete rationale (Publicity), can consider the rationale relevant (Relevance) and can appeal against the decision (Appeals), and each of these conditions - Publicity, Relevance and Appeals - is enforced (Enforcement). All ART candidates were told whether, and many were also told why they could receive ART or not. Programs used various means to promote candidates' understanding. Many, but not all, rationales could be considered relevant. Appeal mechanisms existed but were not used to challenge selection decisions or criteria, which were considered unchangeable. There was enforcement of criteria but insufficient enforcement of Publicity and Relevance, and none of Appeals.

Question: Is the selection of patients for anti-retroviral treatment in Uganda fair?

Decisions are insufficiently fair and legitimate. Effective mechanisms should be created for appeals, enforcement, and communication of complete rationales. Nonetheless, decisions and rationales are available, and criteria applied even-handedly. Such aspects are a benchmark for less adequate decision-making reported elsewhere.

Answer the question based on the following context: Chronic fatigue syndrome (CFS) is often associated with significant levels of disability. Although fatigue and depression have been found to be independently related to severity of disability, it is not clear how these three factors are mutually related. The present study sought to address this issue by specifically testing a model of mediation whereby depression was hypothesized to influence relations between fatigue and disability. Participants included 90 individuals seeking treatment for CFS at a tertiary care facility. Each provided demographic information and completed standardized measures of depression and fatigue severity, as well as a measure of disability, which assessed difficulties in physical, psychosocial, and independence domains. Analyses indicated that depression and fatigue were positively correlated with one another, as well as all three disability domains. Analyses of mediation indicated that depression completely mediated the relation between fatigue and psychosocial disability and partially mediated the relation between fatigue and the other two disability domains. Indirect effects tests indicated that the inclusion of depression in the statistical models was statistically meaningful.

Question: Does depression mediate the relation between fatigue severity and disability in chronic fatigue syndrome sufferers?

These results replicate previous findings that fatigue and depression are independently related to disability in those with CFS. A more complex statistical model, however, suggested that depression severity substantially influenced the strength of the relation between fatigue and disability levels across a range of domains, including complete mediation in areas involving psychosocial functioning. These results may aid in clarifying contemporary conceptualizations of CFS and provide guidance in the identification of appropriate treatment targets.

Answer the question based on the following context: The purpose of this study is to prospectively examine the independent contribution of symptoms of insomnia on sick leave. We used a historical cohort design with 4 years of follow-up. Information on sick leave was obtained from Norwegian official registry data and merged with health information from the Hordaland Health Study in Western Norway, 1997 to 1999. Six thousand eight hundred ninety-two participants aged 40 to 45 years were assessed for self-reported symptoms of insomnia, sociodemographic factors, lifestyle behaviors, body mass index, symptoms of sleep apnea, anxiety, depression, as well as a range of somatic diagnoses, somatic symptoms, and pain. The outcome was the total number of sick days during a 4-year follow-up period, as registered in the official registries by the National Insurance Administration. Overall, insomnia was found to be a significant predictor of sick leave [odds ratio (OR)=2.20; 95% confidence interval (CI), 1.77-2.74], and the effect remained significant when adjusting for possible confounders (OR=1.51; 95% CI, 1.19-1.94). The effect increased with longer durations of sickness leave.

Question: Does insomnia predict sick leave?

This is the first study to demonstrate that insomnia is an independent risk factor for long-term sick leave.

Answer the question based on the following context: The measurement of cardiac markers is still the gold standard for diagnosing myocardial infarction (MI), but there is always a transition period between the time of infarction and when a marker can be measured in the blood. Therefore, clinicians are shifting their focus to the identification of potential new analytes capable of predicting MIs before the standard cardiac markers increase. In this study, we tested whether measurement of the concentration of soluble intercellular adhesion molecule 1 (sICAM-1) in plasma can be used for this purpose. In this prospective study, we included 60 male patients who had a left main coronary artery lesion or a left main equivalent and who underwent elective (group I, n = 20), urgent (group II, n = 20), or emergent (group III, n = 20) coronary artery bypass grafting (CABG). We excluded patients who had increased cardiac markers at admission, and drew blood samples for sICAM-1 measurements from other patients immediately after coronary angiography evaluations. We divided the patients into 3 groups according to their clinical characteristics and cardiac marker levels. Only patients with increased cardiac markers underwent emergent CABG (group III). We measured sICAM-1 concentrations immediately after coronary angiography and measured creatine kinase MB (CK-MB) and cardiac troponin I (cTnI) just before CABG. We then evaluated the results for correlations. CK-MB, cTnI, and sICAM-1 levels were significantly higher in group III than in groups I and II (P<.05 for all). Our analysis for correlations between the sICAM-1 level and cardiac marker levels revealed no significant correlations in group I (CK-MB, r = 0.241 [P = .15]; cTnI, r = -0.107 [P = .32]) and group II (CK-MB, r = -0.202 [P = .19]; cTnI, r = 0.606 [P = .002]), but our analysis did reveal highly significant correlations in group III (CK-MB, r = 0.584 [P = .003]; cTnI, r = 0.605 [P = .002]).

Question: Does the level of soluble intercellular adhesion molecule 1 predict myocardial injury before cardiac markers increase?

Measuring the plasma concentration of sICAM-1 before the concentrations of cardiac markers increase in patients with MI may provide clinicians with faster and reliable data for deciding on and administering the most appropriate procedures and/or therapies.

Answer the question based on the following context: Wheezing associated with acute respiratory infections (ARI) is responsible for unnecessary use of antibiotics. To evaluate the response of children with ARI and wheezing managed according to the World Health Organization (WHO) protocol. Cross-sectional study of children aged 2-59 months conducted in a Brazilian pediatric public hospital. Children showing fast breathing received inhalations of bronchodilator. Those who persisted with fast breathing had chest radiographs taken. When appropriate, oral antibiotics were prescribed for pneumonia. Audible wheezing was also registered. We included 217 children: mean age 25.7 months (SD = 17.5) with 54.4% (118/217) being males. Audible wheezing was detected in 18.6% (40/217). In 87.6% (190/217) of children normal respiratory rates were reached after inhalations. In cases of pneumonia, 26% (7/27) persisted with fast breathing.

Question: Wheezing and respiratory infections in Brazilian children: does a standard management work?

A good response using WHO protocol suggests its usefulness in emergency rooms, although few cases will continue to receive antibiotics unnecessarily.

Answer the question based on the following context: To assess the robustness of the association between intelligence quotient (IQ) and mortality in older adults and to examine whether or not the association can be explained by more specific cognitive processes, including individual differences in executive functioning. We examined the associations among Full Scale IQ, individual IQ subtest scores, and 10-year mortality among older community-dwelling, adult participants in the Canadian Study of Health and Aging, who were verified as disease and cognitive-impairment free at baseline via comprehensive medical and neurological evaluation (n = 516). Survival analysis including Cox proportional hazards regression models were used to examine mortality risk as a function of Full Scale IQ and its specific subcomponents. An inverse association was found between IQ and mortality, but this did not survive adjustment for demographics and education. The association between IQ and mortality seemed to be predominantly accounted for by performance on one specific IQ subtest that taps executive processes (i.e., Digit Symbol (DS)). Performance on this subtest uniquely and robustly predicted mortality in both unadjusted and adjusted models, such that a 1-standard deviation difference in performance was associated with a 28% change in risk of mortality over the 10-year follow-up interval in adjusted models.

Question: Does executive function explain the IQ-mortality association?

The association between IQ and mortality in older adults may be predominantly attributable to individual differences in DS performance.

Answer the question based on the following context: Morbid obesity (body mass index (BMI)>or =40 kg/m(2)) is associated with thyroid function disturbances, with a high rate of subclinical hypothyroidism (SH) being the most consistently reported. We evaluated the circulating thyroid function parameters in morbid obese patients and related the results to the presence of circulating thyroid antibodies (Thyr-Ab). Morbid obese patients were consecutively enrolled (n=350). Two control groups were used: control group (CG)1, healthy normo-weight subjects (n=50); CG2, normo-weight patients with SH (n=56) matched for TSH with the obese patients with SH. Serum levels of free triiodothyronine (FT(3)), free thyroxine (FT(4)), TSH, antithyroglobulin antibodies, and antithyroperoxidase antibodies were measured in all patients. i) Compared with CG1, obese patients having thyroid function parameters in the normal range and negative Thyr-Ab showed significantly higher serum TSH and lower free thyroid hormones levels, but a similar FT(4)/FT(3) ratio; ii) SH was recorded in 13.7% obese patients; iii) compared with CG2, obese patients with untreated SH had a significantly lower rate of positive Thyr-Ab (32.1 vs 66.1%; P<0.005); iv) no gender prevalence was observed in SH obese patients with negative Thyr-Ab; and v) the comparison of the untreated SH patients (obese and normo-weight) with CG1 demonstrated that in SH obese subjects, unlike normo-weight SH patients, the FT(3) levels were significantly lower. This resulted in a normal FT(4)/FT(3) ratio in SH obese patients.

Question: Raised serum TSH levels in patients with morbid obesity: is it enough to diagnose subclinical hypothyroidism?

Thyroid autoimmunity is not a major cause sustaining the high rate of SH in morbid obese patients. In these patients, the diagnosis of SH itself, as assessed by a raised TSH alone, appears questionable.

Answer the question based on the following context: To present a geographic information systems (GIS) method for exploring the spatial pattern of injuries and to demonstrate the utility of using this method in conjunction with classic ecological models of injury patterns. Profiles of patients' socioeconomic status (SES) were constructed by linking their postal code of residence to the census dissemination area that encompassed its location. Data were then integrated into a GIS, enabling the analysis of neighborhood contiguity and SES on incidence of injury. Data for this analysis (2001-2006) were obtained from the British Columbia Trauma Registry. Neighborhood SES was calculated using the Vancouver Area Neighborhood Deprivation Index. Spatial analysis was conducted using a join-count spatial autocorrelation algorithm. Male and female patients over the age of 18 and hospitalized from severe injury (Injury Severity Score>12) resulting from an assault or intentional self-harm and included in the British Columbia Trauma Registry were analyzed. Male patients injured by assault and who resided in adjoining census areas were observed 1.3 to 5 times more often than would be expected under a random spatial pattern. Adjoining neighborhood clustering was less visible for residential patterns of patients hospitalized with injuries sustained from self-harm. A social gradient in assault injury rates existed separately for men and neighborhood SES, but less than would be expected when stratified by age, gender, and neighborhood. No social gradient between intentional injury from self-harm and neighborhood SES was observed.

Question: Are injuries spatially related?

