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Answer the question based on the following context: The reliability of clinical judgment for the tapering of glucocorticoids in patients with active inflammatory bowel disease has been questioned. The current study compared decision-making strategies on the basis of a combination of disease indices and serum concentrations of orosomucoid (strategy A) and disease indices only (strategy B) for the tapering of prednisolone. Twenty-nine patients with clinically active ulcerative colitis and 59 patients with Crohn's disease and increased concentrations of S-orosomucoid participated. The initial dose of prednisolone was 40 or 75 mg, which was tapered off over a minimum of 6 or 8 weeks. The tapering schedule was completed in 11 of 44 (25%) patients treated in accordance with strategy A, whereas 28 of 44 patients (64%) and prednisolone completely tapered, in accordance with strategy B. At follow-up 4 of 11 patients (36%) and 17 of 28 patients (61%) treated in accordance with strategies A and B, respectively, had clinical relapse (0.10>P>0.05). By means of multiple regression analysis a high serum concentration of orosomucoid and previous disease activity were identified as predictors of relapse.

Question: Serum concentrations of orosomucoid: improved decision-making for tapering prednisolone therapy in patients with active inflammatory bowel disease?

A therapeutic end-point of normalization of an increased level of S-orosomucoid in addition to clinical remission may be difficult to use, as serum concentrations may be continuously increased in spite of clinical remission. However, this goal may still be relevant, as a trend towards higher risk of relapse was found in patients with increased orosomucoid concentrations after completing therapy.

Answer the question based on the following context: Currently, surgery- and catheter-mediated ablation is applied when drug refractoriness of atrial fibrillation is evident, although little is known about the long-term incidence of new atrial arrhythmia and the preservation of sinus node function. To address this issue, 30 patients with successful corridor surgery for lone paroxysmal atrial fibrillation and normal preoperative sinus node function were followed in a single outpatient department. Five years after surgery, the actuarial proportion of patients with recurrence of atrial fibrillation arising in the corridor was 8% +/- 5%, with new atrial arrhythmias consisting of atrial flutter and atrial tachycardia in the corridor 27% +/- 8%, and with incompetent sinus node requiring pacing therapy 13% +/- 6%. Right atrial transport was preserved in 69% of the patients without recurrence of atrial fibrillation and normal sinus node function. Stroke was documented in two patients.

Question: Long-term follow-up of corridor operation for lone atrial fibrillation: evidence for progression of disease?

Corridor surgery for atrial fibrillation is a transient or palliative treatment instead of a definitive therapy for drug refractory atrial fibrillation. This observation strongly affects patient selection for this intervention and constitutes a word of caution for other, nonpharmacologic interventions for drug refractory atrial fibrillation.

Answer the question based on the following context: Suicide mortality among medical practitioners is in many countries significantly higher compared with other professionals and the general population. Differences between male and female physicians are difficult to estimate reliably because previous comparisons are mainly based on crude mortality rates. Age-specific mortality rates were calculated for physicians, other professionals and the general population, males and females separately, as well as standardized mortality ratios (SMR) comparing physicians with the other groups. Crude mortality rates were calculated for the specialist groups. The SMR for male (female) physicians was 0.9 (2.4) compared with the general male (female) population and 2.4 (3.7) compared with other male (female) professionals. The SMR between male and female physicians was 1.2 (95% CI 0.9-1.7).

Question: Suicide mortality among medical doctors in Finland: are females more prone to suicide than their male colleagues?

Our results do not support the claim that female physicians have a greater risk of suicide than their male colleagues, but are concordant with previous observations of a higher suicide rate in female physicians compared with the general population and other female professionals.

Answer the question based on the following context: The health care market is demanding increasing amounts of information regarding quality of care in health plans. Physicians are a potentially important but infrequently used source of such information. To assess physicians' views on health plan practices that promote or impede delivery of high-quality care in health plans and to compare ratings between plans. Minneapolis-St Paul, Minn. One hundred physicians in each of 3 health plans. Each physician rated 1 health plan. Likert-type items that assessed health plan practices that promote or impede delivery of high-quality care. A total of 249 physicians (84%) completed the survey. Fewer than 20% of all physicians gave plans the highest rating (excellent or strongly agree) for health plan practices that promote delivery of high-quality care (such as providing continuing medical education for physicians, identifying patients needing preventive care, and providing physicians feedback about practice patterns). Barriers to delivering high-quality care related to sufficiency of time to spend with patients, covered benefits and copayment structure, and utilization management practices. Ratings differed across health plans. For example, the percentage of physicians indicating that they would recommend the plan they rated to their own family was 64% for plan 1, 92% for plan 2, and 24% for plan 3 (P<.001 for all comparisons).

Question: Are all health plans created equal?

Physician surveys can highlight strengths and weaknesses in health plans, and their ratings differ across plans. Physician ratings of health plan practices that promote or impede delivery of high-quality care may be useful to consumers and purchasers of health care as a tool to evaluate health plans and promote quality improvement.

Answer the question based on the following context: A decrease in the estimated relative risk of cerebrovascular and cardiovascular diseases associated with known disease risk factors has been observed among elderly cohorts, perhaps suggesting that continued risk factor management in the elderly may not be as efficacious as with younger age groups. In this paper, the differential magnitude of the association of risk factors with atherosclerosis across the age spectrum from 45 years to older than 75 years is presented. Subclinical atherosclerosis as measured by carotid ultrasonography and risk factor prevalence were assessed using similar methods among participants aged 45 to 64 years in the Atherosclerosis Risk in Communities (ARIC) study and among participants 65 years and older in the Cardiovascular Health Study (CHS). Pooling these two cohorts provided data on the relationship of risk factors and atherosclerosis on nearly 19,000 participants over a broad age range. Regression analyses were used to assess the consistency of the magnitude of the association of risk factors with atherosclerosis across the age spectrum separately for black and white participants in cross-sectional analyses. As expected, each of the risk factors was globally (across all ages) associated with increased atherosclerosis. However, the magnitude of the association did not differ across the age spectrum for hypertension, low density lipoprotein cholesterol (LDL-c), fibrinogen, or body mass index (BMI). For whites, there was a significantly greater impact of smoking and HDL-C among older age strata but a smaller impact of diabetes. For black women, the impact of HDL-C decreased among the older age strata.

Question: Does the association of risk factors and atherosclerosis change with age?

These data suggest that most risk factors continue to be associated with increased atherosclerosis at older ages, possibly suggesting a continued value in investigation of strategies to reduce atherosclerosis by controlling risk factors at older ages.

Answer the question based on the following context: The aim of the present study was to examine the value of pulse oximetry in the diagnosis of aspiration by comparing it with the gold standard, videofluoroscopy, by use of a prospective, controlled, single-blind study design. Pulse oximetry was performed simultaneously with videofluoroscopy in 54 consecutive dysphagic stroke patients. Oxygen saturation measurements were taken before the video-fluoroscopic examination (baseline), on swallowing and continuously for 2 minutes after swallowing, and 10 minutes later. Pulse oximetry reliably predicted aspiration or lack of it in 81.5% of cases. The predictive value of the test was low in patients aged>or = 65 years and possibly those with chronic lung disease. One smoker also had a false-negative pulse oximetry result, ie, normal oxygen saturation despite radiological evidence of aspiration.

Question: Does pulse oximetry reliably detect aspiration in dysphagic stroke patients?

Pulse oximetry is a reliable method of diagnosis of aspiration in most dysphagic patients. However, careful interpretation of pulse oximetry data is necessary in older subjects, possibly those with chronic pulmonary disease, and smokers. The method is noninvasive, simple, and quick, and can be used routinely in the clinical assessment of dysphagic patients.

Answer the question based on the following context: Among several mediators, nitric oxide (NO) and calcitonin gene-related peptide (CGRP) were suggested to be involved in the mechanism of preconditioning. We examined the possible role of the cardiac capsaicin-sensitive sensory innervation in pacing-induced preconditioning, as well as in the cardiac NO and CGRP content. Wistar rats were treated subcutaneously with capsaicin or its solvent in the sequence of 10, 30, and 50 mg/kg increasing single daily doses for 3 days to deplete neurotransmitters of the sensory innervation. Isolated hearts from both groups were then subjected to either preconditioning induced by three consecutive periods of pacing at 600 beats per minute for 5 min with 5 min interpacing periods, or time-matched non-preconditioning perfusion, followed by a 10-min coronary occlusion. NO content of left ventricular tissue samples was assayed by electron-spin resonance, and CGRP release was determined by radioimmunoassay. CGRP immunohistochemistry was also performed. In the non-preconditioned, solvent-treated group, coronary occlusion decreased cardiac output (CO) from 68.1 to 32.1 mL/min, increased left ventricular end-diastolic pressure (LVEDP) from 0.58 to 1.90 kPa, and resulted in 200 mU/min/g LDH release. Preconditioning significantly increased ischaemic CO to 42.9 mL/min (P<0.05), decreased ischaemic LVEDP to 1.26 kPa (P<0.05) and decreased LDH release to 47 mU/min/g (P<0.05) in the solvent-treated group. Preconditioning did not confer protection in the capsaicin-pretreated group (ischaemic CO: 35.6 mL/min; 1.76 kPa; LDH 156 mU/min/g). Capsaicin-treatment markedly decreased cardiac NO content, CGRP release, and CGRP-immunoreactivity.

Question: Capsaicin-sensitive local sensory innervation is involved in pacing-induced preconditioning in rat hearts: role of nitric oxide and CGRP?

(i) The presence of an intact local sensory innervation is a prerequisite to elicit pacing-induced preconditioning in the rat heart. (ii) A significant portion of cardiac basal NO content may be of neural origin. (iii) Release of NO and CGRP from capsaicin-sensitive nerves may be involved in the mechanism of pacing-induced preconditioning.

Answer the question based on the following context: To study the appropriateness of lipid-lowering drugs treatment through four methods of calculating coronary risk (CR). Crossover study. Primary care centre. All patients receiving lipid-lowering drugs. CR was determined for individuals with application criteria by four methods: the simplified Framingham, Dundee-Risk-Disk, modified Sheffield label and Cardiovascular Risk in Primary Care (CVRap). 330 patients followed the treatment, 137 men and 193 women with an average age of 58.8 (SD 10.2). 54.2% received statims, 28.5% clofibrates, 13.6% resins and 3.6% other drugs. 186 patients were included, 75 (22.7%) being excluded because of secondary prevention and the rest because they were not the right age or had no cholesterol data prior to treatment. 38.3% were at high CR according to Framingham, 25.6% according to CVRap, 18.7% according to Dundee-Risk-Disk and 16% according to modified Sheffield. Concordance between these methods was adequate.

Question: Do the patients we treat with hypolipemic drugs have a coronary risk?

Between 16% and 38.3% of the individuals treated are at high CR. If we also include patients with severe Hypercholesterolaemia and diabetics with Hypercholesterolaemia, this percentage rises to 59.7-73.3%, according to the CR assessment method used.

Answer the question based on the following context: Conventional exercise testing before hospital discharge is the most useful procedure in order to estimate postinfarction prognosis and in detecting multivessel coronary disease which is associated with a poor long-term prognosis. There are no bibliographic reports about it in younger myocardial infarction survivors. The aim of the study was to evaluate sensitivity, specificity and predictive value of symptoms limited maximal exercise testing for multivessel disease diagnosis in young patients after myocardial infarction. Myocardial infarction survivors until the age of 40 performed symptoms limited maximal exercise testing and had a coronary arteriography before hospital discharge. A total of 100 consecutive patients were included, although in only 83 of them exercise tests and coronariographic studies were done. In this group, multivessel disease was confirmed in 27 patients (15 with positive tests and 12 with normal exercise testing). In the remaining 56 young adults without multivessel involvement, positive tests were only observed in 15 patients and normal tests in 45. Thus, a sensitivity of 56%, specificity of 73%, positive predictive value of 50% and negative predictive value of 77% were found. When patients showed high risk exercise test criteria, the exercise test positive predictive value increased to 80%.

Question: Is the predischarge exercise test valid in patients younger than 40 years old after myocardial infarct for determination of multivascular disease?

Due to the lower sensitivity of this test in young myocardial infarction survivors for detecting multivessel artery disease, we remark on the need for predischarge complementary tests such as isotopic, stress echocardiography or coronariography testing.