This study demonstrates the added utility of integrating GIS technology into injury prevention research. Crucial information on the associated social and environmental influences of intentional injury patterns may be under-recognized if a spatial analysis is not also conducted. The join-count spatial autocorrelation is an ideal approach for investigating the interconnectedness of injury patterns that are rare and occur in only a small percentage of the population.

Answer the question based on the following context: Both the 10-item Alcohol Use Disorders Identification Test (AUDIT) and its abbreviated 3-item version (Alcohol Use Disorders Identification Test-Consumption [AUDIT-C]) are considered to detect unhealthy alcohol use accurately. To examine whether the AUDIT-C is as accurate as the full AUDIT for detecting unhealthy alcohol use in adults. MEDLINE, EMBASE, CINAHL, Web of Science, PsycINFO, and BIOSIS Previews from 1998 to July 2008. Three independent reviewers selected studies that administered both the AUDIT and the AUDIT-C, applied a valid reference standard, avoided verification and incorporation bias, and reported relevant data. No language restrictions were applied. Two reviewers extracted study characteristics and outcome data, which were cross-checked by a third reviewer. One reviewer assessed methodological quality with a standardized checklist. Fourteen studies were found. Most involved primary care patients in Europe and the United States. Sample sizes ranged between 112 and 13 438 patients, and sex and age distributions varied considerably. No statistically significant differences were found between the overall accuracy of the AUDIT and the AUDIT-C for detecting risky drinking, alcohol use disorders, or unhealthy alcohol use in primary care. Hierarchical summary receiver-operating characteristic curve analysis yielded pooled positive likelihood ratios of 6.62 for the AUDIT and 2.99 for the AUDIT-C, respectively, for detecting risky drinking; 4.03 and 3.82, respectively, for detecting any alcohol use disorder; and 4.82 and 3.91, respectively, for detecting risky drinking or any alcohol use disorder. Findings from a few studies on general population samples and inpatients suggested but did not prove that the AUDIT might be better than the AUDIT-C for identifying severe conditions, such as alcohol dependence. Studies used different reference standards and had heterogeneous findings.

Question: Meta-analysis: are 3 questions enough to detect unhealthy alcohol use?

Available evidence is inconclusive but suggests that the full AUDIT may be superior to the AUDIT-C for identifying unhealthy alcohol use in adults in some settings.

Answer the question based on the following context: Herniation of the brain outside of its normal intracranial spaces is assumed to be accompanied by clinically apparent neurologic dysfunction. The authors sought to determine if some patients with brain herniation or significant brain shift diagnosed by cranial computed tomography (CT) might have a normal neurologic examination. This is a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) II cranial CT database compiled from a multicenter, prospective, observational study of all patients for whom cranial CT scanning was ordered in the emergency department (ED). Clinical information including neurologic examination was prospectively collected on all patients prior to CT scanning. Using the final cranial CT radiology reports from participating centers, all CT scans were classified into three categories: frank herniation, significant shift without frank herniation, and minimal or no shift, based on predetermined explicit criteria. These reports were concatenated with clinical information to form the final study database. A total of 161 patients had CT-diagnosed frank herniation; 3 (1.9%) had no neurologic deficit. Of 91 patients with significant brain shift but no herniation, 4 (4.4%) had no neurologic deficit.

Question: Can patients with brain herniation on cranial computed tomography have a normal neurologic exam?

A small number of patients may have normal neurologic status while harboring significant brain shift or brain herniation on cranial CT.

Answer the question based on the following context: To determine the incidence and features of urothelial carcinoma (UC) involving the prostate (UCP) and of prostate adenocarcinoma (PA) in radical cystoprostatectomy (RCP) for bladder cancer. The whole-mount prostate sections of 248 RCP consecutively examined from 1995 to 2007 were reviewed to determine the incidence and features of UCP and PA. UCP was separately evaluated for UC originating from the urethra and peri-urethral ducts (PUC) and for direct extension of bladder UC. There was UCP in 94 (37.9%) of 248 patients, whereas PUC was present in 78 (31.5%). UC in situ and noninvasive papillary PUC was present in 42 (53.9%) of the 78, whereas stromal invasion was present in 36 (46.1%). Direct extension of UC from the bladder only was present in 16 (6.5%) patients. PA was present in 123 (49.6%) of 248 patients; 96 (78.1%) were in the peripheral zone. In 107 patients (87%) the Gleason score was<or=6; 96 (78.1%) were pT2a, with a lower frequency in other pT categories. The margins were negative in 96.7% of cases. All patients were pN0 for PA; in 116 (95.1%) the volume was<0.5 mL. Of the 123 patients with incidental prostate cancer, 100 cancers (81.3%) were considered clinically insignificant. UCP coexisted with PA in 43 (17.3%) of 248 patients, whereas PUC and PA occurred together in the same prostate in 32 (12.9%). Direct extension of UC from the bladder and PA occurred together in the same prostate in 11 (4.4%) patients.

Question: Urothelial and incidental prostate carcinoma in prostates from cystoprostatectomies for bladder cancer: is there a relationship between urothelial and prostate cancer?

UC involving the prostate and PA are present in most RCP specimens. UC can arise from extension of trigonal or bladder-neck tumours, proximal prostate ducts/urethra, or from cell implantation from manipulation of vesical neoplasms. The frequent high coincidence of prostate and bladder cancer can be explained by a common pathway of carcinogenesis.

Answer the question based on the following context: Informed decision making regarding screening mammography is recommended for women under age 50. To what extent it occurs in clinical settings is unclear. Using a mailed instrument, we surveyed women aged 40-44 prior to their first screening mammogram. All women were members of a large health maintenance organization and received care at a large medical practice in the Greater Boston area. The survey measured informed decision making, decisional conflict, satisfaction, and screening mammography knowledge and intentions to undergo screening. Ninety-six women responded to the survey (response rate 47%). Overall, women reported limited informed decision making regarding screening mammography, both with respect to information exchange and involvement in the decision process. Less than half (47%) reported discussing the benefits of screening; 23% the uncertainties; and only 7% the harms. About 30% reported discussing the nature of the decision or clinical issue; and 29% reported their provider elicited their preferred role in the decision; 38% their preferences; and 24% their understanding of the information. Women who were uninformed had higher decisional conflict (2.37 vs. 1.83, P=0.005) about screening mammography and were more likely to be dissatisfied with the information and involvement. Women's screening mammography knowledge was limited in most areas; however being presented with information did not diminish their intentions to undergo screening.

Question: Informed decision making before initiating screening mammography: does it occur and does it make a difference?

Informed decision making before initiating screening mammography is limited in this setting. There appears to be little indication that information about the benefits and harms decreases women's intentions to undergo screening. Methods to communicate information to women before initiating screening mammography are needed.

Answer the question based on the following context: This prospective clinical study was designed to examine the healing process during the first 12 months after sinus grafting (SG) with autogenous culture-expanded bone cells (ABC) and bovine bone mineral (BBM) histomorphometrically and radiologically. Twenty-two sinuses of 12 patients (mean age 56.2+/-9.3 years) were grafted. Four weeks before, SG bone biopsies were obtained with a trephine burr and the bone cells were isolated and expanded. Every sinus was grafted with BBM and ABC. After 6 months, a biopsy was taken from each sinus and implants (n=82) were placed. These were uncovered after another 6 months and fitted with dentures. The percent newly formed bone (NB) and the NB-to-BBM contact area were determined on undecalcified histologic sections. The sinus graft volume was evaluated by dental CT after SG (CT 1), after implant placement (CT 2) and after implant uncovery (CT 3). Postoperative healing was uneventful. The NB was 17.9+/-4.6% and the contact area 26.8+/-13.1%. The graft volume (in mm(3)) was 2218.4+/-660.9 at the time of CT 1, 1694+/-470.4 at the time of CT 2 and 1347.9+/-376.3 at the time of CT 3 (P<.01). Three implants were lost after uncovery. Reimplantation and prosthodontic rehabilitation were successful throughout.

Question: Are culture-expanded autogenous bone cells a clinically reliable option for sinus grafting?

These results suggest that SG with ABC and BBM in a clinical setting provides a bony implant site which permits implant placement and will tolerate functional loading.

Answer the question based on the following context: Within the bilaterians, the appearance and evolution of vertebrates is accompanied by enormous changes in anatomical, morphological and developmental features. This evolution of increased complexity has been associated with two genome duplications (2R hypothesis) at the origin of vertebrates. However, in spite of extensive debate the validity of the 2R hypothesis remains controversial. The paucity of sequence data in early years of genomic era was an intrinsic obstacle in tracking the genome evolutionary history of chordates. In this article I review the 2R hypothesis by taking into account the recent availability of genomic sequence data for an expanding range of animals. I argue here that genetic architecture of lower metazoans and representatives of major vertebrate and invertebrate lineages provides no support for the hypothesis relating the origin of vertebrates with widespread gene or genome duplications.

Question: Are we degenerate tetraploids?

It appears that much of the genomic complexity of modern vertebrates is very ancient likely predating the origin of chordates or even the Bilaterian-Nonbilaterian divergence. The origin and evolution of vertebrates is partly accompanied by an increase in gene number. However, neither can we take this subtle increase in gene number as an only causative factor for evolution of phenotypic complexity in modern vertebrates nor we can take it as a reflection of polyplodization events early in their history.

Answer the question based on the following context: The potential impact of HIV-1 on falciparum malaria has been difficult to determine because of diagnostic problems and insufficient epidemiological data. In a prospective, cross-sectional study, clinical and laboratory data was registered consecutively for all adults admitted to a medical ward in the Central Hospital of Maputo, Mozambique, during two months from 28th October 2006. Risk factors for fatal outcome were analysed. The impact of HIV on the accuracy of malaria diagnosis was assessed, comparing "Presumptive malaria", a diagnosis assigned by the ward clinicians based on fever and symptoms suggestive of malaria in the absence of signs of other infections, and "Verified malaria", a malaria diagnosis that was not rejected during retrospective review of all available data. Among 333 included patients, fifteen percent (51/333) had "presumptive malaria", ten percent (28 of 285 tested persons) had positive malaria blood slides, while 69.1% (188/272) were HIV positive. Seven percent (n = 23) had "verified malaria", after the diagnosis was rejected in patients with neck stiffness or symptom duration longer than 2 weeks (n = 5) and persons with negative (n = 19) or unknown malaria blood slide (n = 4). Clinical stage of HIV infection (CDC), hypotension and hypoglycaemia was associated with fatal outcome. The "presumptive malaria" diagnosis was rejected more frequently in HIV positive (20/31) than in HIV negative patients (2/10, p = 0.023).

Question: Falciparum malaria and HIV-1 in hospitalized adults in Maputo, Mozambique: does HIV-infection obscure the malaria diagnosis?

The study suggests that the fraction of febrile illness attributable to malaria is lower in HIV positive adults. HIV testing should be considered early in evaluation of patients with suspected malaria.

Answer the question based on the following context: The discrepancy between minimal disease on biopsy and disease found in the subsequent prostatectomy specimen, in terms of the size and grade of tumor, extracapsular extension or positive margins, led several authors to dispute the existence of clinically insignificant impalpable tumors of the prostate. However, considering that prostate-specific antigen (PSA) is an indicator of prostate malignancy and since many impalpable prostatic carcinomas (PCs) are detected by a combination of PSA, transurethral ultrasound and needle biopsy (T1c), in the era of PSA screening, it is expected that most of the impalpable tumors found incidentally at transurethral resection of the prostate (stage T1a/b), could be clinically insignificant.AIM: The aim of this study was to identify the characteristics of latent, impalpable PCs and to analyze the incidence of clinically insignificant PCs among hypothetical stage T1 prostate cancers in tumors found incidentally at postmortem examination. We examined 40 cases of impalpable PCs found in 212 prostate autopsy specimens of men between 30 and 98 years of age who died of diseases other than carcinoma of the prostate and related conditions. Most of T1 histological PCs (57.5%) had a Gleason score between 2 and 4, while 30% had Gleason score between 5 and 6. Only 5 (12.5%) had a Gleason score above 7. Twenty-nine of 40 stage T1 histological cancers (67.5%) had volume of<1 cm(3). The highest volume tumors were those of intermediate and high grade (Gleason sums 5-8). Among tumors with volumes of<1 cm(3), 96.55% were confined within the prostatic capsule.

Question: Do clinically insignificant tumors of the prostate exist?

The majority of impalpable PCs were low-volume, well-differentiated tumors corresponding to clinically insignificant neoplasms. Similar characteristics could be attributed to most of the impalpable carcinomas detected after prostatectomy in clinical practice.

Answer the question based on the following context: Similar to the other von Hippel-Lindau (VHL)-related tumors such as renal cell carcinomas and capillary hemangioblastomas, serous cystadenomas (SCAs) of the pancreas are also characterized by clear cells. Over the years, we have also noticed that the tumor epithelium shows a prominent capillary network. Eighteen cases of SCA were reviewed histologically, and immunohistochemical analysis was performed for CD31 and vascular endothelial growth factor (VEGF) as well as the molecules implicated in clear-cell tumorigenesis: GLUT-1, hypoxia-inducible factor-1 (HIF-1alpha), and carbonic anhydrase IX (CA IX). There was an extensively rich capillary network that appears almost intraepithelially in all cases of SCA, which was confirmed by CD31 stain that showed, on average, 26 capillaries per every 100 epithelial cells. VEGF expression was identified in 10/18 cases. Among the clear-cell tumorigenesis markers, CA IX was detected in all cases, GLUT-1 and HIF-1alpha in most cases.

Question: Is serous cystadenoma of the pancreas a model of clear-cell-associated angiogenesis and tumorigenesis?

As in other VHL-related clear-cell tumors, there is a prominent capillary network immediately adjacent to the epithelium of SCA, confirming that the clear-cell- angiogenesis association is also valid for this tumor type. Molecules implicated in clear-cell tumorigenesis are also consistently expressed in SCA. This may have biologic and therapeutic implications, especially considering the rapidly evolving drugs against these pathways. More importantly, SCA may also serve as a model of clear-cell-associated angiogenesis and tumorigenesis, and the information gained from this tumor type may also be applicable to other clear-cell tumors.

Answer the question based on the following context: Ever since the introduction of invasive hemodynamic monitoring to major burn care, its utility remains controversial. Besides complications, invasive monitoring as a guideline for burn shock resuscitation is often associated with significant excessive fluid burden. This study was to summarize the clinical experiences of noninvasive esophageal echo-Doppler (ED) monitoring in burn shock resuscitation and discuss the significance of hemodynamic variables in assessment of fluid therapeutic goal. Twenty-one burn patients with an average total body surface area of 78.86% +/- 7.75% (62-92%) was enrolled in this retrospective study. Fluid therapy was guided according to Chinese general formula and adjusted with urinary output 1 mL/kg/hr as resuscitation goal. Hemodynamic parameters using ED was obtained, including cardiac output (CO), stroke volume (SV), myocardial contractility parameter--maximum acceleration at onset of systole (Acc), afterload parameter--total systemic vascular resistance (TSVR), preload parameter SV/Acc. All patients were clinically diagnosed with a relatively stable condition during early shock stage. There existed inherent and dynamic tendency of hemodynamics during burn shock resuscitation with low CO, Acc, SV/Acc, and high TSVR at first followed by a continuous trend of increase in CO, Acc and SV/Acc and decrease in TSVR. Significant correlations could be seen between CO and Acc, CO and TSVR, CO and SV/Acc. The Standardized Regression Coefficients of Acc, TSVR, and SV/Acc with CO as dependent variable were 0.343, -0.670, and 0.053, respectively demonstrating that myocardial contractility and angiotasis played more important role than blood volume did in hemodynamic variation.

Question: Esophageal echo-Doppler monitoring in burn shock resuscitation: are hemodynamic variables the critical standard guiding fluid therapy?

Hemodynamic variables cannot routinely substitute traditional variables as the burn shock resuscitation goal. Because of its noninvasiveness, ability to real-timely provide complete profile of hemodynamics, ED monitoring is a good adjunctive method for clinical judgment.

Answer the question based on the following context: Currently it is not yet defined if the rapid virologic response (RVR) can predict a sustained virologic response (SVR) in relapsers and nonresponders. To evaluate treatment-RVR as a predictive factor of SVR in genotype 1 hepatitis C treatment naive, relapsers, and nonresponder patients treated with pegylated interferon-alpha (PEG-IFN-alpha2b) and ribavirin. One hundred sixty-seven genotype 1 hepatitis C patients who were treated with PEG-IFN-alpha2b and ribavirin and had SVR assessed were included. Hepatitis C virus RNA analysis at the fourth week of treatment was performed in all patients. The exclusion criteria were hepatitis B virus and/or HIV co-infection. A comparative analysis was performed between the groups with and without RVR and a logistic regression model was applied. One hundred sixty-seven patients were analyzed, 103 (62%) were naives, 22 (13%) relapsers, and 42 (25%) nonresponders. The SVR rates were 44% in naives, 68% in relapsers, and 12% in nonresponders. RVR was attained in 51/167 (31%) patients and in this group the SVR was higher than in those without RVR (75% vs. 23%; P<0.001). This difference was also observed in all subgroups: naives (71% vs. 29%; P=0.001), relapsers (92% vs. 40%; P=0.02), and nonresponders (50% vs. 8%; P=0.06). A stepwise logistic regression model identified RVR and absence of cirrhosis as the factors independently associated to SVR.

Question: Is the rapid virologic response a positive predictive factor of sustained virologic response in all pretreatment status genotype 1 hepatitis c patients treated with peginterferon-alpha2b and ribavirin?

RVR and absence of cirrhosis are the strongest predictive factors of SVR in HCV genotype 1 patients. Assessment of RVR is very useful in all pretreatment status patients in predicting SVR and provides information for individualizing therapy.

Answer the question based on the following context: Randomized clinical trial. This study is evaluates whether the use of a cervical collar after single-level anterior cervical fusion with plating increases the fusion rate and improved clinical outcomes. Plates limit motion between the graft and the vertebra in anterior cervical fusion. Still, the use of cervical collars after instrumented anterior cervical fusion is widely practiced. Patients enrolled in an FDA-regulated, multicenter trial in 32 centers treated with single-level decompression and arthrodesis using allograft and an anterior cervical plate were included in the analysis. Patients were divided into Braced and Nonbraced groups regardless of type of brace. SF-36, Neck Disability Index (NDI), Numerical Rating Scales (0-100) for neck and arm pain were determined before surgery, 1.5, 3, 6, 12, and 24 months after surgery. Fusion was assessed by independent radiologists at 6, 12, and 24 months after surgery using upright AP, lateral, and flexion-extension views. Fusion success was defined as the presence of bridging trabecular bone, angulation of less than or equal 4 degrees on flexion-extension radiographs; and absence of radiolucencies. Two hundred fifty-seven patients were included in the analysis, 149 were braced and 108 were not. Demographic characteristics and baseline outcome measures of both groups were similar. There was also no statistically significant difference in any of the clinical measures at baseline except for SF-36 Physical Component Summary score. The SF-36 Physical Component Summary, NDI, neck, and arm pain scores were similar in both groups at all time intervals and showed statistically significant improvement when compared with preoperative scores. There was no difference in the proportion of patients working at any time point between the Braced and Nonbraced group. Independent radiologists reported higher rates of fusion in the Nonbraced group over all time intervals, none of which were statistically significant.

Question: Use of cervical collar after single-level anterior cervical fusion with plate: is it necessary?

Our results show that the use of a cervical brace does not improve the fusion rate or the clinical outcomes of patients undergoing single-level anterior cervical fusion with plating.

Answer the question based on the following context: The objective of this study was to determine whether a trained rescuer could teach untrained bystanders to perform basic life support (BLS) during a simulated cardiac arrest. Volunteers were recruited from hospital ancillary staff and relatives of patients attending an emergency department. None had previous formal training in BLS. They were asked to perform BLS without instruction on a Laerdal 'Resusi Annie'. An instructor then gave training whilst performing BLS. When volunteers felt competent they performed BLS on their own. A penalty score was used to assess their performance. Fifty-one volunteers completed the study (32 female, 19 male) mean age was 39 years (range 18-67 years). All the 51 volunteers showed an improvement in their penalty score after instruction. The score improved from 86.9 (SD=13.8) to 38.2 (SD=11.8). This decline was statistically significant (paired-sample t-test, P<0.0001).

Question: Can effective basic life support be taught to untrained individuals during a cardiac arrest?

Untrained individuals showed an improvement in BLS skills when taught during a cardiac arrest.

Answer the question based on the following context: In this study, the patients with the diagnosis of RA treated with TNFa inhibitors followed in our hospital were recruited. A protocol was applied including demographic, clinical and laboratory data, in order to calculate DAS 28. The presence/absence of IgM RF and associated therapies were record. Fifty-seven patients, 52 female, with a mean duration of anti-TNFa treatment of 30,9+/-15,9 months were studied. Twenty-four patients were being treated with infliximab, 17 with adalimumab and 16 with etanercept. Forty-one patients had IgM RF detectable in serum (RF positive group). In the RF positive group, the variation of DAS 28 was -1,75 +/- 1,53 vs -1,04 +/- 1,76 in the RF negative group (p=0,135). The mean duration of anti-TNFalpha treatment was similar in both groups (31,9+/-15,9 vs 29,5+/-16,16 months). Patients who were treated with methotrexate presented a higher variation of DAS 28 (-1,87 +/- 1,70 vs -0,80 +/- 1,09; p=0,041) and this variation was dose dependent (p=0,056).