Answer the question based on the following context: To identify variances in the microcirculation of the affected leg of stroke patients and to correlate them with a number of variables that are clinically associated with a possible circulatory disorder ("cold leg"). Survey. Large regional (tertiary care) rehabilitation center. From 93 acute, first-ever stroke patients admitted for stroke rehabilitation, 10 individuals were selected. Patients with vascular or cardiopulmonary pathology and severe cognitive or speech impairments were excluded. A clinical assessment of the following variables was performed: subjective complaints of the affected leg, medication, walking performance, degree of lower-leg edema, trophic pathology, voluntary muscle activity of the dorsal flexors of the affected foot, and the degree of spasticity of the calf muscles. The microcirculation of the affected leg was registered via transcutaneous oxygen measurement (TcPO2). The clinical picture associated with a circulatory disorder ("cold leg") was partially and modestly present in seven patients. The TcPO2 values showed no differences between the paretic and nonparetic lower legs, nor did values change in the course of time after stroke: mean 77.9 mmHg (range 42-124) versus 86.1 (41-124) after 8 weeks (n = 10, p = .17); 76.9 (45-96) versus 73.1 (50-96) after 14 weeks (n = 9, p = .38); and 65.8 (44-88) versus 65.8 (37-78) after 20 weeks (n = 8, p = .48). The clinical symptoms could not be objectified in relation to the microcirculation.

Question: Transcutaneous oxygen measurement in stroke: circulatory disorder of the affected leg?

In selected stroke patients, no differences were established between microcirculation in both lower legs. TcPO2 measurement does not seem to be a suitable method for clinical research on this topic.

Answer the question based on the following context: Non-insulin-dependent diabetes mellitus (NIDDM) and hyperhomocysteinemia are both associated with increased lipid peroxidation (oxidative stress). This may contribute to the accelerated vascular disease associated with these conditions. It is not known whether the coexistence of elevated homocysteine levels will stimulate oxidative stress further than that caused by diabetes alone. Plasma concentrations of thiobarbituric acid reactive substances (TBARS), an index of lipid peroxidation, were measured in patients with NIDDM who had previously had a methionine load test; some of the patients had hyperhomocysteinemia. Plasma TBARS concentrations were elevated in diabetics with vascular disease. The additional presence of hyperhomocysteinemia was not associated with a further increase in plasma TBARS concentrations.

Question: Oxidative stress in diabetic macrovascular disease: does homocysteine play a role?

Lipid peroxidation is increased in patients with diabetes mellitus and macrovascular disease and is not further elevated by the coexistence of elevated homocysteine levels. It is possible that diabetes maximally stimulates oxidative stress and any further acceleration of vascular disease in patients who have coexistent hyperhomocysteinemia is mediated through mechanisms other than lipid peroxidation.

Answer the question based on the following context: Chest pain (CP), its cause unknown, is a common and often prominent symptom of sarcoidosis. We determined the frequency and character of CP in patients with pulmonary sarcoidosis and examined its relationship with (1) length of time since diagnosis, (2) roentgenograhic stage, and (3) radiographic abnormalities on spiral chest computed tomography (CT). Twenty-two patients were studied: 14 of 22 patients (64%) had CP, with 4 of 14 (29%) identifying pain as their primary symptom. Eleven of 14 (79%) had pleuritic CP; 12 of 22 (54.5%) described CP as substernal; and 5 of 22 (22.7%) described CP between the scapula. There was not a significant correlation between CP and the presence or degree of lymphadenopathy. There was no significant correlation between CP and the presence or location of pleural disease. Abnormalities of other thoracic structures also had no significant correlation with the presence of CP.

Question: Is there an anatomic explanation for chest pain in patients with pulmonary sarcoidosis?

We conclude that there is no "anatomic reason" for CP in patients with pulmonary sarcoidosis that is evident on chest CT.

Answer the question based on the following context: To determine the effect of the use of polylysine-coated (PLC) slides for cytocentrifugation on the morphology and number of cells in cerebrospinal fluid (CSF) and its effectiveness in improving the diagnostic sensitivity of the cytologic examination of CSF. We assessed the morphology and numbers of cells in 50 CSF samples obtained from 50 consecutive lumbar punctures. After centrifugation of the aliquots, 400 microL was used for cytocentrifugation on PLC and plain glass slides. After Giemsa staining, random area cell counts were made for a total of 100 microscopic fields (using a 40 x objective), and cytomorphology was assessed. There was no difference in cytomorphologic quality between PLC and plain glass slides. The total number of cells was higher on the PLC slides (30,674 vs. 28,426; mean value per slide, 614 vs. 569), with ranges of 0-11,076 (median value, 38) and 0-10,980 (median value, 24), respectively. This difference was significant (Wilcoxon matched-pairs signed-rank test, P<.05). The higher number of cells influenced the diagnostic assessment in one case, in which only the PLC slide was conclusive.

Question: Cytology of cerebrospinal fluid. Are polylysine-coated slides useful?

A significantly higher number of cells was found when PLC slides were used in cytopathologic assessment of CSF samples, resulting, however, in only minor improvements in diagnostic sensitivity. These findings do not warrant the routine use of PLC slides during cytocentrifugation of CSF.

Answer the question based on the following context: Although there have been two reports suggesting that it is not necessary to obtain chest radiographs of all children with cancer who are hospitalized for fever and neutropenia, this practice continues. Fifty-four children with cancer who were hospitalized for 108 episodes of fever and neutropenia were followed prospectively. Data on their respiratory signs and symptoms were collected on admission and throughout their hospital course. Chest radiographs were obtained at the discretion of the pediatric oncology attending physician and were interpreted by a pediatric radiologist. Pneumonia was documented by chest radiograph in 4 of the 108 episodes (3.7%) of fever and neutropenia. In 10 of the 108 episodes, the children had abnormal respiratory findings; this group included the 4 children with pneumonia documented by chest X-ray examination. None of the children with normal respiratory findings hospitalized for the remaining 98 episodes had pneumonia. Chest radiographs were not obtained for 40 of the 108 episodes of fever and neutropenia. None of the children with these 40 episodes had respiratory abnormalities and all recovered without a problem. Chest radiographs were obtained for the remaining 68 episodes of fever and neutropenia. Of the four children in this group with pneumonia documented by chest X-ray, two were diagnosed on admission, and another two whose initial radiographs were normal developed pneumonia later in their hospital course. There were no differences in age, absolute neutrophil count, temperature at presentation, or type of malignancy between the children who had chest radiographs and the children who did not.

Question: Routine chest radiography of children with cancer hospitalized for fever and neutropenia: is it really necessary?

Pneumonia is an uncommon cause of infection in children with cancer hospitalized for fever and neutropenia. Therefore, the authors believe it is not necessary to obtain a chest radiograph in children with no respiratory abnormalities who are hospitalized for fever and neutropenia. [See editorial on pages 1009-10, this issue.]

Answer the question based on the following context: We addressed the question whether in patients with cardiac chest pain referred for stress myocardial perfusion scintigraphy, Tc-99m MIBI SPECT stress imaging should always be followed by a rest imaging procedure. Using Tc-99m MIBI imaging a stress rest sequence is usually performed implying that the resting study always follows the stress study irrespective of the results of the stress study. As a normal stress study would eliminate a subsequent resting study, it appears desirable to potentially define certain subsets of patients in whom a normal stress study can be expected in order to determine a more selective referral approach to the nuclear medicine department. The consequences of such a more streamlined approach would less impose on the logistics of the department of nuclear medicine, with decrease of investigation time, radiation dose, and costs in a time of retrenchment in the medical sector. A consecutive series of 460 patients (mean age 58.2 years) was studied who were stratified to 269 patients without prior myocardial infarction, and to 191 patients with documented evidence of a previously sustained myocardial infarction. All patients underwent Tc-99m MIBI SPECT imaging according to a two-day stress-rest protocol. Patients with and without a previous myocardial infarction showed suboptimal overall predictive accuracies for the exercise electrocardiograms (58% and 60%, respectively). In the total group of 460 patients, 94 (20%) patients showed a normal stress-rest Tc-99m MIBI SPECT; this occurred in 86/269 (32%) patients without a previous myocardial infarction and in only 8/191 (4%) patients with a previous myocardial infarction.

Question: Should imaging at stress always be followed by imaging at rest in Tc-99m MIBI SPECT?

Patients with a stress defect at Tc-99m MIBI SPECT imaging should always undergo a resting SPECT study irrespective of the clinical and stress electrocardiographic findings. As patients without a previous myocardial infarction had a normal stress SPECT study in almost one-third (32%) of patients compared to only 4% in patients with a previously myocardial infarction, it may be useful to employ different referral and imaging strategies i.e., a stress-only versus a stress-rest procedure. To schedule referring patients differently according to the presence or absence of a previously sustained myocardial infarction may be cost-saving, less demanding for the nuclear medicine personnel, and patient-convenient. In addition, a stress-only imaging procedure reduces radiation exposure to the individual patient.

Answer the question based on the following context: To examine the hypothesis that gold rings might delay articular erosion at the metacarpophalangeal (MCP) joint of the left ring finger in ring wearers with rheumatoid arthritis (RA). Consecutive patients with RA were recruited. They were classified as ring wearers if they had worn a gold ring on the left ring finger throughout most of the time since disease onset, or as non-ring wearers if they had never worn a gold ring. Standard hand radiographs (with rings removed, where possible) were taken and articular erosion was quantified at the MCP and proximal interphalangeal joints. Thirty ring wearers (27 female) and 25 non-ring wearers (12 female) were included. The median (25th-75th centile) Larsen score in the left hand ring MCP joint of ring wearers was 1.0 (1.0-2.0), which was significantly less than in their equivalent right hand joint (1.0, 1.0-5.0, p = 0.01). It also tended to be less than the equivalent left hand joint of non-ring wearers (4.0, 1.0-5.0, p = 0.06), with a similar but significant difference observed at the adjacent middle finger MCP joint (p = 0.01).

Question: Do gold rings protect against articular erosion in rheumatoid arthritis?

The results of this preliminary study suggest that there may be less articular erosion at the left hand ring, and perhaps adjacent, MCP joints observed in ring wearers with RA. These data support the hypothesis that gold could pass from a gold ring through skin and local lymphatics 'downstream' to nearby MCP joint in sufficient quantities to delay articular erosion.

Answer the question based on the following context: To investigate on a population basis the suggestion that certain factors naturally alter the odds of having a boy or a girl, and that some women are predisposed towards having children of one particular gender. Routine data analysis. Routinely collected data on singleton infants born in Scotland from 1975 to 1988, linked so that births (live and still) to the same mother could be identified. The analyses relate to 549,048 first to fifth order births occurring to 330,088 women whose records were complete from the first delivery onwards. Gender of infant. Of 549,048 births, 51.4% were male. Apart from random variation, the sex ratio of 1.06 remained constant at all birth orders (P = 0.18). The probability of a male infant appeared unrelated to the genders of the preceding siblings (P>0.20 in second to fifth deliveries), and there was no evidence of variation with maternal age (P = 0.31), maternal height (P = 0.69), paternal social class (P = 0.12), maternal social class (P = 0.57), year of delivery (P = 0.84) or season of birth (P = 0.41). Whilst mothers whose children were all the same gender were more likely to continue childbearing than those with children of different genders, there was no evidence that those with daughters were more likely to continue than those with sons.

Question: Sex ratios: are there natural variations within the human population?

The suggestion that some women have a natural predisposition towards having children of a particular gender is not supported by these data. On a population basis there is no evidence to suggest that gender determination is anything other than a chance process.

Answer the question based on the following context: To look for the frequency and the influence of apatite-like deposits in the synovial membrane of advanced osteoarthritic joints. Synovium of 16 joints undergoing total arthroplasty for advanced primary osteoarthritis was embedded in paraffin. Adjacent sections were stained with alizarin red S, Mowat's pentachrome, Hematoxylin-eosin and Gomori to show apatite-like deposits, collagen, cartilage fragments, vessels, cells and iron respectively. Histomorphometry was carried out for the apatite-like and collagen deposits by the point counting method; the density of vessels and cells was also quantified. 14 out of the 16 specimens contained apatite-like material, mostly on the synovial surface or just beneath. There was no correlation between the apatite-like deposits and any other measured histological parameter (fibrosis, villus length, synovial lining cell width, density of synovial vessels or cells). Interestingly, the p value for a correlation between the amounts of apatite and collagen deposits was close to significance (r = 0.53; p = 0.055) when the relative volume of the apatite-like material was less than 1.2% (n = 13).