Question: Is the response to anti-TNFalpha treatment influenced by the presence of IgM rheumatoid factor, in Rheumatoid Arthritis patients?

Despite needing a replication in a larger cohort, our results suggest that the presence of IgM RF in the serum did not interfere with the response to treatment with TNFalpha inhibitors.

Answer the question based on the following context: Twelve glass-ceramic blocks (6x6 x4 mm) (Vita VM7) were conditioned with 10% hydrofluoric acid for 1 min, washed and rinsed thoroughly and silanized. The resin cement was applied on the treated-surface and the cement-ceramic sets were sectioned to produce specimens with the bonded areas of about 0.7x0.7 mm (0.5 mm(2)-Gr1), 1x1 mm (1 mm(2)-Gr2), 1.4x1.4 mm (2 mm(2)-Gr3), which were submitted to the microtensile test. The results were affected significantly by bonded surface area (P<0.0001) with the highest mean value (MPa) obtained from Gr1 (26.3+/-8.2a), followed by Gr2 (20.8+/-6.5b) and Gr3 (16.1+/-5.7c) (ANOVA and Tukey's test, alpha=0.05). A negative correlation was found between the bonded surface area and the bond strength results (r=-0.5234; P<0.0001) (Pearson correlation test). Pre-test failures were more common when the bonded surface area was 0.5 mm(2).

Question: Does the bonded cross-sectional surface area affect the microtensile bond strength of resin cement to glass-ceramic?

With the increased bonded surface area, the mean microtensile bond strength of the resin cement to the feldspathic ceramic decreased.

Answer the question based on the following context: We analyzed the approach of Italian centers in looking for ICDVT using the observational MASTER registry which prospectively collected information on patients with acute symptomatic venous thromboembolism. ICDVT was diagnosed in 170 of the 1772 patients with leg DVT (9.6%). The rate of diagnosed ICDVT vs total DVT differed between centers from 0% to 24%. Patients with ICDVT were younger (P<0.0001); diagnosis was more frequently delayed (P<0.0001), temporary risk factors were more frequent, cancer was less frequent (P<0.001), and pulmonary embolism (PE) was more frequent at presentation (P<0.05). More ICDVT patients received LMWH only, not followed by oral anticoagulation (P<0.001).

Question: Do Italian vascular centers look for isolated calf deep vein thrombosis?

The diagnostic strategy for suspected leg DVT differs greatly among Italian centers. A relatively high rate of PE was recorded in patients with ICDVT for reasons which are open to debate. Prospective, well designed studies on the clinical risks and the need for diagnosing ICDVT, and the advantages/disadvantages of the two diagnostic procedures are urgently needed.

Answer the question based on the following context: To investigate the association between calmodulin1 (CALM1) gene or estrogen receptor-alpha (ESR1) polymorphisms and double curve of adolescent idiopathic scoliosis (AIS). 67 double curve patients (30 degrees<Cobb angle<90 degrees ), 100 controls. There were 4 polymorphic loci, rs12885713 (-16C>T) and rs5871 locus in CALM1 gene, rs2234693 (PvuII) and rs9340799 (XbaI) in ESR1 gene analyzed sequence by ABI3730 genetic analyzer. There were 60 patients with Cobb angle>or = 40 degrees . According to the apical location of major curve, there were 40 thoracic curve patients. Furthermore, 1) there are statistical differences on the polymorphic distribution of ESR1 gene rs2234693 site between the double curve, Cobb angle>or = 40 degrees or thoracic curve patients and the controls, respectively (chi(2) = 6.081, 5.554, 6.1935; P = 0.014, 0.0128, 0.0184); 2) between the double curve cases and the controls, there is difference on the polymorphic distribution of rs12885713 site in CALM1 gene (chi(2) = 4.478; P = 0.034); 3) Between the thoracic curve patients and the controls, there is difference on the distribution of rs5871 allele polymorphism in CALM1 gene (chi(2) = 6.6061; P = 0.0102).

Question: Is calmodulin 1 gene/estrogen receptor-alpha gene polymorphisms correlated with double curve pattern of adolescent idiopathic scoliosis?

Double curve patterns might be related to ESR1 gene rs2234693 (PvuII) site polymorphism. It is necessary to clarify the association between the polymorphisms of ESR1 gene and CALM1 gene and different subtypes of adolescent idiopathic scoliosis in the further study.

Answer the question based on the following context: Access to potentially life-saving screening colonoscopy is limited by the high cost of sedation. We explored the practicability of having supervised trainees perform unsedated colonoscopies. A nursing shortage at our Veterans Administration gastroenterology training program necessitated discontinuing sedated colonoscopy. We offered the procedure without sedation to restore local access to screening colonoscopy. From September 2002 to June 2005, 145 of 483 patients accepted the unsedated option. The procedure was done by second-year gastroenterology (GI) fellows who had performed about 100 sedated colonoscopies in their first year of training. Cecal intubation was achieved in 81% of 138 well purged patients without obstructive lesions. Implementation obviated the need for 2 registered nurses, the escort requirement, and postprocedure activity restriction. It also eliminated sedation-related complications.

Question: Unsedated colonoscopy: time to revisit this option?

This report confirms the feasibility of unsedated colonoscopy performed by supervised trainees. The unsedated option minimizes direct and indirect costs of colonoscopy. Describing unsedated screening colonoscopy to patients as a "sedation risk-free" procedure encouraged them to consider the benefits. We recommend that future studies test primary care providers' willingness to inform patients of the feasibility of this nonstandard option, and perhaps reshape the practice of colonoscopy for colorectal cancer screening.

Answer the question based on the following context: To compare whether there are differences among hospital and population controls. Two case-control studies were conducted on lung cancer risk factors in the Santiago de Compostela Public Health District. Whereas one used randomly chosen census-based population controls, the other used consecutive hospital controls that went to the reference hospital for non-smoking-related trivial interventions. The differences were analyzed using logistic regression. The dependent variable was type of control (hospital or population). Hospital controls had a similar tobacco habit than population controls, but consumed more alcohol. For those consuming more than 50 ml daily, the risk of being a hospital control was 4.83 (95%CI: 2.55-9.14).

Question: Population-based versus hospital-based controls: are they comparable?

There may be some differences between hospital and population-based controls, which must be taken into account in the design of case-control studies. It is necessary to ascertain whether such differences are reproduced at other geographic locations and whether they can affect estimation of exposure-disease.

Answer the question based on the following context: Preoperative portal vein embolization (PVE) is increasingly used as a preparation for major hepatectomy in patients with inadequate liver remnant volume or function. However, whether segment 4 (S4) portal veins should be embolized is controversial. The effect of S4 PVE on the volume gain of segments 2 and 3 (S2+3) was examined. Among 73 patients with uninjured liver who underwent right portal vein embolization (RPVE, n = 15) or RPVE extended to S4 portal veins (RPVE+4, n = 58), volume changes in S2+3 and S4 after embolization were compared. Clinical outcomes and PVE complications were assessed. After a median of 27 days, the S2+3 volume increased significantly after both RPVE and RPVE+4, but the absolute increase was significantly higher for RPVE+4 (median, 106 mL vs 141 mL; P = .044), as was the hypertrophy rate (median, 26% vs 54%; P = .021). There was no significant difference between RPVE and RPVE+4 in the absolute S4 volume increase (52 mL for RPVE vs 55 mL for RPVE+4; P = .61) or the hypertrophy rate of S4 (30% for RPVE vs 26% for RPVE+4; P = .45). Complications of PVE occurred in 1 patient (7%) after RPVE and 6 (10%) after RPVE+4 (P>.99). No PVE complication precluded subsequent resection. Curative hepatectomy was performed in 13 patients (87%) after RPVE and 40 (69%) after RPVE+4 (P = .21).

Question: Is embolization of segment 4 portal veins before extended right hepatectomy justified?

RPVE+4 significantly improves S2+3 hypertrophy compared with RPVE alone. Extending RPVE to S4 does not increase PVE-associated complications.

Answer the question based on the following context: Although portal venous tumor thrombus (PVTT) is regarded as an ominous prognostic factor in patients with hepatocellular carcinoma (HCC), the optimal treatment method for maximizing both safety and long-term outcome has not yet been discussed. We describe a surgical technique in which the venous wall is peeled off from the PVTT. In the peeling off (PO) technique, the portal venotomy was placed after adequate vascular control of portal flow. The PVTT was dissected from the portal venous wall and removed through the opening. Macroscopically residual PVTTs intruding into tiny branches were meticulously extracted. This procedure was compared with the en bloc resection of PVTT. Between 1995 and 2006, 49 patients underwent curative hepatic resections for HCC with macroscopic PVTT; these patients were classified according to whether the PO technique (n = 20) or the en bloc technique (n = 29) had been utilized. Both the short- and long-term results were compared between the 2 groups. No mortalities occurred in either group. Both the 5-year overall survival and the recurrence-free survival rates of the PO group were comparable with those of the en bloc group (39% vs 41% [P = .90] and 23% vs 18% [P = .89], respectively). No local recurrences or regrowth of the PVTT occurred in either group.

Question: Is there any difference in survival according to the portal tumor thrombectomy method in patients with hepatocellular carcinoma?

Our procedure is useful for removing PVTT extending beyond the bifurcation or into other sectors that should be preserved in terms of liver function and enables a more conservative resection than an en bloc technique without sacrificing curability.

Answer the question based on the following context: In patients with digestive endocrine tumors (DET) and liver metastases (LM) surgical resection is the only curative treatment. However, 5-year recurrence occurs in 50-80% of patients in the literature. The effect of adjuvant chemotherapy (CT) on relapse-free survival (RFS) and overall survival (OS) is unknown.AIM: To assess the safety and the efficacy of systemic adjuvant CT with streptozotocin and 5-fluorouracil (5-FU) following LM resection in patients with DET. Between 1996 and 2006, 52 consecutive patients (23 males, median age 54 years [21-69]) underwent surgery for LM of well-differentiated DET in our center. The primary tumor was resected. After R0 resection of LM, patients were considered for adjuvant CT if the primary tumor was pancreatic, if LM was>or=10, or if the patient was<50 years old, in patients with other primary tumors. Twenty-nine patients received adjuvant CT and 23 were in the observation group. Adjuvant CT included 4 postoperative courses of i.v. streptozotocin-5-FU (500 and 400 mg/m(2), respectively, daily for 5 days every 42 days). RFS, OS and toxicity were evaluated. Log rank and chi-square analysis were used to identify prognostic factors. Median post-operative follow-up was 47 months (4-162). In the adjuvant CT group, all patients except one received the 4 cycles. Two patients had grade 3-4 toxicity, including 1 febrile neutropenia resulting in death. Recurrence occurred in 43% and 65% of patients in the observation and adjuvant CT groups, respectively. RFS at 3 and 5 years was 51% and 38% in the observation group and 40% and 20% in the adjuvant CT group, respectively (P = .36). In univariate analysis, the significant prognostic factors associated with RFS were the number of LM (>or=10) and synchronous LM. Administration of adjuvant CT was not correlated with RFS. OS at 3 and 5 years was 90% and 76% in the observation group and 96% and 96% in the adjuvant CT group, respectively (P = .58).

Question: Is adjuvant therapy with streptozotocin and 5-fluorouracil useful after resection of liver metastases from digestive endocrine tumors?

RFS in patients receiving adjuvant CT was similar to that reported in the observation group and in historical cohorts without adjuvant CT. Thus, administration of streptozotocin-5-FU cannot be recommended in this indication.

Answer the question based on the following context: Use of illicit drugs results in an increased risk of morbidity and mortality, which is often seen in the Emergency Department (ED). Chest pain is frequently associated with cocaine and methamphetamine use. To determine if the self-report of recent cocaine or methamphetamine use is reliable in illicit stimulant drug users who present to the ED with chest pain. A retrospective review of patients presenting to the ED from July 1, 2004 through June 30, 2006 was undertaken. Inclusion criteria were: age>or= 18 years, chief complaint of chest pain, documented social history of drug abuse, positive urine toxicology screen and myoglobin and troponin levels measured, sent from the ED. For the 318 patients who met the inclusion criteria, the self-report rate of cocaine or methamphetamine use was 51.8% (95% confidence interval [CI] 0.46-0.57). No difference was found in the self-report rate between users of methamphetamine vs. cocaine (odds ratio [OR]1.12, 95% CI 0.7-1.7). There also was no difference in the self-report rate by patient age<50 years compared to patient age>or= 50 years (OR 0.67, 95% CI 0.42-1.08). The self-report rate for males compared to females was not significantly different (OR 0.87, 95% CI 0.54-1.4). Patients who had a positive troponin were not significantly more likely to self-report drug use than patients who did not have a positive troponin (OR 1.1, 95% CI 0.55-2.2).

Question: Is the self-report of recent cocaine or methamphetamine use reliable in illicit stimulant drug users who present to the Emergency Department with chest pain?

The self-report rate among cocaine- or methamphetamine-using patients presenting to the ED with chest pain was 51.8%. There seems to be no significant difference in the self-report rate among those who use methamphetamine vs. those who use cocaine, nor by gender, nor stratified by age over 50 years.

Answer the question based on the following context: To compare the intra- and post- operative morbidities on the use of radiofrequency ultrasonic dissector (US) with the use of laser during tonsillectomy in the same patients. A randomized comparative study was implemented where all patients underwent tonsillectomy at Al-Hada Armed Forces Hospital, Taif, and Aouhod Hospital, Al-Madinah, Kingdom of Saudi Arabia during the period January 2000 to December 2005 were recruited for the study. Radiofrequency US was used in one side, and laser was used in the other side of the same patient. Intra- and post- operative blood losses, and duration of the operation, in addition to postoperative pain score were recorded. Five hundred and twenty-eight patients were recruited for the study. The mean operation duration was significantly shorter in the US group as compared to the laser group (p<0.01). Intraoperative blood loss was significantly lesser in the US group (p<0.001). Post-operative pain score was significantly lower among US subjects (p<0.001). No significant difference in postoperative hemorrhage was detected between the compared groups.

Question: Does the use of radiofrequency ultrasonic dissector in tonsillectomy have a beneficial effect over the use of laser?

The use of US in tonsillectomy showed a beneficial effect on intraoperative blood loss, duration of the operation, as well as, postoperative pain over the use of laser.

Answer the question based on the following context: Enoxaparin is an important molecule which had been using in prophylaxis and treatment of deep venous thrombosis. Also, it is showed that it prevents postsurgical peritoneal adhesions in rats. It is aimed to evaluate its effects on gastrointestinal wound healing. Thirty Wistar albino rats were divided into three groups as control, subcutan, and intraperitoneal enoxaparin groups. Left colon anastomoses were performed. On postoperative seventh day, anastomotic healing was evaluated by measuring anastomotic bursting pressure, tissue hydroxyproline levels, and histopathological examination. The anastomotic bursting pressure was highest in subcutan enoxaparin group (p<0.001), intraperitoneal enoxaparin group (p<0.01) came the second, and the control group has the worst value. The hydroxyproline results were found nearly similar to the bursting pressure values (subcutan (p<0.001)>intraperitoneal (p<0.05)>control). Neovascularization in subcutan group (p<0.001) has a statistically significant difference to other groups.

Question: Does low molecular weight heparin impair anastomotic wound healing?

Enoxaparin did not interfere with colonic anastomotic resistance but improved the intestinal wound healing.

Answer the question based on the following context: During augmentation and Mitrofanoff procedures, conduits are usually implanted into the posterior bladder wall. Anatomical considerations may necessitate an anterior conduit. To compare the relative drainage efficiency in patients with posterior and anterior conduits, we studied their rates of bladder stone formation and urinary tract infection (UTI). A retrospective chart review identified exstrophy patients who underwent augmentation and Mitrofanoff between 1991 and 2003. Patients with 3 years or greater follow-up were included. Fifty-four patients fit this criterion, with a conduit implanted anteriorly (33) or posteriorly (21). We compared rates of bladder stone formation and UTI. Stomal revisions and the status of the bladder neck were also noted. Stone formation and UTI rates were higher in the anterior conduits, although only UTI showed a statistically significant difference. Patient demographics were similar between the two groups, including age and sex. The rates of stomal complications and the bladder neck status were also similar.

Question: Mitrofanoff continent catheterizable conduits: top down or bottom up?

Patients with anterior conduits had an increased risk of UTI and bladder stone formation compared to those with posterior conduits, although this was not significant in the case of bladder stone rate. This may indicate sub-optimal bladder drainage and should be addressed with careful preoperative counseling and close follow-up.

Answer the question based on the following context: Many surgeons are using the ipsilateral rotation of the TRAM flap because of easier flap insetting and improved aesthetic outcomes; however studies evaluating these techniques are limited to case series without groups for comparison. Our purpose was to evaluate the safety of the ipsilateral technique through a retrospective cohort study. We retrospectively evaluated consecutive contralateral and ipsilateral TRAM flaps for mastectomy breast reconstruction. The incidence of ischemia-related flap complications and the incidence of major and minor complications were compared between the two groups. Multiple logistic regression was used to assess the effect of rotation type on complication rates, while controlling for potential confounding variables. Comparing 58 ipsilateral to 32 contralateral pedicle TRAM patients, the rate of a major complication was 20.7% and 28.1%, respectively, p=0.425; a minor complication was 50.0% vs. 34.4%, respectively, p=0.153; and total ischemic-related flap complications were 22.4% and 25.0% respectively, p=0.781. When controlling for potential confounders, the type of pedicle TRAM flap did not have a significant effect on the above complications. Advanced patient age was significantly correlated with an increased incidence of major complications (OR=1.09, p=0.031) and ischemic flap complications (OR=1.11, p=0.016).

Question: Ipsilateral pedicle TRAM flaps for breast reconstruction: are they as safe as contralateral techniques?

The ipsilateral pedicle TRAM flap appears as safe as the contralateral technique for breast reconstruction. Given the increased pedicle length and preservation of both the medial inframammary fold and xiphoid subunit, we believe that the ipsilateral technique is preferred over the contralateral rotation.

Answer the question based on the following context: Subcutaneous phosphatidylcholine (PC) injection has become a popular technique for treating localized fat accumulation. Some clinical studies reported minor local soft tissue complications, such as ecchymosis, edema, and pain. However, there are no data on how PC affects the peripheral nervous tissue. To investigate the local effect of PC on the peripheral nervous tissue of rats. Twenty adult Lewis rats weighing between 200 and 300 g were divided into 2 experimental groups (n=10). In group 1, animals received an intrafascicular injection of 0.1 mL PC (Lipostabil 250 mg/5 mL) with a 30-gauge needle into the left posterior tibial nerve. In group 2, as a negative control group, 0.1 mL normal saline was injected intrafascicularly respectively. After the operation, rats were evaluated on days 7, 14, and 21 with walking track analysis. On day 21, all the animals were sacrificed and the left tibial nerves were taken for histologic study. Light and electron microscopic studies, along with morphometric analysis, were performed. According to the tibial nerve indices, there were no signs of nerve damage observed in either of the groups, and there was no statistical difference between the groups (P>.05). The nerves that received PC and saline injections could not be distinguished grossly and appeared similar to segments of the nerve that did not come in contact with either solution. The number and diameter of fibers, the thickness of the myelin, and the percentage of neural tissue were comparable with normal controls. According to these analyses, there were no statistical differences between the 2 groups (P>.05).

Question: Is phosphatidylcholine harmful to the peripheral neural tissue?

This study demonstrates that in a rat model, even direct intraneural injection of PC causes no damage. This information should encourage people to consider broader applications of PC.

Answer the question based on the following context: To assess the effect of a simulated tackling task on shoulder joint position sense (JPS) in rugby players. The study also aimed to assess if differences in JPS occurred between mid range and end of range JPS, and if the tackling task had angle-specific effects on these values. Repeated measures. University human performance laboratory. Twenty-two asymptomatic professional rugby union players. JPS was assessed using two criterion angles in the 90 degrees shoulder abduction position (45 degrees and 80 degrees external rotation) prior to and following a simulated tackling task. Prior to the tackling task JPS (absolute error scores) was worse at the 45 degrees than 80 degrees criterion angle (p<0.05). Following the tackling task absolute error scores were significantly increased at the 80 degrees angle (p<0.001), with no significant change at the 45 degrees angle (p>0.05), and no significant difference was present for error scores between angles (p=0.74).

Question: Does a tackling task effect shoulder joint position sense in rugby players?

This study found JPS to be significantly reduced following a fatiguing task. But this change was only true for the end of range position, with JPS in the mid range not changing. If the mechanoreceptors are unable to accurately report shoulder position in the outer range (stretch) position due to repetitive tackling, then there is a potential for the anterior structures to become stressed before any compensatory muscle contraction can take place. These results highlight the presence of sensorimotor system deficits following repeated tackling. These deficits are proposed to contribute to overuse injuries and micro-instability of the glenohumeral joint which may be related to the increasing rate of shoulder injuries in rugby.