Question: Morphometric studies on synovium in advanced osteoarthritis: is there an association between apatite-like material and collagen deposits?

Apatite-like deposits are frequently observed in the synovium of late stage osteoarthritis. Although not statistically significant, these results suggest a possible association between apatite-like and collagen deposits when the amount of apatite deposits is low. Further quantitative studies are recommended to investigate this observation.

Answer the question based on the following context: We evaluated the extent to which detailed review of axial source images enhances the interpretation of projectional reconstructions of two-dimensional time-of-flight MR arteriograms of the tibial vessels. Thirty-one patients (34 limbs) with limb-threatening ischemia underwent two-dimensional time-of-flight imaging and contrast-enhanced angiography of the below-knee arteries. Maximum-intensity-projection (MIP) reconstructions of the MR arteriograms were independently interpreted by three observers. The studies were then reinterpreted after detailed review of the axial source images. A consensus reading of each study was performed as well. The observers commented on the patency of 816 vascular segments and graded the extent of disease for 272 vessels. Interobserver agreement and correlation with contrast-enhanced angiography were determined. On average, the addition of axial images altered the observers' interpretation of MR arteriograms in 13% of segments for patency and in 18% of vessels for grading of disease severity. For determining the patency of vascular segments, mean interobserver agreement was 0.79 without and 0.80 with axial image interpretation, and mean agreement with contrast-enhanced angiography improved from 0.69 to 0.72 with the addition of axial images. When evaluating the extent of disease, correlation between observers improved for all combinations of observers with the addition of axial images, and correlation with contrast-enhanced angiography improved for two of three observers. Based on the consensus interpretation of the MR arteriograms, review of axial images was found to improve agreement with contrast-enhanced angiography in 34 vascular segments. In addition, axial image review correctly altered the number of stenoses identified in 12 vessels. When consensus interpretation identified a vessel as patent without significant stenosis on the MIP images, the MIP-based interpretation was found to be correct in all cases.

Question: Time-of-flight MR arteriography of below-knee arteries with maximum-intensity-projection reconstruction: is interpretation of the axial source images helpful?

Review of axial source images provides limited benefit to interpretation of MR arteriograms of the distal lower extremity in patients with peripheral vascular disease. Although selective review of axial source images may be appropriate, axial images can improve interpretation when MIP images are complicated by the presence of patient motion, difficult anatomy, or artifacts. Axial image review may also be appropriate when a significant stenosis is identified on the MIP images.

Answer the question based on the following context: The detection of an infraclinical primary by tonsillectomy in case of cervical lymph node of an epidermoid carcinoma with unknown primary after a radical neck dissection, allows avoiding irradiation of the normal larynx. The aim of this study is to quantify the rate of tonsil primary to justify this procedure. From 1969 to 1992, 87 patients had a tonsillectomy as part of the workup for cervical nodal metastasis of an epidermoid carcinoma with unknown primary. The mean age was 57 years (range: 39-75 years) and the sex ratio was 8.6. Sixty-seven patients had a single cervical adenopathy (17 N1, 30 N2a, 5 N3, 15 Nx), and 20 patients multiple cervical adenopathies (17 N2b, 3 N2c). The treatments included always an irradiation to the node areas (50 Gy), and to the pharyngolarynx in case of normal tonsil (50 Gy), or to the tonsil if it was the primary (50 Gy with a brachytherapy boost of 20-25 Gy). In this last case, the larynx could be protected. Tonsillectomy never induced specific complication. Out of 87 patients, 26% had a tonsil primary. There was not specific histological differentiation in this group. In the 67 patients with a single cervical adenopathy, 31% had a tonsil primary (6 N1, 7 N2, 1 N3, 7 Nx). It was a subdigastric adenopathy in 38%, a submandibular in 28% and a midjugulocarotidian in 23%. Among the 17 patients N2b, none had a tonsil primary. In the three patients N2c, two presented a tonsil carcinoma (two subdigastric nodes).

Question: Cervical lymph node metastasis from an unknown primary: is a tonsillectomy necessary?

Tonsillectomy allows avoiding irradiation of normal larynx in 26% of patients who have a cervical lymph node with unknown primary. It should be performed in case of a single node of the subdigastric, midjugulocarotidian or submandibular area or bilateral subdigastric adenopathies.

Answer the question based on the following context: Studies of the effect of meteorological factors on suicide have yielded inconclusive and often contradictory results. This may be due to a variety of methodological problems including small numbers and variability in the definition of suicide. The relationship has not been examined in the elderly. To study the effect of weather conditions on suicide rate in an elderly population of 40,000 of North Cheshire aged 65 and above. In this study, coroner's verdicts of suicide and open verdict which were recorded in a specified period were included. Five-year data of deaths resulting from suicide within North Cheshire were analysed in relation to meteorological data, which were measured at the nearest Met office to the study population. Significant positive association was demonstrated between suicide in the elderly and hours of sunshine (p<0.01) and relative humidity (p<0.05). These effects were independent of sex.

Question: Elderly suicide and weather conditions: is there a link?

Weather may influence suicide in the elderly, probably interacting with biological and social variables. The rate of reported suicide appears to be positively related to fine weather conditions, during early summer, and not to extreme weather conditions as previously reported. Method of death appears to be also associated with weather conditions.

Answer the question based on the following context: Surveys of residency graduates and employers have suggested that residency programs do not prepare residents well for practice. Since 1988, pediatric residents at the University of Massachusetts have been paired one-on-one with an office-based pediatrician for their 3-year continuity experience. This survey was conducted to determine if graduates of such a program are prepared to enter pediatric practice. Graduates of the program from 1991 through 1995 who entered primary care practice were surveyed about their preparedness for practice. The questionnaire was also sent to the residents' first employers. The 32 questions were directed to overall sense of preparedness, ability to manage the pace of practice, common illnesses, common behavior problems, anticipatory guidance, office management, and subspecialty problems. Data from all 25 residents who entered practice and the employers of 20 of the 25 residents were obtained and analyzed. Both groups rated overall resident preparedness to be "well-prepared" or "very well-prepared" and gave high scores on working at the pace of practice, diagnosing and treating common illnesses, diagnosing and treating common behavior problems, and providing anticipatory guidance. Areas in which residents were considered to be less well-prepared included anticipatory guidance about nutrition, managing problems by telephone, office management, gynecology, and orthopedics.

Question: The University of Massachusetts Medical Center office-based continuity experience: are we preparing pediatrics residents for primary care practice?

The results suggest that continuity experiences in office practices are associated with preparation for the pace and types of visits that occur commonly in primary care practice, abilities which previous surveys of residency alumni and employers have found lacking. Some areas may benefit from a formal curriculum which may be implemented in the office practice, at the medical center, or at both sites. Preceptors may benefit from faculty development and continuing medical education that is directed not only at teaching skills but also at content areas which were not addressed in their own residencies.

Answer the question based on the following context: To investigate the evolution of metabolic effects associated with intravenous salbutamol infusion given together with 2 doses of intramuscular steroids in the treatment of preterm labour. Preterm labour was inhibited with an intravenous infusion of salbutamol in 8 women between 26 and 32(+6) weeks with normal singleton pregnancies. Serum glucose concentration, serum potassium, sodium and insulin concentrations, and total white cell count both during the infusion as well as post-therapy, were plotted against time. Intravenous salbutamol infusion administered at a rate required to inhibit uterine contractions in preterm labour causes a rise in serum glucose and plasma insulin concentrations. The serum glucose and plasma insulin levels peaked soon after cessation of therapy and took 2-3 hours to come to pre-infusion levels. The decline in serum potassium concentration was gradual and plateaued after 2 hours. Once the salbutamol infusion was stopped the potassium levels were back to normal by 2 hours. There is an increase in total white cell count within an hour of the initiation of therapy.

Question: Is there a need to treat hypokalaemia associated with intravenous salbutamol infusion?

There is no need to administer insulin for hyperglycaemia and/or potassium for hypokalaemia unless the patient is a known diabetic or when a patient needs immediate surgery.

Answer the question based on the following context: Previous studies have indicated that propofol anaesthesia may reduce the incidence of postoperative nausea and vomiting after strabismus surgery in children. This study was designed to investigate the incidence of vomiting after strabismus surgery at two different levels of propofol anaesthesia compared to thiopental/isoflurane anaesthesia. Ninety ASA class I or II children, aged 5-14 yrs were randomly assigned to one of three groups: Group T/I (n = 30) induction with 5 mg kg-1 of thiopental and maintenance with isoflurane, group P5 (n = 31) induction with propofol 2 mg kg-1, maintenance with propofol infusion 5 mg kg-1 h-1 or group P10 (n = 29) induction with propofol 2 mg kg-1, maintenance with propofol 10 mg kg-1 h-1. All received glycopyrrolate, vecuronium, fentanyl and controlled ventilation with O2/N2O 30/70. Ketorolac i.v. was given to prevent postoperative pain. If additional analgesia was needed, ibuprofen/acetaminophen or buprenorphine was given according to clinical need. There were no differences between study groups with respect to age, weight, history of previous anaesthesia or emesis after previous anaesthesia, duration of anaesthesia, surgery or sleep after anaesthesia, or number of muscles operated. The incidence of vomiting was 37%, 29% and 28% in groups T/I, P5 and P10, respectively. There were no statistically significant differences between the three groups in the incidence of vomiting. The median age of patients who vomited was 7.5 (range 5.0-13.7) yrs while the median age of the patients who did not vomit was 9.1 (range 5.0-14.0) yrs (P<0.01).

Question: Does propofol reduce vomiting after strabismus surgery in children?

In the present study, propofol anaesthesia compared to thiopental/isoflurane anaesthesia did not reduce the incidence of vomiting following strabismus surgery in children.

Answer the question based on the following context: Infrared tympanic thermometry (ITT) is a method for body temperature measurement. Correct measuring technique is said to be important to achieve good results with this method. The objective of this study was to investigate the accuracy and effect of training in the use of infrared tympanic thermometry (ITT) on the measurement results. Nurses trained in the use of ITT, and nurses not trained performed measurement sequences on 65 patients: one rectal and two ITT measurements in each sequence. Mean rectal temperatures were significantly (P<0.01) higher than with ITT (0.44 +/- 0.42 (SD) degree C for trained, 0.56 +/- 0.4 (SD) degree C for untrained). Coefficient of repeatability for ITT measurements was +/- 0.54 degree C for trained nurses, and +/- 0.48 degree C for untrained. With ITT temperatures adjusted upwards of 0.5 degree C, the sensitivity of ITT for detecting fever as defined by rectal measurements would be 70% for trained, and 54% for untrained nurses. Repeatability and sensitivity for trained and untrained nurses were not significantly (P>0.05) different.

Question: Can training improve the results with infrared tympanic thermometers?

Training had little effect on the accuracy of the measurements. According to our results, ITT is often unreliable and should be used with caution.

Answer the question based on the following context: To review the results of the surgical treatment of all types of hyperthyroidism (Graves' disease, toxic nodular goitre, and toxic solitary adenoma). Retrospective study. University hospital and private hospital, Greece. 400 Consecutive patients who were operated on between 1982 and 1991. Near total/total thyroidectomy in 226 patients with toxic nodular goitre and 87 patients with Graves' disease. Subtotal thyroidectomy in 25 patients with Graves' disease (early period of the study); lobectomy with resection of the isthmus of the thyroid in 62 patients with a solitary toxic adenoma. Mortality, morbidity and patients' self assessment of the results of operation (symptoms, scar, ophthalmopathy). There was no mortality. Morbidity included 2 postoperative bleeds that required reoperation; 2 patients developed permanent unilateral vocal cord paralysis and 2 had permanent hypoparathyroidism. In 27 of the 400 patients (7%) a thyroid carcinoma was found in the resected specimen. No patient had persistent or recurrent hyperthyroidism 2 to 10 years after operation. Of the 49 patients with Graves' disease and opthalmopathy at the time of operation, 35 (71%) reported improvement in their ophthalmopathy and 14 (29%) reported no improvement. No patient had worsening of their exophthalmos; 388 (97%) were satisfied with their incision; and 360 (90%) reported a significant improvement in their preoperative symptoms (tachycardia, weakness, anxiety, and pressure in the neck).

Question: Should the primary treatment of hyperthyroidism be surgical?

We suggest that the primary treatment of all types of hyperthyroidism should be surgical.

Answer the question based on the following context: To find out whether p53 overexpression correlates with metastatic potential and other adverse prognostic factors in early invasive colorectal carcinoma and whether measurement of the expression of p53 protein could be helpful in the choice of treatment (endoscopic/local or radical resection). Retrospective study. University hospital, Japan. Overexpression of p53 protein in the primary tumour was examined immunohistochemically in 50 patients with early invasive colorectal cancer. Differences in p53 overexpression between subgroups. Abnormal accumulation of nuclear p53 was detected in the primary tumour of 20 patients (40%) with early invasive colorectal cancer. We found p53-positive cells in 7 (78%) of 9 that had metastasised to regional lymph nodes or distant organs, or both, and in 13 (32%) of 41 that had not metastasised (p = 0.02). p53 Immunoreactivity was also present in 10 (71%) of 14 superficial (type II) lesions compared with 10 (28%) of 36 protruding (type I) ones (p = 0.009) and in 12 (57%) of 21 moderately differentiated adenocarcinomas compared with 8 (28%) of 29 well-differentiated adenocarcinomas (p = 0.045). There was no significant correlation between p53 overexpression and the depth of tumour invasion or angiolymphatic involvement. The p53-positive metastasising tumours had features that corresponded to those of early carcinoma arising de novo.

Question: Does p53 overexpression cause metastases in early invasive colorectal adenocarcinoma?

Our results seem to support the postulate that p53 overexpression in early invasive colorectal carcinomas is associated with an increase in their metastatic potential.

Answer the question based on the following context: To assess, using both qualitative/inductive and quantitative data, whether people with rheumatoid arthritis (RA) have schemas related to arthritis. Themes identified from interview and focus group transcripts were used to develop 1) questionnaire items, and 2) statements participants were asked to recall during home interviews. Two hundred one people with RA completed questionnaires and recall tasks of the type used in cognitive research, followed 10 days later by another recall assessment by telephone. Qualitative methods, item-level questionnaire data, and category-level recall data yielded convergent results supporting 4 final categories: mastery, support, loss of independence, and depression. Regression analyses indicated that category of earlier recollections predicted subsequent recollections assessed via phone.

Question: Do people with rheumatoid arthritis develop illness-related schemas?

Results from widely different methods offer at least partial support for arthritis schemas and suggest that the concepts identified are meaningful to patients as well as to researchers.

Answer the question based on the following context: To determine the success rate, complications and morbidity from open pyeloplasty. The study included 63 patients with confirmed pelvi-ureteric junction (PUJ) obstruction who underwent 66 pyeloplasties. Their records were analysed retrospectively for age, clinical presentation, serum creatinine level, presence of infection, surgical technique, and pre- and post-operative isotopic renography. The mean (range) follow-up was 15.5 (3-60) months. Pain was the most common presenting symptom; most pyeloplasties were dismembered and 77% of the procedures were performed by urological trainees. Retrograde pyelography did not alter the management in any patient. The complications were persisting PUJ obstruction in four, urinary leakage in two, transient vesico-ureteric obstruction in two and meatal stenosis in one. There were no complications in non-intubated pyeloplasties. Pain was successfully relieved in 98% of patients, renal function improved or remained stable in 92% and deteriorated in 7.7%. One patient underwent a revision pyeloplasty and another required nephrectomy. A younger patient, absence of urinary tract infection and absence of palpable mass were favourable factors.

Question: Is open pyeloplasty still justified?

Pyeloplasty is the most effective and permanent treatment for PUJ obstruction. Newer endoscopic procedures currently used must be carefully assessed against this 'gold standard' before becoming widespread.

Answer the question based on the following context: In order to evaluate the association between alcohol intake and the risk of liver cirrhosis in the absence of B and C hepatitis viruses, we analyzed data from three hospital-based case-control studies performed in various Italian areas. From the case and control series we excluded HBsAg and/or anti-HCV positive patients. Cases were 221 cirrhotic patients admitted for the first time to hospital for liver decompensation. Controls were 614 patients admitted to the same hospitals during the same period as the cases for acute diseases unrelated to alcohol. Alcohol consumption was expressed as lifetime daily alcohol intake (LDAI). We found a dose-effect relationship between LDAI and the risk of liver cirrhosis (LC). Considering the extreme LDAI categories (LDAI = 0 g: lifetime teetotallers and LDAI>or = 100 g), the LC odds ratio (OR) increased from 1.0 (reference category) to 44.7 (95% confidence interval: 95% CI: 20.0-99.9). An increased risk of LC associated with the female gender independent of alcohol consumption was also observed (OR = 2.9; 95% CI: 1.8-4.6).

Question: Is alcohol a risk factor for liver cirrhosis in HBsAg and anti-HCV negative subjects?

Alcohol intake acts as a risk factor for symptomatic liver cirrhosis also in the absence of HBV and/or HCV infection. Besides alcohol and viruses, some unknown gender-related factors might be involved in the occurrence of the disease.

Answer the question based on the following context: The risk of cholangiocarcinoma in primary sclerosing cholangitis is widely recognized to be 8-30%, whereas the risk of acquiring hepatocellular carcinoma in primary sclerosing cholangitis is unknown. As in other chronic liver diseases, the presence of hepatocellular carcinoma in a patient with primary sclerosing cholangitis undergoing evaluation for orthotopic liver transplantation would clearly impact on the candidacy, diagnostic evaluation, and alternative treatment options. Thus, the aim of our study was to determine the prevalence of hepatocellular carcinoma in patients undergoing liver transplantation for primary sclerosing cholangitis. The records of the 520 patients undergoing orthotopic liver transplantation at our institution between 1985 and May 1995 were reviewed. Of the 134 patients with primary sclerosing cholangitis, three (2%) had hepatocellular carcinoma. In the 386 patients without primary sclerosing cholangitis undergoing orthotopic liver transplantation, 22 (6%) had hepatocellular carcinoma. Neither the duration of primary sclerosing cholangitis (range 7-23 years) nor the presence of ulcerative colitis (two of three patients) distinguished those patients with primary sclerosing cholangitis plus hepatocellular carcinoma from those with primary sclerosing cholangitis alone. None of the three patients with primary sclerosing cholangitis plus hepatocellular carcinoma had evidence for hepatitis B or C, alpha-1-antitrypsin deficiency, or hemochromatosis. None of the tumors was of the fibrolamellar variety of hepatocellular carcinoma.

Question: Are patients with cirrhotic stage primary sclerosing cholangitis at risk for the development of hepatocellular cancer?

The prevalence of hepatocellular carcinoma in patients with primary sclerosing cholangitis undergoing orthotopic liver transplantation is 2%. These data suggest that patients with advanced cirrhotic-stage primary sclerosing cholangitis are at increased risk for developing hepatocellular carcinoma and should be screened for hepatocellular carcinoma as well as for cholangiocarcinoma prior to orthotopic liver transplantation.

Answer the question based on the following context: The awareness of the risk of overwhelming sepsis after splenectomy prompted surgeons to attempt splenic preservation in patients who had hematologic diseases for which splenectomy was the conventional treatment. Partial splenectomy for Gaucher's disease was widely performed before the introduction of alglucerase. In sporadic cases a second partial splenectomy had also been attempted. The authors present three cases of failed repeated partial splenectomy attempted before alglucerase was available. The role of angiography in planning operative strategy and the surgical pitfalls of this unusual reintervention are discussed.

Question: Should repeated partial splenectomy be attempted in patients with hematological diseases?

New indications for partial splenectomy in other hematologic diseases makes the experience gained with Gaucher's disease valuable for management decisions.

Answer the question based on the following context: Asthma caused by allergy to house dust mite is a growing problem. Patients with allergy who do not have asthma (yet) might develop asthma depending on exposure to precipitating factors. We sought to determine whether house dust mite avoidance measures have an effect on the development of asthma. Patients with allergy (n = 29) who had no diagnosis of asthma (FEV1 of 99.1% +/- 10.6% of predicted, peak flow variability of 5.21% +/- 3.41%, reversibility of FEV1 after 400 microg salbutamol of 3.92% +/- 3.75% according to the reference values) were randomly allocated (subjects blinded) to a treatment (n = 16) and a placebo group (n = 13). House dust mite avoidance treatment consisted of applying Acarosan (Allergopharma, J. Ganzer KG, Hamburg, Germany) (the placebo group used water) to the floors (living room, bedroom), and the use of covers for mattresses and bedding that were impermeable to house dust mite (the placebo group used cotton covers for mattresses only). We tested whether the intervention had an effect on peak flow parameters and asthma symptom scores during 6 weeks of treatment. Significant improvements were seen in the treatment group in symptom scores (Borg score) for disturbed sleep, breathlessness, wheeze, and overall symptom score. Slight but statistically significant improvements in peak flow (morning, evening, and variability) were seen in the treatment group also. No significant changes were seen in the placebo group.

Question: House dust mite avoidance measures improve peak flow and symptoms in patients with allergy but without asthma: a possible delay in the manifestation of clinical asthma?

Although this study is not long enough to study the development of asthma, the results indicates that house dust mite avoidance measures had an effect on peak flow parameters and asthma symptoms in patients with allergy but without asthma. These findings might implicate that a shift in developing clinically manifest asthma could be achieved with house dust mite avoidance measures. To give a better answer to whether preventing the development of asthma is possible, larger studies with a longer follow-up period are necessary.

Answer the question based on the following context: This study evaluated the effectiveness of dietary advice in primary prevention of chronic disease. A meta-analysis was conducted of 17 randomized controlled trials of dietary behavior interventions of at least 3 months' duration. Results were analyzed as changes in reported dietary fat intakes and biomedical measures (serum cholesterol, urinary sodium, systolic and diastolic blood pressure) in the intervention group minus changes in the control group at 3 to 6 months and 9 to 18 months of follow-up. After 3 to 6 months, mean net changes in each of the five outcomes favored intervention. For dietary fat as a percentage of food energy, the change was -2.5% (95% confidence interval [CI] = -3.9%, -1.1%). Mean net changes over 9 to 18 months were as follows: serum cholesterol, -0.22 (95% CI = -0.39, -0.05) mmol/L; urinary sodium, -45.0 (95% CI = -57.1, -32.8) mmol/24 hours; systolic blood pressure, -1.9 (95% CI = -3.0, 0.8) mm Hg; and diastolic blood pressure, -1.2 (95% CI = -2.6, 0.2) mm Hg.

Question: Can dietary interventions change diet and cardiovascular risk factors?

Individual dietary interventions in primary prevention can achieve modest improvements in diet and cardiovascular disease risk status that are maintained for 9 to 18 months.

Answer the question based on the following context: This study examined whether incarceration during pregnancy is associated with infant birthweight. Multivariable analyses compared infant birthweight outcomes among three groups of women: 168 women incarcerated during pregnancy, 630 women incarcerated at a time other than during pregnancy, and 3910 women never incarcerated. After confounders were controlled for, infant birthweights among women incarcerated during pregnancy were not significantly different from women never incarcerated; however, infant birthweights were significantly worse among women incarcerated at a time other than during pregnancy than among never-incarcerated women and women incarcerated during pregnancy.

Question: Is incarceration during pregnancy associated with infant birthweight?

Certain aspects of the prison environment (shelter, food, etc.) may be health-promoting for high-risk pregnant women.

Answer the question based on the following context: The diagnosis of the long-QT syndrome (LQTS) may be difficult to establish in patients with normal or borderline prolongation of the QT interval. Noninvasive markers are needed to identify patients with LQTS. Fourteen patients with known LQTS, 9 unaffected family members, and 40 control subjects underwent modified Bruce protocol exercise testing. The RT interval (peak of R wave to peak of T wave) and rate-corrected RT interval (RTc) were measured during exercise and recovery. The RT interval at 1 minute into recovery was subtracted from the RT interval at a similar heart rate during exercise (deltaRT). The RTc shortened by 61 milliseconds (ms) in the LQTS patients compared with 23 to 26 ms in the other two groups (P=.003 by ANOVA). The RT interval shortened in a linear fashion in all patients but demonstrated persistent shortening during recovery in the LQTS patients. This was manifested as a hysteresis loop in the curve relating the RT interval to cycle length. The hysteresis loop was present in 13 of 14 LQTS patients and only 4 of 40 control subjects. DeltaRT>25 ms had a sensitivity of 73%, a specificity of 92%, a positive predictive value of 79%, and a negative predictive value of 90% for LQTS.