Answer the question based on the following context: To quantify the uncertainties associated with incorporating diagnostic positron emission tomography/CT (PET/CT) and PET into the radiotherapy treatment-planning process using different image registration tools, including automated and manual rigid body registration methods, as well as deformable image registration. The PET/CTs and treatment-planning CTs from 12 patients were used to evaluate image registration accuracy. The PET/CTs also were used without the contemporaneously acquired CTs to evaluate the registration accuracy of stand-alone PET. Registration accuracy for relevant normal structures was quantified using an overlap index and differences in the center of mass (COM) positions. For tumor volumes, the registration accuracy was measured using COM positions only. Registration accuracy was better with PET/CT than with PET alone. The COM displacements ranged from 3.2 +/- 0.6 mm (mean +/- 95% confidence interval, for brain) to 8.4 +/- 2.6 mm (spinal cord) for registration with PET/CT data, compared with 4.8 +/- 1.7 mm (brain) and 9.9 +/- 3.1 mm (spinal cord) with PET alone. Deformable registration improved accuracy, with minimum and maximum errors of 1.1 +/- 0.8 mm (brain) and 5.4 +/- 1.4 mm (mandible), respectively.

Question: Can positron emission tomography (PET) or PET/Computed Tomography (CT) acquired in a nontreatment position be accurately registered to a head-and-neck radiotherapy planning CT?

It is possible to incorporate PET and/or PET/CT acquired in diagnostic positions into the treatment-planning process through the use of advanced image registration algorithms, but precautions must be taken, particularly when delineating tumor volumes in the neck. Acquisition of PET/CT in the treatment-planning position would be the ideal method to minimize registration errors.

Answer the question based on the following context: To investigate risk factors and prognostic significance of postembolization fever (PEF)--a temperature of more than 38.0 degrees C--after chemoembolization in patients with hepatocellular carcinoma (HCC). The authors retrospectively analyzed data from 442 patients with unresectable HCC who underwent their first session of chemoembolization without other procedure-related complications except postembolization syndrome between January 2005 and December 2006. Of the 442 patients, 362 (81.9%) were men and 80 (18.1%) were women; patients ranged in age from 28 to 86 years (median, 61 years). PEF after chemoembolization developed in 91 patients (20.6%). Occurrence of PEF was closely associated with several clinical-laboratorial variables, although not with response to chemoembolization. With use of logistic regression analysis, however, a tumor size larger than 5 cm was the only independent factor related to PEF development (odds ratio, 8.192; 95% confidence interval [CI]: 3.641, 18.435; P<.001). Although PEF was not an independent predictor of progression-free survival, it significantly increased the risk of death by about 1.4-fold, in correlation with overall survival (hazard ratio, 1.378; 95% CI: 1.003, 1.893; P = .048).

Question: Does postembolization fever after chemoembolization have prognostic significance for survival in patients with unresectable hepatocellular carcinoma?

PEF after chemoembolization in patients with HCC was strongly correlated with large tumor size and was a significant independent predictor of overall survival.

Answer the question based on the following context: This study evaluated whether changes in the electromygraphic (EMG) pattern during rapid point-to-point movements in individuals diagnosed with PD can: (1) distinguish PD subjects from healthy subjects and (2) determine if differences in the EMG pattern reflect disease severity in PD. Three groups of 10 PD subjects and 10 age/sex-matched healthy subjects performed rapid 72 degree point-to-point elbow flexion movements. PD subjects were divided, a priori, into three groups based upon off medication motor UPDRS score. Measures related to the EMG pattern distinguished all PD subjects and 9 out of 10 healthy subjects, resulting in 100% sensitivity. Further, significant correlations were shown between EMG measures and the motor UPDRS score. After 30 months, the one healthy subject whose EMG pattern was abnormal was reexamined. The EMG measures remained abnormal and the motor UPDRS score went from 0 to 10. Parkinson's disease was diagnosed.

Question: Variability of EMG patterns: a potential neurophysiological marker of Parkinson's disease?

Measures related to the variability of the EMG pattern during rapid point-to-point movements provide neurophysiological measures that objectively distinguish PD subjects from healthy subjects. These measures also correlate with disease severity.

Answer the question based on the following context: A publication on behalf of the European Society of Urological Oncology questioned the need for removing the seminal vesicles during radical prostatectomy in patients with prostate specific antigen less than 10 ng/ml except when biopsy Gleason score is greater than 6 or there are greater than 50% positive biopsy cores. We applied the European Society of Urological Oncology algorithm to an independent data set to determine its predictive value. Data on 1,406 men who underwent radical prostatectomy and seminal vesicle removal between 1998 and 2004 were analyzed. Patients with and without seminal vesicle invasion were classified as positive or negative according to the European Society of Urological Oncology algorithm. Of 90 cases with seminal vesicle invasion 81 (6.4%) were positive for 90% sensitivity, while 656 of 1,316 without seminal vesicle invasion were negative for 50% specificity. The negative predictive value was 98.6%. In decision analytic terms if the loss in health when seminal vesicles are invaded and not completely removed is considered at least 75 times greater than when removing them unnecessarily, the algorithm proposed by the European Society of Urological Oncology should not be used.

Question: Is it necessary to remove the seminal vesicles completely at radical prostatectomy?

Whether to use the European Society of Urological Oncology algorithm depends not only on its accuracy, but also on the relative clinical consequences of false-positive and false-negative results. Our threshold of 75 is an intermediate value that is difficult to interpret, given uncertainties about the benefit of seminal vesicle sparing and harm associated with untreated seminal vesicle invasion. We recommend more formal decision analysis to determine the clinical value of the European Society of Urological Oncology algorithm.

Answer the question based on the following context: We investigated routinely the bile ducts by magnetic resonance cholangiopancreaticography (MRCP) prior to cholecystectomy. The aim of this study was to analyze the rate of clinically inapparent common bile duct (CBD) stones, the predictive value of elevated liver enzymes for CBD stones, and the influence of the radiological results on the perioperative management. In this prospective study, 465 patients were cholecystectomized within 18 months, mainly laparoscopically. Preoperative MRCP was performed in 454 patients. With MRCP screening, clinically silent CBD stones were found in 4%. Elevated liver enzymes have only a poor predictive value for the presence of CBD stones (positive predictive value, 21%; negative predictive value, 96%). Compared to the recent literature, the postoperative morbidity in this study was low (0 bile duct injury, 0.4% residual gallstones).

Question: Is routine MR cholangiopancreatography (MRCP) justified prior to cholecystectomy?

Although MRCP is diagnostically useful in the perioperative management in some cases, its routine use in the DRG-era may not be justified due to the costs.

Answer the question based on the following context: Elderly and younger patients who were successfully resuscitated and hospitalized following out-of-hospital cardiac arrest were studied to determine if there was a significant difference in hospital course and long-term survival between the two groups. The study consisted of 214 consecutive patients, divided into two age groups: elderly (more than 70 years, n = 112) and younger (less than 70 years, n = 102). Hospital charts and paramedic run data were retrospectively reviewed for each patient and findings were compared between the two age groups. Prior to cardiac arrest, 47 of 112 (42 percent) elderly patients had a history of heart failure, compared with 19 of 102 (18 percent) younger patients, and were more commonly taking digitalis (51 percent versus 29 percent) and diuretics (47 percent versus 26 percent). Younger patients, however, more often had an acute myocardial infarction at the time of the cardiac arrest (33 percent versus 16 percent). At the time of cardiac arrest, 83 percent of younger patients demonstrated ventricular fibrillation, compared with 71 percent of the elderly. In contrast, electromechanical dissociation was five times more common in the elderly patients. Although hospital deaths were more common in the elderly (71 percent versus 53 percent), the length of hospitalization and stay in intensive care units were not significantly different between the age groups. The number of neurologic deaths was similar in both age groups, as were residual neurologic impairments. Only five elderly patients and six younger patients required placement in extended-care facilities. Calculated long-term survival curves demonstrated similar survival in both age groups, with approximately 65 percent of hospital survivors alive at 24 months after hospital discharge.

Question: Should the elderly be resuscitated following out-of-hospital cardiac arrest?

Resuscitation of elderly patients in whom out-of-hospital cardiac arrest occurs is reasonable and appropriate, according to the findings of this study. Even though elderly patients are more likely than younger patients to die during hospitalization, the hospital stay of the elderly is not longer, the elderly do not have more residual neurologic impairments, and survival after hospital discharge is similar to that in younger patients.

Answer the question based on the following context: Infectious endocarditis (IE) is a bacterial infection of the endocardium. Diagnosis is based on results obtained from echocardiography, blood cultures, and molecular genetic screening for bacteria and on data for inflammatory markers such as the leukocyte (WBC) count and the C-reactive protein (CRP) concentration. The aim of the present study was to evaluate lipopolysaccharide-binding protein (LBP) as a supportive biomarker for the diagnosis and therapeutic monitoring of IE. We measured LBP and CRP concentrations and WBC counts in 57 IE patients at hospital admission, 40 patients with noninfectious heart valve diseases (HVDs), and 55 healthy blood donors. The progression of these 3 markers and the influence of cardiac surgery on them were evaluated in 29 IE patients and 21 control patients. Serum LBP concentrations were significantly higher in IE patients [mean (SD), 33.41 (32.10) mg/L] compared with HVD patients [6.67 (1.82) mg/L, P<0.0001] and healthy control individuals [5.61 (1.20) mg/L]. The progression in the LBP concentration during therapy of IE patients correlated with the changes in the CRP concentration. The 2 markers were equally influenced by antibiotic treatment and surgical intervention.

Question: Lipopolysaccharide-binding protein: a new biomarker for infectious endocarditis?

Serial LBP measurement may provide an effective and useful tool for evaluating the response to therapy in IE patients. We found a strong correlation between LBP and CRP concentrations; LBP has a tendency to increase earlier in cases of reinfection.

Answer the question based on the following context: Intensive insulin therapy (IIT) is the standard of care in the ICU, but precise implementation of insulin protocols has been difficult in clinical practice. The authors' objective was to quantify adherence to an IIT protocol in a practice setting, and to describe how adherence impacts overall blood glucose (BG) control. A retrospective analysis of a cohort of critically ill patients treated with IIT was performed. Protocol adherence was evaluated by assessing the timing of BG measurements. Each measurement was categorized according to the time from the previous reading: early (<1 hour), on time (1-3 hours), and late (>3 hours). Outcome measures included mean and median BG for each time category as well as the proportion of values within the target range. In 1106 trauma and surgical ICU patients, 54,139 measurements were available for analysis. The overall mean BG (116 mg/dL) was near the target (80-110 mg/dL), but only 46% of values were within this range. There were 45,806 (86%) measurements on time, 2749 (5%) early, and 4478 (9%) were late. BG values of late measurements were less likely to be within range (34% vs 46% for on time measurements, P<.001). Of late measurements, 19% were>200 mg/dL, 13% were 150-200 mg/dL, and 16% were<60 mg/dL.