Question: Hysteresis of the RT interval with exercise: a new marker for the long-QT syndrome?

Hysteresis of the RT interval with exercise may be useful for the diagnosis of LQTS.

Answer the question based on the following context: It has long been believed that pleural fluid must be directly aspirated into a heparinized syringe to obtain an accurate value. Many operators aspirate 30 to 60 mL of pleural fluid into a syringe without heparin, and then place 1 mL into a heparinized syringe from which the pH is determined. We postulated that this technique does not cause a clinically significant difference in pleural pH values. Patients undergoing thoracentesis in the outpatient clinic, general ward, and medical ICU were eligible. After the initial entry of the needle into the pleural space, a heparinized syringe was used to obtain pleural fluid for pH determination. A 60-mL syringe was then used to aspirate additional pleural fluid for biochemical analysis and culture. At the end of the procedure, a second aliquot of pleural fluid was placed into a heparinized syringe for pH determination. A difference of 0.1 in pH was taken as clinically important. Twenty-one pleural fluid samples were obtained from 20 patients. Pleural fluid pH determinations were within 0.1 in all but one patient. The mean pH for the directly collected group was 7.39 (25%: 7.35; 75%: 7.45). The mean for the indirectly collected group was 7.41 (25%: 7.35; 75%: 7.45). The difference between the two means (0.02; 95% confidence interval, 0.0368 to 0.00131) was statistically significant but clinically unimportant (p=0.037).

Question: Is direct collection of pleural fluid into a heparinized syringe important for determination of pleural pH?

Pleural fluid can be collected in a large syringe and then placed into a heparinized syringe to assess pH. This is useful information because the use of just one syringe saves time and reduces the risk of iatrogenic complications.

Answer the question based on the following context: Prolonged mechanical ventilation (MV) is associated with high morbidity, mortality, and cost. However, few and limited data are available on the prediction of duration of MV. We conducted an observational cohort study to seek predictive criteria. The study was performed in a surgical ICU (SICU) in a university hospital. One hundred ninety-five consecutive unselected patients and 203 episodes of MV were prospectively analyzed to determine if clinical features, physiologic parameters, or multifactor scoring systems, at the time of admission or intubation, could be used as predictors of MV>or = 15 days. A univariate statistical analysis and a multiple logistic regression were used. A prospective validation study was then conducted to determine the accuracy of the results. (1) Univariate statistical analysis indicated that SICU length of stay, emergent endotracheal intubation as opposed to elective intubation, indication for MV, sepsis score at the time of admission and intubation, lung injury score (LIS) at the time of admission and intubation, number of organ system failures at the time of admission and intubation, and serum albumin concentration were significantly different between the two groups. (2) Only the circumstances (emergency) of endotracheal intubation (odds ratio [OR]=3.5, p=0.02) and the LIS (OR=3.7, p=0.004) independently predicted a duration of endotracheal intubation>or = 15 days. One hundred twenty-eight consecutive patients requiring emergent intubation and MV were included in the prospective validation. The accuracy of the LIS>or = 1 used to predict MV>or = 15 days was as follows: sensitivity=0.88; specificity=0.28; positive predictive value=0.24; negative predictive value=0.91.

Question: Is the duration of mechanical ventilation predictable?

Low incidence of MV>or = 15 days was observed (13% and 20%, respectively, in observational cohort study and validation study) in unselected SICU patients. LIS>or = 1 at the time of intubation provides excellent negative predictive value (0.93 and 0.91) of duration of MV>or = 15 days. These data suggest that tracheotomy should not be considered for patients with LIS<1.

Answer the question based on the following context: To examine the effect of full implementation of advanced skills by ambulance personnel on the outcome from out of hospital cardiac arrest. Patients with cardiac arrest treated at the accident and emergency department of the Royal Infirmary of Edinburgh. All cardiorespiratory arrests occurring in the community were studied over a one year period. For patients arresting before the arrival of an ambulance crew, outcome of 92 patients treated by emergency medical technicians equipped with defibrillators was compared with that of 155 treated by paramedic crews. The proportions of patients whose arrest was witnessed by lay persons and those that had bystander cardiopulmonary resuscitation (CPR) were similar in both groups. There was no difference in the presenting rhythm between the two groups. Eight of the 92 patients (8.7%) treated by technicians survived to discharge compared with eight of 155 (5.2%) treated by paramedics (NS). Of those in ventricular fibrillation or pulseless ventricular tachycardia, eight of 43 (18.6%) in the technician group and seven of 80 (8.8%) in the paramedic group survived to hospital discharge (NS). For patients arresting in the presence of an ambulance crew, four of 13 patients treated by technicians compared with seven of 15 by paramedics survived to hospital discharge. Only two patients surviving to hospital discharge received drug treatment before the return of spontaneous circulation.

Question: Can the full range of paramedic skills improve survival from out of hospital cardiac arrests?

No improvement in survival was demonstrated with more advanced prehospital care.

Answer the question based on the following context: To investigate how well junior doctors in accident and emergency (A&E) were able to diagnose significant x ray abnormalities after trauma and to compare their results with those of more senior doctors. 49 junior doctors (senior house officers) in A&E were tested with an x ray quiz in a standard way. Their results were compared with 34 consultants and senior registrars in A&E and radiology, who were tested in the same way. The quiz included 30 x rays (including 10 normal films) that had been taken after trauma. The abnormal films all had clinically significant, if sometimes uncommon, diagnoses. The results were compared and analysed statistically. The mean score for the abnormal x rays for all the junior doctors was only 32% correct. The 10 junior doctors were more experience scored significantly better (P<0.001) but their mean score was only 48%. The mean score of the senior doctors was 80%, which was significantly higher than the juniors (P<0.0001).

Question: Interpretation of trauma radiographs by junior doctors in accident and emergency departments: a cause for concern?

The majority of junior doctors misdiagnosed significant trauma abnormalities on x ray. Senior doctors scored well, but were not infallible. This suggests that junior doctors are not safe to work on their own in A&E departments. There are implications for training, supervision, and staffing in A&E departments, as well as a need for fail-safe mechanisms to ensure adequate patient care and to improve risk management.

Answer the question based on the following context: Does background stress heighten or dampen children's cardiovascular responses to acute stress? To address this question, the cardiovascular responses to four acute laboratory stressors of 150 children and adolescents were evaluated according to their self-reported background stress level. Background stress was determined during a standardized interview and was a priori classified according to its importance, frequency, and whether it was ongoing or resolved. Results showed that children and adolescents who reported important stressors or stressors that were ongoing and frequent exhibited a larger increase in diastolic blood pressure and total peripheral resistance during all four laboratory stressors than their low stress counterparts. Additional analysis showed that the results could not be accounted for by sociodemographic variables or by the personality traits measured in this study.

Question: Does background stress heighten or dampen children's cardiovascular responses to acute stress?

Results suggest the importance of measuring background stress in understanding an individual's acute stress response.

Answer the question based on the following context: To assess the relation between individual operator coronary interventional volume and incidence of complications, the in-hospital outcome at a single, moderate volume urban academic center was prospectively collected over a 3-year period. A minimum of 75 coronary interventions/operator per year may be required in the future to obtain formal certification. However, few data exist regarding individual operator volumes and procedural outcome. Between January 1993 and December 1995, 1,389 consecutive procedures were performed or supervised by nine geographic full-time operators: 171 (12.3%) utilized various devices, and 350 (25.2%) involved multivessel coronary intervention. Left ventricular ejection fraction was 59 +/- 15% (mean +/- SD), and there were 1.7 +/- 0.7 vessels diseased (with>or = 70% stenosis). Clinical indications included stable angina in 22.5% of cases, unstable angina in 31.9%, acute myocardial infarction (MI) in 2.9%, post MI in 20.6%, shock or acute heart failure in 3.0% and restenosis in 19.1%. In the last consecutive 857 lesions in 655 cases, 20.7% type A, 55.5% type B and 23.8% type C lesions were categorized before coronary intervention. Average yearly operator volume ranged from 26 to 83 cases (mean 51 +/- 26). Each operator has performed a total of 590 +/- 268 coronary interventions, with 10.0 +/- 4.3 years of coronary interventional experience. The mean angioplasty volume rating for the nine operators was 180 +/- 37 (>170 considered adequate). The in-hospital major complication rate was 1.4% (95% confidence interval 0.7% to 1.893%) for all coronary interventions, including death in 3 patients, bypass surgery in 13, arrhythmia in 3 and Q wave MI in 2. To ascertain how these outcomes compared with standard measures of coronary interventional outcome, four previously published registries were reanalyzed in a similar manner. The rate of complications in the present study was found to be significantly lower than that of the 1992-1993 Society for Cardiac Angiography and Intervention registry (1.9%, n = 19,594, p<0.05 [excludes ventricular arrhythmias]), the 1994 American College of Cardiology database (3.9%, n = 38,963, p = 0.001), the Mid-America Heart Institute outcome in 1988 (2.3%, n = 5,413, p = 0.02) and the 1985-1986 National Heart, Lung, and Blood Institute Registry (7.2%, n = 1,801, p = 0.001). Odds ratios and 95% confidence intervals showed the outcome in the current study to be at least comparable to the standard registries.

Question: Does low individual operator coronary interventional procedural volume correlate with worse institutional procedural outcome?

Despite individual operator volumes below those currently being considered for credentialing, the overall institutional outcome was excellent in a diverse and complex patient population.

Answer the question based on the following context: This study sought to investigate the independent effect of ethnicity on the utilization of invasive cardiac procedures after acute myocardial infarction (AMI). The precise role of ethnicity in access to cardiovascular procedures is unknown, particularly because of difficulty in isolating ethnicity from financial and other socioeconomic factors. We conducted a retrospective analysis of the use of cardiac catheterization and coronary revascularization procedures after AMI in military health care beneficiaries. The Military Health Services System (MHSS) ensures equal access to care in an environment without financial incentives for procedural utilization; furthermore, socioeconomic differences between patients beyond ethnicity are minimized. Data were analyzed from the Civilian External Peer Review Program representing abstracted chart reviews from 125 military health care facilities worldwide for all patients (1,208 white; 233 nonwhite [155 black]) with the principal or secondary diagnosis of AMI from March to September 1993. Rates of cardiac catheterization were similar in white and nonwhite patients (34.8 vs. 39.1%, p = 0.21). After controlling for age, gender, cardiovascular risk factors and AMI variables, including infarct size and other risk markers, there were no differences in the use of this procedure during the AMI admission in comparisons of white versus nonwhite patients (estimated odds ratio [OR] 0.96, 95% confidence interval [CI]0.69 to 1.34) and white versus black patients (OR 1.19, 95% CI 0.80 to 1.78). However, white patients were significantly more likely than nonwhite patients to be "considered" for future cardiac catheterization (OR 1.77, 95% CI 1.19 to 2.61). Coronary revascularization within 180 days was not significantly affected by race in white versus nonwhite (OR 0.90, 95% CI 0.59 to 1.39) and white versus black patients (OR 1.11, 95% CI 0.65 to 1.89). Outcomes (30- and 180-day mortality and readmission rates) were similar for all race groups.

Question: Can characteristics of a health care system mitigate ethnic bias in access to cardiovascular procedures?

There is a limited relation between ethnicity and the use of invasive cardiac procedures in the MHSS. These data raise the promise that characteristics of a health care system can mitigate ethnic bias in medicine.

Answer the question based on the following context: The present study examined whether angina 48 h before myocardial infarction provides protection in adult and elderly patients. The mortality rate for coronary artery disease is greater in elderly than in young patients. In experimental studies, ischemic preconditioning affords an endogenous form of protection against ischemia-reperfusion injury in adult but not in senescent hearts. Angina before myocardial infarction, a clinical equivalent of experimental ischemic preconditioning, has a protective effect in adult patients. It is not known whether angina before myocardial infarction is also protective in aged patients. We retrospectively verified whether antecedent angina within 48 h of myocardial infarction exerts a beneficial effect on in-hospital outcomes in adult (<65 years old, n = 293) and elderly (>or = 65 years old, n = 210) patients. In-hospital death was more frequent in adult patients without than in those with previous angina (10% vs. 2.6%, p<0.01), as were congestive heart failure or shock (10.7% vs. 3.3%, p<0.02) and the combined end points (in-hospital death and congestive heart failure or shock) (20.7% vs. 5.9%, p<0.0003). In contrast, the presence or absence of previous angina before acute myocardial infarction in elderly patients seems not to influence the incidence of in-hospital death (14.4% vs. 15.2%, p = 0.97), congestive heart failure or shock (11.0% vs. 11.9%, p = 0.99) and the combined end points (25.4% vs. 27.1%, p = 0.89). Logistic regression analysis models for in-hospital end points show that previous angina is a positive predictor in adult but not in elderly patients.