Question: Intensive insulin therapy in practice: can we do it?

IIT is difficult to implement precisely in a complex ICU environment. Measurement timing impacts overall BG control, with late measurements more often associated with severe hyperglycemic (BG>150 mg/dL) and hypoglycemic (BG<60 mg/dL) episodes.

Answer the question based on the following context: There are more than 3,500 new cases of oral cancer each year in the UK. The purpose of this study was to establish the proportion of patients attending a dental access centre that are at risk of developing oral cancer because of lifestyle habits, and in turn determine whether access centres are a suitable location for the provision of advice on smoking cessation and alcohol consumption. Data were collected prospectively about the smoking and drinking habits of patients attending a dental access centre in Nottingham. Three hundred and fifty-nine patients attended the dental access centre during the survey period. Patients were categorised into one of four groups ranging from low risk to high risk, according to their smoking history and alcohol intake. More than 50% of patients attending the dental access centre were smokers, with almost 40% of the patients in high or very high tobacco and alcohol use groups. The majority of attendees were under 45 years of age.

Question: Is there scope for providing oral cancer health advice in dental access centres?

Significant numbers of patients attending the dental access centre have lifestyle habits that make them vulnerable to oral cancer. Dental access centres could usefully provide opportunistic health messages to patients about risk factors in the development of oral cancer.

Answer the question based on the following context: This case-control study was conducted from January 2005 to December 2006 at the antenatal clinics of the Department of Obstetrics and Gynecology, Aga Khan University, Karachi, Pakistan. The sample included 137 infertile women with PCOS; of these, 105 conceived while taking metformin (cases), while 32 conceived spontaneously without metformin (controls). Outcomes were measured in three groups of cases which were formed according to the duration of use of metformin during pregnancy. Comparison was made between these groups and women with PCOS who conceived spontaneously. All 137 women in this study had a confirmed diagnosis of PCOS (Rotterdam criteria). These women were followed up during their course of pregnancy; data forms were completed once they had delivered. Cases were divided into three groups: group A, 40 women who stopped metformin between 4-16 weeks of pregnancy; group B, 20 women who received metformin up until 32 weeks of gestation; and group C; 45 women who continued metformin throughout pregnancy. All the groups were matched by age, height and weight. Comparison was in terms of early and late pregnancy complications, intrauterine growth restriction and live birth rates. In groups A, B and C the rate of pregnancy-induced hypertension/pre-eclampsia was 43.7%, 33% and 13.9% respectively (P<0.020). Rates of gestational diabetes requiring insulin treatment in groups A and B were 18.7% and 33.3% compared to 2.5% in group C (P<0.004). The rate of intrauterine growth restriction was significantly low in group C: 2.5% compared to 19.2% and 16.6% in groups A and B respectively (P<0.046). Frequency of preterm labor and live birth rate was significantly better in group C compared to groups A and B. Overall rate of miscarriages was 7.8%. Controls were comparable to group A in terms of early and late pregnancy complications.

Question: Does continuous use of metformin throughout pregnancy improve pregnancy outcomes in women with polycystic ovarian syndrome?

In women with PCOS, continuous use of metformin during pregnancy significantly reduced the rate of miscarriage, gestational diabetes requiring insulin treatment and fetal growth restriction. No congenital anomaly, intrauterine death or stillbirth was reported in this study.

Answer the question based on the following context: The use of human embryonic stem cells (hESCs) in research is increasing and hESCs hold the promise for many biological, clinical and toxicological studies. Human ESCs are expected to be chromosomally stable since karyotypic changes represent a pitfall for potential future applications. Recently, several studies have analysed the genomic stability of several hESC lines maintained after prolonged in vitro culture but controversial data has been reported. Here, we prompted to compare the chromosomal stability of three hESC lines maintained in the same laboratory using identical culture conditions and passaging methods. Molecular cytogenetic analyses performed in three different hESC lines maintained in parallel in identical culture conditions revealed significant differences among them in regard to their chromosomal integrity. In feeders, the HS181, SHEF-1 and SHEF-3 hESC lines were chromosomally stable up to 185 passages using either mechanical or enzymatic dissection methods. Despite the three hESC lines were maintained under identical conditions, each hESC line behaved differently upon being transferred to a feeder-free culture system. The two younger hESC lines, HS181 (71 passages) and SHEF-3 (51 passages) became chromosomally unstable shortly after being cultured in feeder-free conditions. The HS181 line gained a chromosome 12 by passage 17 and a marker by passage 21, characterized as a gain of chromosome 20 by SKY. Importantly, the mosaicism for trisomy 12 gradually increased up to 89% by passage 30, suggesting that this karyotypic abnormality provides a selective advantage. Similarly, the SHEF-3 line also acquired a trisomy of chromosome 14 as early as passage 10. However, this karyotypic aberration did not confer selective advantage to the genetically abnormal cells within the bulk culture and the level of mosaicism for the trisomy 14 remained overtime between 15%-36%. Strikingly, however, a much older hESC line, SHEF-1, which was maintained for 185 passages in feeders did not undergo any numerical or structural chromosomal change after 30 passages in feeder-free culture and over 215 passages in total.

Question: Human ESCs predisposition to karyotypic instability: Is a matter of culture adaptation or differential vulnerability among hESC lines due to inherent properties?

These results support the concept that feeder-free conditions may partially contribute to hESC chromosomal changes but also confirm the hypothesis that regardless of the culture conditions, culture duration or splitting methods, some hESC lines are inherently more prone than others to karyotypic instability.

Answer the question based on the following context: Part-time working is a growing phenomenon in medicine, which is expected to influence informal networks at work differently compared to full-time working. The opportunity to meet and build up social capital at work has offered a basis for theoretical arguments. Twenty-eight teams of medical specialists in the Netherlands, including 226 individuals participated in this study. Interviews with team representatives and individual questionnaires were used. Data were gathered on three types of networks: relationships of consulting, communication and trust. For analyses, network and multilevel applications were used. Differences between individual doctors and between teams were both analysed, taking the dependency structure of the data into account, because networks of individual doctors are not independent. Teams were divided into teams with and without doctors working part-time. Contrary to expectations we found no impact of part-time working on the size of personal networks, neither at the individual nor at the team level. The same was found regarding efficient reachability. Whereas we expected part-time doctors to choose their relations as efficiently as possible, we even found the opposite in intended relationships of trust, implying that efficiency in reaching each other was higher for full-time doctors. But we found as expected that in mixed teams with part-time doctors the frequency of regular communication was less compared to full-time teams. Furthermore, as expected the strength of the intended relationships of trust of part-time and full-time doctors was equally high.

Question: Is networking different with doctors working part-time?

From these findings we can conclude that part-time doctors are not aiming at efficiency by limiting the size of networks or by efficient reachability, because they want to contact their colleagues directly in order to prevent from communication errors. On the other hand, together with the growth of teams, we found this strategy, focussed on reaching all colleagues, was diminishing. And our data confirmed that formalisation was increasing together with the growth of teams.

Answer the question based on the following context: Bladder catheterization is a common practice after several surgical procedures; a wrong trans-urethral catheter position can affect the outcomes of some urological maneuvers. We assess with a physical model the variation of intra-vesical pressures due to different locations of the catheter. Using a plastic bag fulfilled with 5l of normal saline, we try to reproduce bladder condition assessing pressures in case of catheter located over or under the thigh. In case of catheter over the thigh, the flow of liquid is not allowed, and only a pressure of 23 cm of water induces the passage of fluid.

Question: Urological concerns: Should trans-urethral catheter be located over or under the thigh?

A wrong catheter position may adversely affect intravesical pressures; this finding has to be taken into consideration, especially when dealing with post-urological surgery catheterization.

Answer the question based on the following context: Physician compliance with hand hygiene guidelines often has been reported as insufficient. The study was conducted in 2 hospitals (Hadassah Ein Kerem [EK] and Mt Scopus [MS]) in Jerusalem, Israel. Covert observations were conducted during morning rounds by trained observers. The data were recorded as the percentage of times that hand hygiene was applied out of the total contacts with patients. After the observational step, an intervention-providing an alcohol gel and encouraging its use-was instituted in several wards. Physicians' compliance with hand hygiene averaged 77% at MS and 33% at EK (P<.001), and was characterized by a marked additional heterogeneity among wards. Rates of adherence ranged from as low as 4% in a gynecology ward to as high as 96% in a neonatal unit. Availability of a handwashing basin in the room and seniority status of the physician were associated with higher compliance rates but explained only a small part of the variation. Compliance improved significantly in 2 wards exposed to the intervention.

Question: Hand hygiene compliance by physicians: marked heterogeneity due to local culture?

The remarkable heterogeneity in physicians' hand hygiene compliance among sites within the same institution is consistent with an important role of the local ward culture.

Answer the question based on the following context: To evaluate the effectiveness of a program to increase walking to and from school. A cluster randomised controlled trial. 24 primary public schools in inner west Sydney, Australia. 1996 students aged 10-12 years and their parents. A two-year multi-component program included classroom activities, development of school Travel Access Guides, parent newsletters and improving environments with local councils. Two measures were used: a survey completed by students on how they travelled to and from school over five days, and a survey completed by their parents on how their child travelled to and from school in a usual week. The percentage of students who walked to and from school increased in both the intervention and control schools. Data from parent surveys found that 28.8% of students in the intervention group increased their walking, compared with 19% in the control group (a net increase of 9.8%, p=0.05). However this effect was not evident in the student data.

Question: Increasing active travel to school: are we on the right track?

The study produced a mixed result, with a high variation in travel patterns from school to school. Intervention research should address the complexity of multiple factors influencing student travel to school with a focus on changing local environments and parents' travel to work.

Answer the question based on the following context: To assess the frequency and recognition of abnormal nutritional status and elevated admitting blood pressure (BP) in hospitalized children. From children aged 3 to 18 years who were hospitalized during 4 months of 2005 (n = 1143), a stratified sample of paper-based medical records were reviewed for demographics, anthropometric and BP measurements and interpretations, care related to nutrition and BP, and discharge diagnoses. Records of 317 of 337 (94%) selected patients were reviewed, and data from 277 of these patients (records with weight and height documented) were analyzed. US references were applied to assign body mass index and BP percentiles. Data were weighted to account for sampling. A total of 51% of subjects were Medicaid/self-pay, with a median age of 9.1 years; and 20% of subjects were obese (14% overweight, 58% healthy weight, 8% underweight). Body mass index was plotted/calculated for 35% of subjects. Six percent of subjects had BP>99th percentile + 5 mm Hg (18% BP 95th to<or =99th percentile + 5 mm Hg). A nutrition referral was documented for 61% of subjects who were underweight and 39% of subjects who were obese. BP concerns were documented for 26% of subjects with BP>99th percentile + 5 mm Hg.