Question: Angina-induced protection against myocardial infarction in adult and elderly patients: a loss of preconditioning mechanism in the aging heart?

The presence of angina before acute myocardial infarction seems to confer protection against in-hospital outcomes in adults; this effect seemed to be less obvious in elderly patients. This study suggests that the protection afforded by angina in adult patients may involve the occurrence of ischemic preconditioning, which seems to be lost in senescent patients.

Answer the question based on the following context: The purpose of this study was to examine the theories that underlie the clinical decision to perform endoscopy in patients with symptoms of gastroesophageal reflux disease (GERD). Physicians reported that they use endoscopic findings to modify medical treatment of GERD. This study was undertaken to test this hypothesis in clinical practice. A consortium of community specialists in gastrointestinal disease was formed. Physicians completed a database on patients undergoing elective endoscopy for symptoms of GERD, which includes symptom severity, endoscopic findings, and medical treatment before and after endoscopy. An increase in medical treatment was defined as an increase in acid suppression therapy, and/or the addition of a promotility drug, and/or referral for surgery. Data were collected prospectively over 6 months on 664 patients with symptoms of GERD, and complete data were available on 598 patients. Barrett's esophagus or active esophagitis (erythema, erosions, or ulceration) was present in 374 patients. Of these patients, 74% had an increase in therapy after endoscopy; for only 5% did therapy decrease. In contrast, among 224 patients with a normal-appearing esophagus, 35% had an increase in treatment and 65% had either a decrease in treatment or no change. In most cases, the increase in treatment was due to persistence of symptoms or because of endoscopic findings in the stomach or duodenum. The differences in treatment changes between the two groups was highly significant (p<0.0001).

Question: Management of symptoms of gastroesophageal reflux disease: does endoscopy influence medical management?

The results support the theory that physicians often use endoscopic results to tailor medical therapy in patients with symptoms of GERD.

Answer the question based on the following context: To determine whether the failure to decrease blood pressure normally during sleep is associated with more prominent target organ damage. Cardiac and vascular structure and function were characterized in 183 asymptomatic, unmedicated hypertensive patients and compared with their ambulatory blood pressures. The 104 patients with a normal (>10%) nocturnal fall in systolic blood pressure (dippers) were similar to the 79 patients with an abnormal fall (nondippers) in sex, race, body size, smoking history, and average awake ambulatory blood pressure. Nondippers tended to be older (57 versus 54 years, P = 0.06). The supine blood pressure upon completion of the ultrasound studies was higher in the nondippers (156/93 versus 146/89 mmHg, P<0.005) as was the variability of the awake diastolic blood pressure. There were no differences between dippers and nondippers in left ventricular mass (170 versus 172 g), mass index (90 versus 91 gm/m2), prevalence of abnormal ventricular geometry, common carotid artery diameter (5.74 versus 5.75 mm), and vascular strain. Although nondippers were more likely to have carotid artery plaque (41 versus 27%, P = 0.053) and an increased intimal-medial thickness (0.84 versus 0.79 mm, P<0.05), adjustment for age rendered the differences insignificant. There were no differences in the relation of awake and sleeping systolic pressures to the left ventricular mass (r = 0.36 and 0.35, respectively, both P<0.005) or to the carotid wall thickness (r = 0.28 and 0.29, respectively, both P<0.005). When the 114 men and 69 women were considered separately, similar findings were obtained. When the 109 whites and 56 blacks (African-Americans and Afro-Caribbeans) were considered separately, there were no differences in left ventricular structure in either group, and differences in vascular structure were confined to the white subgroup.

Question: Is the absence of a normal nocturnal fall in blood pressure (nondipping) associated with cardiovascular target organ damage?

The lack of a normal nocturnal fall in blood pressure is not associated with an increase in left ventricular mass or in arterial disease independently of age. Age-related changes in carotid artery wall thickness and plaque among nondippers may reflect a contribution of an altered baroreceptor function to the lack of normal nocturnal and supine blood pressure decreases.

Answer the question based on the following context: Our goal was to evaluate whether active management of labor lowers cesarean section rates, shortens the length of labor, and overcomes any negative effects of epidural analgesia on nulliparous labor. We randomly assigned 405 low-risk term nulliparous patients to either an active management of labor (n = 200) or our usual care control protocol (n = 205). Patients who were undergoing active management of labor were diagnosed as being in labor on the basis of having painful palpable contractions accompanied by 80% cervical effacement, underwent early amniotomy, and were treated with high-dose oxytocin for failure to progress adequately in labor. The cesarean section rate in the active management of labor group was lower than that of controls but not significantly so (active management, 7.5%; controls, 11.7%; p = 0.36). The length of labor in the active management group was shortened by 1.7 hours (from 11.4 to 9.7 hours, p = 0.001). Fifty-five percent of patients received epidural analgesics; a reduction in length of labor persisted despite the use of epidural analgesics (active management 11.2 hours vs control 13.3 hours, p = 0.001). A significantly greater proportion of active management patients were delivered by 12 hours compared with controls (75% vs 58%, p = 0.01); this difference also persisted despite the use of epidural analgesics (66% vs 51%, p = 0.03).

Question: Active management of labor: does it make a difference?

Patients undergoing active management had shortened labors and were more likely to be delivered within 12 hours, differences that persisted despite the use of epidural analgesics. There was a trend toward a reduced rate of cesarean section.

Answer the question based on the following context: In cardiac hypertrophy, ECG T-wave changes imply an abnormal sequence of ventricular repolarization. We investigated the hypothesis that this is due to changes in the normal regional differences in action potential duration. We assessed the contribution of potassium- and calcium-dependent currents to these differences. Both the altered sequence of ventricular repolarization and the underlying cellular mechanisms may contribute to the increased incidence of ventricular arrhythmias in hypertrophy. Rats received daily isoproterenol injections for 7 days. Myocytes were isolated from basal subendocardial (endo), basal midmyocardial (mid), and apical subepicardial (epi) regions of the left ventricular free wall. Action potentials were stimulated with patch pipettes at 37 degrees C. The ratio of heart weight to body weight and mean cell capacitance are increased by 22% and 18%, respectively, in hypertrophy compared with controls (P<.001). Normal regional differences in action potential duration at 25% repolarization (APD25) are reduced in hypertrophy (control: endo, 11.4+/-0.9 ms; mid, 8.2+/-0.9 ms; epi, 5.1+/-0.4 ms; hypertrophy: endo, 11.6+/-0.9 ms; mid, 10.4+/-0.8 ms; epi, 7.8+/-0.6 ms). The regional differences in APD25 are still present in 3 mmol/L 4-aminopyridine. Hypertrophy affects APD75 differently, depending on the region of origin of myocytes (ANOVA P<.05). APD75 is shortened in subendocardial myocytes but is prolonged in subepicardial myocytes (control: endo, 126+/-7 ms; epi, 96+/-10 ms; hypertrophy: endo, 91+/-6 ms; epi, 108+/-7 ms). These changes in APD75 are altered by intracellular calcium buffering.

Question: Effects of hypertrophy on regional action potential characteristics in the rat left ventricle: a cellular basis for T-wave inversion?

Normal regional differences in APD and the changes observed in hypertrophy are only partially explained by differences in I(tol). In hypertrophy, the normal endocardial/epicardial gradient in APD75 appears to be reversed. This may explain the T-wave inversion observed and will have implications for arrhythmogenesis.

Answer the question based on the following context: To determine the prevalence of Lactobacillus spp. in vaginal flora during pregnancy and to assess the protective effects of lactobacilli against preterm labour. Cross-sectional analysis of Lactobacillus spp. in the vaginal flora of the pregnant coloured population of the Western Cape. A total of 480 consecutive pregnant women, aged 13-48 years, seen at their first visit to the Tygerberg Hospital antenatal clinic. Preterm labour, i.e. before 34 and 37 weeks' gestation, premature rupture of membranes, intra-uterine growth retardation and perinatal deaths. A total of 163 patients had negative cultures and 317 positive cultures for lactobacilli, aerobes or both. Delivery before 37 weeks occurred in 18% and 20% of the two groups, respectively. Lactobacillus only was cultured from 116 patients and Lactobacillus and/or other aerobes from 201 patients. Preterm labour occurred in 20% of the first group and in 19% of the second group. The perinatal outcome in patients from whom lactobacilli only were cultivated did not differ from patients from whom other aerobes and lactobacilli or other aerobes only were cultured.

Question: Do vaginal lactobacilli prevent preterm labour?

In patients at high risk for preterm labour, the presence of lactobacilli in the vagina does not seem to play a protective role.

Answer the question based on the following context: Previous studies have found that the intraocular pressure (IOP) variation from postural change is due to the obstruction of aqueous outflow by an increase in episcleral venous pressure. This study investigated if any shift of anterior lens position from postural variation would be another contributing factor. Thirty-three Chinese subjects were recruited with their IOP and anterior chamber depth (ACD) measured in the sitting, supine, and prone postures. The IOP was measured using a Pulsair 2000 noncontact tonometer and ACD with a Nidek US-2000 EchoScan unit. The highest IOP was obtained in the prone position and this value was significantly different from the IOP obtained in other postures, whereas there was no significant difference in ACD.

Question: Does the change of anterior chamber depth or/and episcleral venous pressure cause intraocular pressure change in postural variation?

Because no significant variation in ACD was demonstrated, the prone and supine IOP variation could be due to something other than the change in lens position. However, a higher IOP in the prone position rather than in the supine position also suggests that it is not merely the episcleral venous pressure causing the IOP change. Investigation of the entire iris profile at different postures would be more informative in future studies.

Answer the question based on the following context: To test the hypotheses that patient expectations are a driving force in drug prescribing and that fulfilment of expectations is followed by higher satisfaction. Pre- and post-consultation survey of patients; parallel doctor survey (matched pairs). Primary health care in Göttingen, a town of about 130,000 inhabitants in Germany. Ten general practitioners and 185 randomly addressed patients. Patient expectations with respect to the result of the consultation; doctor's perception of patient expectations; agreement between patient and doctor; patient satisfaction. Nearly half of the patients (86/185) expected a drug prescription from their doctor; 68% (125/185) received a prescription. The doctors recognized the expectation of a prescription in only 40.7% of the patients. A high percentage (82.6%) of patients expecting a drug were issued a prescription. Nearly all the patients (45/48) who expected a drug according to their doctor's judgement left the surgery with a prescription, and 58.4% of the remaining patients were prescribed a drug. There was no difference in satisfaction scores between patients whose expectations were or were not fulfilled.

Question: Are patients more satisfied when they receive a prescription?

These results are in some contrast to the main hypotheses. As fulfilment of expectations was not associated with higher satisfaction, physicians need not necessarily worry that patients will change their doctor if he or she refuses a pharmacologically dubious prescription.

Answer the question based on the following context: We carried out two studies (a and b) to assess general practitioners' attitudes towards a) regionally developed guidelines and b) guidelines developed by the Danish College of General Practitioners. a) A randomized study among all GPs in Aarhus county comparing their attitudes towards guidelines in general and towards regional multidisciplinary developed guidelines on Pap-testing for cervical cancer, and b) a survey among all Danish GPs on attitudes towards earlier submitted guidelines for diabetes Type 2. GPs in Aarhus county and in all Denmark. a) Questionnaires sent to 370 doctors in Aarhus county, and b) to 3471 GPs in all Denmark. a) Attitudes to the known Pap guidelines compared with general attitudes. Themes in question were acceptance of guidelines, acceptance of multidisciplinary involvement, especially from the administrative staff, perceived effect on the consultation and the quality of care. In study b) remembrance of receiving, having read and used previous guidelines. Wishes with respect to future updates. a) GPs were very positive towards the Pap guidelines they knew, and only few resisted. The number of positive answers was significantly fewer when doctors were asked about guidelines in general. b) There was an overwhelmingly positive attitude towards guidelines from the College on diabetes care and other topics relevant to GP work.