Question: Do hospitalized pediatric patients have weight and blood pressure concerns identified?

Many pediatric inpatients had abnormal nutritional status or elevated BP. Systems to improve interpretation of these measures, which are commonly obtained in pediatric hospital settings, are needed.

Answer the question based on the following context: To test the Mayo Clinic Quadratic (MCQ) equation against isotopic glomerular filtration rate, compared with the Modification of Diet in Renal Disease (MDRD) and the Cockcroft-Gault formulas, in type 2 diabetes. Based on values obtained with iothalamate, 118 type 2 diabetic patients were divided into three groups according to renal function: hyperfiltration (26), normal function (56), or chronic kidney disease (CKD) stages 3-4 (36). ANOVA, the Bland-Altman procedure, and Lins coefficient (Rc) were performed to study accuracy. In the hyperfiltration and normal function groups, all prediction equations significantly underestimated the value obtained with isotopic glomerular filtration rate (P<0.05). In the CKD group, all equations also presented significant differences with the isotopic method. However, MDRD had a bias of -5.3 (Rc 0.452), Cockcroft-Gault formula -0.2 (Rc 0.471), and the MCQ -4.5 (Rc 0.526).

Question: Is the new Mayo Clinic Quadratic equation useful for the estimation of glomerular filtration rate in type 2 diabetic patients?

The MCQ and prediction equations proved inaccurate (excessive underestimation) in type 2 diabetic patients with hyperfiltration or normal renal function. With regard to CKD, the results obtained provided no evidence of superiority of the MCQ over the MDRD or the Cockcroft-Gault formula.

Answer the question based on the following context: To estimate the incidence of dog bites in the USA and compare it with similar estimates from 1994. Nationally representative cross-sectional, list-assisted, random-digit-dialed telephone survey conducted during 2001-2003. Weighted estimates were generated from data collected by surveying 9684 households during 2001-2003 and compared with results from a similar survey conducted in 1994. Estimates for persons aged 15-17 years were extrapolated on the basis of rates for 10-14-year-olds. Whereas the incidence of dog bites among adults remained relatively unchanged, there was a significant (47%) decline in the incidence of dog bites among children compared with that observed in the 1994 survey, particularly among boys and among those aged 0-4 years. Between 2001 and 2003, an estimated 4 521 300 persons were bitten each year. Of these, 885 000 required medical attention (19%). Children were more likely than adults to receive medical attention for a dog bite. Among adults, bite rates decreased with increasing age. Among children and adults, having a dog in the household was associated with a significantly increased incidence of dog bites, with increasing incidence also related to increasing numbers of dogs.

Question: Dog bites: still a problem?

Dog bites continue to be a public health problem affecting 1.5% of the US population annually. Although comparison with similar data from 1994 suggests that bite rates for children are decreasing, there still appears to be a need for effective prevention programs.

Answer the question based on the following context: To examine ethnic variations in trends in road traffic injuries in London. Analysis of STATS19 data comparing trends in road traffic casualty rates by ethnic group. London, 2001-6. Children (<or=14 years) and adults (>or=15 years). Annual casualty rates in white, black, and Asian pedestrians, cyclists, and car occupants. Casualty rates in London declined each year between 2001 and 2006 by an average of 8.8% (95% CI 8.5% to 9.0%). After adjustment for area-level deprivation, there was good evidence that the average annual reduction in injury rates in car occupants was significantly less in Asian than in white adults (10.9% vs 14.4%, p<0.001). There was some evidence that average annual reductions in injury rates were lower in black than in white adult pedestrians (7.4% vs 9.3%, p = 0.041) and car occupants (13.2% vs 14.4%, p = 0.03).

Question: Does the decline in road traffic injury in London vary by ethnicity?

Casualty rates in London have declined for pedestrians, cyclists, and car occupants in three broad ethnic groups. Asian car drivers appear to have benefited least from these reductions.

Answer the question based on the following context: Palliative operative resection in patients with locally advanced cancer of the gallbladder (GBC) found not to be amenable to radical resection for cure at exploration has received little attention. This article evaluates the benefits, if any, of cholecystectomy with biliary drainage in such patients. Available records of locally advanced but nonmetastatic GBC patients treated in the Department of Surgical Oncology, B.H.U., Varanasi, India, during the last 8 years were retrospectively reviewed. Of these, 30 patients (group I) with GBC (T(3-4),N(0-1),M(0)) treated with cholecystectomy +/- biliary bypass were selected and compared with equal number of controls matched for age (+/-5 years), sex, histopathology, stage, residence, and postoperative chemotherapy who underwent biopsy +/- biliary bypass only (group II) followed by chemotherapy during the same period. Survival rates were calculated by using Kaplan-Meier curves. Follow-up ranged from 1-15 months. The median survival was 7 and 2 months for groups I and II (P<0.0001), respectively. The 30-day postoperative mortality and morbidity was 3% vs. 12% and 13% vs. 16% in groups I and II, respectively.

Question: Is there a role for cholecystectomy in gallbladder carcinoma discovered to be unresectable for cure at laparotomy?

Results suggest that a better median survival can be achieved after cholecystectomy in locally advanced unresectable GBC compared with only bypass and biopsy procedures. These findings may justify a palliative cholecystectomy in selected patients with locally advanced GBC.

Answer the question based on the following context: Supernumerary nipples (SNN), or polythelia, are the most common form of the accessory mammary tissue malformation. The frequency of this condition ranges from 0.2% to 5.6% depending on various factors. This condition is associated with several anomalies, although this association is often controversial. The aim of this study was to evaluate the association between SNN and kidney/urinary tract (K/UT) anomalies, where anomalies is taken to mean functional disorders, malformations and diseases. A case-control study was performed. The study evaluated 166 children (case group) referred to the Pediatric Nephrology Unit of the Department of Pediatrics of the Catholic University of Rome and 182 children (control group) admitted to the Department of Pediatrics because of pathologies not involving the urinary tract. There were 11 children with SNN in the case group, and only two patients in the control group (6.62% vs 1.09%, p<0.05).

Question: Polythelia: still a marker of urinary tract anomalies in children?

The results show a high incidence of K/UT anomalies in children with SNN, and therefore K/UT should be investigated in this specific population.

Answer the question based on the following context: To obtain prevalence estimates of seat belt use among adults with and without at least one child in the household and to examine whether having at least one child in the household is associated with adult seat belt use. The Second Injury Control and Risk Survey (ICARIS-2) was a nationwide cross-sectional, list-assisted random-digit-dialing telephone survey of individuals who were at least 18 years old and who spoke either English or Spanish. ICARIS-2 was carried out from 2001 to 2003; a similar study, ICARIS-1, had been conducted in 1994. National estimates were calculated for the prevalence of adult seat belt use and stratified according to the presence or absence of children in the household. Prevalence estimates for the two ICARIS surveys were compared using t-tests. Multivariable logistic regression was used to explore the association between having at least one child in the household and self-reported adult seat belt use. Based on the 9,684 completed household interviews in ICARIS-2, an estimated 15.9% (13 million) of drivers with children in their households did not always wear their seat belt when driving, and 17.5% (15 million) of adult passengers with children in their households did not always wear their seat belt while riding. The prevalence of drivers and passengers who did not always wear their seat belt decreased between ICARIS-1 and ICARIS-2. Both driver and passenger seat belt use were associated with the respondent's age, sex, ethnicity, level of education, current marital status, and self-reported alcohol-impaired driving or riding with an alcohol-impaired driver. Drivers with children in the household, living in the Northeast, North Central, and Southern census regions of the country were significantly more likely than those in the West to report wearing their seat belt less than always.

Question: Adult seat belt use: does the presence of children in the household make a difference?

While seat belt use rates are increasing, many more lives could be saved by more complete restraint use. Effective strategies for increasing seat belt use rates and decreasing the number of both fatal and nonfatal motor vehicle injuries include primary enforcement laws, enhanced enforcement of seat belt use laws, and child safety-seat distribution combined with education programs.

Answer the question based on the following context: A study was conducted to verify if there is an association between occupational noise exposure, noise-induced hearing loss and driving safety expanding on previous findings by Picard, et al. (2008) that the two factors did increase accident risk in the workplace. This study was made possible when driving records of all Quebec drivers were made available by the Societe de l'assurance automobile du Quebec (SAAQ is the state monopoly responsible for the provision of motor vehicle insurance and the compensation of victims of traffic accidents). These records were linked with personal records maintained by the Quebec National Institute of Public Health as part of its mission to prevent noise induced hearing loss in the workplace. Individualized information on occupational noise exposure and hearing sensitivity was available for 46,030 male workers employed in noisy industries who also held a valid driver's permit. The observation period is of five years duration, starting with the most recent audiometric examination. The associations between occupational noise exposure levels, hearing status, and personal driving record were examined by log-binomial regression on data adjusted for age and duration of exposure. Daily noise exposures and bilateral average hearing threshold levels at 3, 4, and 6 kHz were used as independent variables while the dependent variables were 1) the number of motor vehicle accidents experienced by participants during the study period and 2) participants' records of registered traffic violations of the highway safety code. The findings are reported as prevalence ratios (PRs) with their 95% confidence intervals (CIs). Attributable numbers of events were computed with the relevant PRs, lesser-noise, exposed workers and those with normal hearing levels making the group of reference. Adjusting for age confirmed that experienced workers had fewer traffic accidents. The data show that occupational noise exposure and hearing loss have the same effect on driving safety record than that reported on the risk of accident in noisy industrial settings. Specifically, the risk of traffic accident (PR = 1.07 (CI 95% [1.01; 1.15]) is significantly associated with the daily occupational noise exposures>or= 100 dBA. For participants having a bilateral average hearing loss ranging from 16 to 30 dB, the PR of traffic accident is 1.06 (CI 95% [1.01; 1.11]) and reaches 1.31 (CI 95% [1.2; 1.42]) when the hearing loss exceeds of 50 dB. A reduction in the number of speeding violations occurred among workers occupationally exposed to noise levels>or= 90 dBA and those with noise-induced hearing loss>or=16 dB. By contrast, the same individuals had an increase in other violations of the Highway safety code. This suggests that noise-exposed workers might be less vigilant to other traffic hazards.

Question: Could driving safety be compromised by noise exposure at work and noise-induced hearing loss?

Daily occupational noise exposures>or= 100 dBA and noise-induced hearing losses-even when just barely noticeable-may interfere with the safe operation of motor vehicles.