Question: Do general practitioners want guidelines?

Danish GPs reported a very positive attitude towards the presented well-known guidelines on Pap testing and diabetes Type 2, and a fairly positive attitude towards hypothetical questions on guidelines in general.

Answer the question based on the following context: Malignant ampullary tumors (AT) require pancreatico-duodenectomy (PD) for curative treatment whereas benign AT can be appropriately treated by local resection. This study evaluated the accuracy of endoscopic exploration combining side-viewing duodenoscopy (SVD) with forceps biopsies, endoscopic sphincterotomy (ES), and endoscopic ultrasonography (EUS) to distinguish benign AT from malignant one. Twenty-six patients with AT had preoperative SVD with forceps biopsies, including 9 with ES, and EUS. Nodal status was evaluated by EUS in all patients, but could not evaluate parietal spread in 6 in whom ES was previously done. Results of endoscopic examination were compared with pathologic examination after resection (2 local excisions for 2 benign AT, and 24 PD for 20 malignant and 4 benign AT). Accuracy of histologic examination of the 26 biopsies of the papilla was 69%. After ES, accuracy of intra-ampullary biopsies was 77%. The EUS had a 75% accuracy for the parietal spread (tumor limited to ampulla or not) and a 69% accuracy for the nodal status. In 11 patients, all explorations were consistent with a benign lesion, but 6 of these patients had a histologically proven malignancy, including one with nodal metastases and two with duodenal involvement.

Question: Are endoscopic procedures able to predict the benignity of ampullary tumors?

Side-viewing duodenoscopy with biopsies, even after ES, combined with EUS is not accurate enough to preoperatively ensure that an AT is benign. Indication for a local resection based on these explorations alone is not safe.

Answer the question based on the following context: Patients with malignant pleural mesothelioma (MPM) eligible for extrapleural pneumonectomy (EPP) may benefit from induction chemotherapy (CT) as historically described, or from induction-accelerated hemithoracic intensity-modulated radiation therapy (IMRT) as a potential alternative. However, the impact of the type of induction therapy on postoperative morbidity and mortality remains unknown. We performed a retrospective study including every patient who underwent EPP for MPM in our institution between January 2001 and December 2014. Patients without induction treatment (n = 7) or undergoing both induction CT and IMRT (n = 2) were then excluded. The remaining patients (study group) were divided according to the type of induction treatment in Group 1-CT and Group 2-IMRT. Major complications were defined by complications of Grade 3 or higher according to the National Cancer Institute Common Terminology Criteria for Adverse Events 4.0 guidelines. Red blood cell (RBC) transfusion was analysed as a number of packs, and dichotomized as<3 vs ≥3 packs. Plasma and platelet transfusion were analysed as a number of units, and dichotomized as no transfusion versus any plasma or platelet transfusion. Altogether, 126 patients (mean age 61.3 ± 8.1 years, males 82.5%, right side 60.3%, 90-day mortality rate 4.8%) accounted for the study group. Sixty-four patients were included in Group 1-CT and 62 patients were included in Group 2-IMRT. When compared with Group 1-CT, Group 2-IMRT was characterized by older patients (59.3 ± 9.2 vs 63.3 ± 8.3 years, P = 0.012), more right-sided resections (46.8 vs 74.1%, P = 0.003), more advanced disease (pathological stage IV: 28.1 vs 53.2%, P = 0.007), less RBC transfusions (5.1 ± 3.0 vs 3.0 ± 2.4 packs, P<0.001), less plasma or platelet transfusions (31.2 vs 9.6%, P = 0.005) and similar rate of major complications (29.6 vs 35.4%, P = 0.614). The 90-day mortality rate was 6.2% in Group 1-CT (n = 4) and 3.2% in Group 2-RT (n = 2, P = 0.680). Induction with IMRT was significantly associated with a decreased risk of transfusion with RBCs [odds ratio (OR) = 0.10, 95% confidence interval (CI) 0.04-0.23, P<0.001] as well as plasma and platelets (OR = 0.25, 95% CI 0.086-0.67, P = 0.008).

Question: Impact of induction therapy on postoperative outcome after extrapleural pneumonectomy for malignant pleural mesothelioma: does induction-accelerated hemithoracic radiation increase the surgical risk?

In this large single-centre series of EPP for MPM, the implementation of induction IMRT was not associated with any significant increase in the surgical risks above and beyond induction CT. The switch from induction CT to induction IMRT was associated with resection in older patients with more advanced tumours, less transfusion requirements, comparable postoperative morbidity and 90-day mortality.

Answer the question based on the following context: Selected patients who failed to be weaned off temporary veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support may be considered for long-term left ventricular assist devices (LVADs). Activation of the systemic inflammatory response due to the cardiopulmonary bypass (CPB) machine and its associated deleterious effects on the coagulation system have been well documented. The aim of the study was to compare the outcome of patients receiving VAD on VA-ECMO with patients who were converted to CPB at the time of VAD implantation. Data of patients undergoing LVAD implantation between January 2010 and September 2015 were retrospectively reviewed. Inclusion criteria were patients with prior VA-ECMO. Perioperative characteristics and postoperative outcome of patients who received LVAD after VA-ECMO with (CPB group) or without CPB (no-CPB group) were compared. A total of 110 permanent VADs were implanted during this time frame. Forty patients had VA-ECMO prior to VAD implantation and met the inclusion criteria. The CPB was used in 23 patients and 17 patients received VAD on VA-ECMO without using CPB. The preoperative characteristics of the patients were comparable except for lower body mass index, higher international normalized ratio (INR) and higher rate of preoperative intra-aortic balloon pump usage in the CPB group (P = 0.035, 0.008 and 0.003, respectively). The incidence of postoperative right VAD implantation and survival rate was comparable between both groups. However, the chest tube blood loss and amount of blood product usage was higher in the CPB group. The total blood loss in the first 24 h after surgery (2469 ± 2067 vs 1080 ± 941 ml, P= 0.05) and number of units of intraoperative fresh frozen plasma administered (4 ± 3 vs 1 ± 2, P= 0.02) remained higher in the CPB group even after adjustment for differences in preoperative INR value by propensity score matching.

Question: Implanting permanent left ventricular assist devices in patients on veno-arterial extracorporeal membrane oxygenation support: do we really need a cardiopulmonary bypass machine?

This study demonstrates that the CPB machine can be safely omitted when a long-term VAD is implanted on VA-ECMO support. Blood loss in the first 24 h after surgery was less and a significantly lower number of blood products were necessary in these patients compared with patients in whom the CPB machine was used. However, similar survival rates between these two groups were observed.

Answer the question based on the following context: Cardiac computed tomography angiography (CCTA) reduces emergency department length of stay compared with standard evaluation in patients with low- and intermediate-risk acute chest pain. Whether diabetic patients have similar benefits is unknown. In this prespecified analysis of the Rule Out Myocardial Ischemia/Infarction by Computer Assisted Tomography (ROMICAT II) multicenter trial, we randomized 1000 patients (17% diabetic) with symptoms suggestive of acute coronary syndrome to CCTA or standard evaluation. The rate of acute coronary syndrome was 8% in both diabetic and nondiabetic patients (P=1.0). Length of stay was unaffected by the CCTA strategy for diabetic patients (23.9 versus 27.2 hours, P=0.86) but was reduced for nondiabetic patients compared with standard evaluation (8.4 versus 26.5 hours, P<0.0001; P interaction=0.004). CCTA resulted in 3-fold more direct emergency department discharge in both groups (each P≤0.0001, P interaction=0.27). No difference in hospital admissions was seen between the 2 strategies in diabetic and nondiabetic patients (P interaction=0.09). Both groups had more downstream testing and higher radiation doses with CCTA, but these were highest in diabetic patients (all P interaction≤0.04). Diabetic patients had fewer normal CCTAs than nondiabetic patients (32% versus 50%, P=0.003) and similar normalcy rates with standard evaluation (P=0.70). Notably, 66% of diabetic patients had no or mild stenosis by CCTA with short length of stay comparable to that of nondiabetic patients (P=0.34), whereas those with>50% stenosis had a high prevalence of acute coronary syndrome, invasive coronary angiography, and revascularization.

Question: Coronary CT Angiography Versus Standard Emergency Department Evaluation for Acute Chest Pain and Diabetic Patients: Is There Benefit With Early Coronary CT Angiography?

Knowledge of coronary anatomy with CCTA is beneficial for diabetic patients and can discriminate between lower risk patients with no or little coronary artery disease who can be discharged immediately and higher risk patients with moderate to severe disease who warrant further workup.

Answer the question based on the following context: Colorectal cancer (CRC) screening programmes based on faecal immunochemical testing for haemoglobin (FIT) typically use a screening interval of 2 years. We aimed to estimate how alternative FIT strategies that use a lower than usual positivity threshold followed by a longer screening interval compare with conventional strategies. We analysed longitudinal data of 4523 Dutch individuals (50-74 years at baseline) participating in round I of a one-sample FIT screening programme, of which 3427 individuals also participated in round II after 1-3 years. The cohort was followed until 2 years after round II. In both rounds, a cut-off level of ≥50 ng haemoglobin (Hb)/mL buffer (corresponding to 10 µg Hb/g faeces) was used, representing the standard scenario. We determined the cumulative positivity rate (PR) and the numbers of subjects diagnosed with advanced adenomas (N_AdvAd) and early stage CRC (N_earlyCRC) in the cohort over two rounds of screening (standard scenario) and compared it with hypothetical single-round screening with use of a lower cut-off and omission of the second round (alternative scenario). In the standard scenario, the cumulative (ie, round I and II combined) PR, N_AdvAd and N_earlyCRC were 13%, 180% and 26%, respectively. In alternative scenarios using a cut-off level of respectively ≥11 and ≥22 ng/HbmL buffer (corresponding to 2 and 4 µg Hb/g faeces), the PRs were 18% and 13%, the N_AdvAd were 180 and 162 and the N_earlyCRC ranged between 22-27 and 22-26.

Question: Immunochemical faecal occult blood testing to screen for colorectal cancer: can the screening interval be extended?

The diagnostic yield of FIT screening using a lowered positivity threshold in combination with an extended screening interval (up to 5 years) may be similar to conventional FIT strategies. This justifies and motivates further research steps in this direction.

Answer the question based on the following context: Some models suggest that homophobia can be explained as a denied attraction toward same-sex individuals. While it has been found that homophobic men have same-sex attraction, these results are not consistent.AIM: This study drew on the dual-process models to test the assumption that sexual interest in homosexual cues among men high in homophobia will depend on their specific impulses toward homosexual-related stimuli. Heterosexual men (N = 38) first completed a scale measuring their level of homonegativity. Then, they performed a manikin task to evaluate their impulsive approach tendencies toward homosexual stimuli (IAHS). A picture-viewing task was performed with simultaneous eye-tracking recording to assess participants' viewing time of the visual area of interest (i.e., face and body). IAHS positively predicted the viewing time of homosexual photographs among men with a high score of homonegativity. Men with a high homonegativity score looked significantly longer at homosexual than at heterosexual photographs but only when they had a high IAHS.

Question: Homophobia: An Impulsive Attraction to the Same Sex?

These findings confirm the importance of considering the variability in impulsive processes to understand why some (but not all) men high in homophobia have homosexual interest. These findings reinforce the theoretical basis for elaborating a dual-process model for behaviors in the sexual context.

Answer the question based on the following context: We compared the efficacy of perioperative ivabradine, bisoprolol, or both for prevention of postoperative atrial fibrillation (AF) in patients undergoing coronary artery bypass grafting (CABG). We enrolled 740 consecutive patients scheduled for elective CABG with/without valve surgery. Patients were assigned to 1 of 3 protocols: ivabradine given perioperatively (48 hours preoperatively, then 1 week postoperatively) 5 mg bid for 24 hours, then 7.5 mg bid thereafter in patients who can tolerate (group 1, n = 212); bisoprolol given perioperatively 5 mg bid (group 2, n = 288); or both drugs given perioperatively (ivabradine as before + bisoprolol 5 mg once daily) (group 3, n = 240). Cardiac rhythm was continuously monitored for 15 days postoperatively by ambulatory event recorder. Clinical follow-up for the occurrence of arrhythmias was performed for the next 15 days. The primary endpoint was the incidence of AF at 30-day follow-up. Mean age was 56.5 ± 8.9 years (30.5% females). All patients completed 30-day follow-up. AF occurred in 10.4%. The 3 groups were matched for most baseline characteristics, echocardiographic and angiographic data (P>0.05 for all). The incidence of AF was significantly lower in group 3 (4.2%), compared with group 1 (15.5%), and group 2 (12.2%), (P<0.001 both). The duration of stay in the intensive care unit was shorter in group 3 versus group 1 and 2 (P<0.001 both).

Question: Atrial Fibrillation After Coronary Artery Bypass Surgery: Can Ivabradine Reduce Its Occurrence?

In patients undergoing elective CABG, adding ivabradine to β-blockers during the perioperative period was associated with reduced incidence of AF at 30-day follow-up, compared with either medication alone.

Answer the question based on the following context: Arteriopathy is the leading cause of childhood arterial ischemic stroke. Mechanisms are poorly understood but may include inherent abnormalities of arterial structure. Extracranial dissection is associated with connective tissue disorders in adult stroke. Focal cerebral arteriopathy is a common syndrome where pathophysiology is unknown but may include intracranial dissection or transient cerebral arteriopathy. We aimed to quantify cerebral arterial tortuosity in childhood arterial ischemic stroke, hypothesizing increased tortuosity in dissection. Children (1 month to 18 years) with arterial ischemic stroke were recruited within the Vascular Effects of Infection in Pediatric Stroke (VIPS) study with controls from the Calgary Pediatric Stroke Program. Objective, multi-investigator review defined diagnostic categories. A validated imaging software method calculated the mean arterial tortuosity of the major cerebral arteries using 3-dimensional time-of-flight magnetic resonance angiographic source images. Tortuosity of unaffected vessels was compared between children with dissection, transient cerebral arteriopathy, meningitis, moyamoya, cardioembolic strokes, and controls (ANOVA and post hoc Tukey). Trauma-related versus spontaneous dissection was compared (Student t test). One hundred fifteen children were studied (median, 6.8 years; 43% women). Age and sex were similar across groups. Tortuosity means and variances were consistent with validation studies. Tortuosity in controls (1.346±0.074; n=15) was comparable with moyamoya (1.324±0.038; n=15; P=0.998), meningitis (1.348±0.052; n=11; P=0.989), and cardioembolic (1.379±0.056; n=27; P=0.190) cases. Tortuosity was higher in both extracranial dissection (1.404±0.084; n=22; P=0.021) and transient cerebral arteriopathy (1.390±0.040; n=27; P=0.001) children. Tortuosity was not different between traumatic versus spontaneous dissections (P=0.70).

Question: Arterial Tortuosity: An Imaging Biomarker of Childhood Stroke Pathogenesis?

In children with dissection and transient cerebral arteriopathy, cerebral arteries demonstrate increased tortuosity. Quantified arterial tortuosity may represent a clinically relevant imaging biomarker of vascular biology in pediatric stroke.

Answer the question based on the following context: An increased prevalence of metabolic syndrome including nonalcoholic fatty liver disease (NAFLD) was reported in psoriasis. NAFLD can progress to nonalcoholic steatohepatitis and fibrosis. Transient elastography (TE) is a noninvasive liver fibrosis assessment. We evaluated the prevalence of significant liver fibrosis or high liver stiffness measurement (LSM) using the LSM cutoff over 7 kPa and its associated factors in psoriatic patients. Subjects underwent TE and ultrasonography. Univariate and multivariate analysis were performed for the associated factors. One hundred and sixty-eight patients were recruited. Three patients were excluded due to TE failure. Mean BMI was 24.8 ± 4.7 kg/m(2). NAFLD, metabolic syndrome, and diabetes were seen in 105 (63.6%), 83 (50.3%), and 31 (18.8%) patients. The total cumulative dose of methotrexate over 1.5 g was seen in 39 (23.6%) patients. Mean LSM was 5.3 ± 2.9 kPa. High LSM was found in 18 (11.0%) patients. Waist circumference (OR: 1.24; 95% CI: 1.11-1.38; P = 0.0002), diabetes (OR: 12.70; 95% CI: 1.84-87.70; P = 0.010), and AST (OR: 1.08; 95% CI: 1.02-1.16; P = 0.017) were associated with high LSM.

Question: Liver Stiffness Measurement in Psoriasis: Do Metabolic or Disease Factors Play the Important Role?

11% of psoriatic patients had significant liver fibrosis by high LSM. Waist circumference, diabetes, and AST level were the independent predictors.

Answer the question based on the following context: Total shoulder arthroplasty (TSA) is a common treatment to decrease pain and improve shoulder function in patients with severe osteoarthritis (OA). In Canada, patients requiring this procedure often wait a year or more. Our objective was to determine patient preferences related to accessing TSA, specifically comparing out-of-pocket payments for treatment, travel time to hospital, the surgeon's level of experience and wait times. We administered a discrete choice experiment among patients with endstage shoulder OA currently waiting for TSA. Respondents were presented with 14 different choice sets, each with 3 options, and they were asked to choose their preferred scenario. A conditional logit regression model was used to estimate the relative preference and willingness to pay for each attribute. Sixty-two respondents completed the questionnaire. Three of the 4 attributes significantly influenced treatment preferences. Respondents had a strong preference for an experienced surgeon (mean 0.89 ± standard error [SE] 0.11), while reductions in travel time (-0.07 ± 0.04) or wait time (-0.04 ± 0.01) were of less importance. Respondents were found to be strongly averse (-1.44 ± 0.18) to surgical treatment by a less experienced surgeon and to paying out-of-pocket for their surgical treatment (-0.56 ± 0.05).

Question: Are patients willing to pay for total shoulder arthroplasty?

Our results suggest that patients waiting for TSA to treat severe shoulder OA have minimal willingness to pay for a reduction in wait time or travel time for surgery, yet will pay higher amounts for treatment by an experienced surgeon.

Answer the question based on the following context: To establish if palpable breast masses with benign greyscale ultrasound features that are soft on shear-wave elastography (SWE) (mean stiffness<50 kPa) have a low enough likelihood of malignancy to negate the need for biopsy or follow-up. The study group comprised 694 lesions in 682 females (age range 17-95 years, mean age 56 years) presenting consecutively to our institution with palpable lesions corresponding to discrete masses at ultrasound. All underwent ultrasound, SWE and needle core biopsy. Static greyscale images were retrospectively assigned Breast Imaging Reporting and Data System (BI-RADS) scores by two readers blinded to the SWE and pathology findings, but aware of the patient's age. A mean stiffness of 50 kPa was used as the SWE cut-off for calling a lesion soft or stiff. Histological findings were used to establish ground truth. No cancer had benign characteristics on both modalities. 466 (99.8%) of the 467 cancers were classified BI-RADS 4a or above. The one malignant lesion classified as BI-RADS 3 was stiff on SWE. 446 (96%) of the 467 malignancies were stiff on SWE. No cancer in females under 40 years had benign SWE features. 74 (32.6%) of the 227 benign lesions were BI-RADS 3 and soft on SWE; so, biopsy could potentially have been avoided in this group.

Question: Shear-wave elastography and greyscale assessment of palpable probably benign masses: is biopsy always required?

Lesions which appear benign on greyscale ultrasound and SWE do not require percutaneous biopsy or short-term follow-up, particularly in females under 40 years.

Answer the question based on the following context: Silver-Russell syndrome (SRS) is a genetically heterogeneous syndrome characterized by low birth weight, severe short stature, and variable dysmorphic features. GH treatment is a registered growth-promoting therapy for short children born small for gestational age, including SRS, but there are limited data on the GH response in SRS children and on differences in response among the (epi)genetic SRS subtypes (11p15 aberrations, maternal uniparental disomy of chromosome 7 [mUPD7], and idiopathic SRS). To compare growth and adult height between GH-treated small for gestational age children with and without SRS (non-SRS), and to analyze the difference in GH response among SRS genotypes. A longitudinal study. Sixty-two SRS and 227 non-SRS subjects. All subjects received GH treatment (1 mg/m(2)/d). Adult height and total height gain. The SRS group consisted of 31 children with 11p15 aberrations, 11 children with mUPD7, and 20 children with idiopathic SRS. At the start of GH treatment, mean (SD) height standard deviation score [SDS] was significantly lower in SRS (-3.67 [1.0]) than in non-SRS (-2.92 [0.6]; P<.001). Adult height SDS was lower in SRS (-2.17 [0.8]) than in non-SRS (-1.65 [0.8]; P = .002), but the total height gain SDS was similar. There was a trend toward a greater height gain in mUPD7 than in 11p15 (P = .12).

Question: Long-Term Results of GH Treatment in Silver-Russell Syndrome (SRS): Do They Benefit the Same as Non-SRS Short-SGA?

Children with SRS have a similar height gain during GH treatment as non-SRS subjects. All (epi)genetic SRS subtypes benefit from GH treatment, with a trend toward mUPD7 and idiopathic SRS having the greatest height gain.

Answer the question based on the following context: Brain natriuretic peptide and its derivative peptide NTproBNP are utilized to exclude cardiac diseases, and predicting risk of mortality in dialysis patients. Our aim was to evaluate both elimination of NTproBNP through dialysate and a possible relationship between plasma and/or dialysate NTproBNP level and membrane transport status of peritoneal dialysis patients. 57 plasma (P) and dialysate (D) samples of 44 peritoneal dialysis (PD) patients were analyzed for NTproBNP. Modified peritoneal equilibration test (PET) results and other variables were obtained from the charts. Median (IQR) NTproBNP concentrations (pg/mL × 1,000) in P and D were 3.3 (1 - 13) and 0.5 (0.2 - 3.6), respectively. There was a linear correlation between P-NTproBNP and D-NTproBNP (r = 0.928, p = 0.0001; regression equation was y = 0.897*x -0.28). Mean P/D-NTproBNP ratio was 5.5 ± 0.5. Median P and D-NTproBNP levels by the membrane transport status were aligned as high (H)>high average (HA)>low average (LA), and the difference between H and LA was statistically significant (p<0.001). Mean arterial pressure (MAP), residual Kt/V and dialysate/plasma ratio of crearinine (D/P Cr) were significant predictors of D-NTproBNP; whereas only MAP and residual Kt/V were significant predictors of P-NTproBNP in multiple regression analysis. Both P- and D-NTproBNP have significant and similar size of correlations with MAP, albumin, D/P Cr ratio, and Na.

Question: Elimination of NTproBNP in peritoneal dialysis patients. Does peritoneal membrane type make a difference in plasma level and elimination of NTproBNP?

D-NTproBNP level is ~ 1/5 of P-NTproBNP, and the issue of relationship between membrane transport status and natriuretic peptide levels needs more work.

Answer the question based on the following context: Recurrent mitral regurgitation (MR) is common after surgical and percutaneous (MitraClip) treatment of functional MR (FMR). However, the Everest II trial suggested that, in patients with secondary MR and initially successful MitraClip therapy, the results were sustained at 4 years and were comparable with surgery in terms of late efficacy. The aim of this study was to assess whether both those findings were confirmed by our own experience. We reviewed 143 patients who had an initial optimal result (residual MR ≤ 1+ at discharge) after MitraClip therapy (85 patients) or surgical edge-to-edge (EE) repair (58 patients) for severe secondary MR (mean ejection fraction 28 ± 8.5%). Patients with MR ≥ 2+ at hospital discharge were excluded. The two groups were comparable. Only age and logistic EuroSCORE were higher in the MitraClip group. Follow-up was 100% complete (median 3.2 years; interquartile range 1.8;6.1). Freedom from cardiac death at 4 years (81 ± 5.2 vs 84 ± 4.6%, P = 0.5) was similar in the surgical and MitraClip group. The initial optimal MitraClip results did not remain stable. At 1 year, 32.5% of the patients had developed MR ≥ 2+ (P = 0.0001 compared with discharge). Afterwards, patients with an echocardiographic follow-up at 2 years (60 patients), 3 years (40 patients) and 4 years (21 patients) showed a significant increase in the severity of MR compared with the corresponding 1 year grade (all P<0.01). Freedom from MR ≥ 3+ at 4 years was 75 ± 7.6% in the MitraClip group and 94 ± 3.3% in the surgical one (P = 0.04). Freedom from MR ≥ 2+ at 4 years was 37 ± 7.2 vs 82 ± 5.2%, respectively (P = 0.0001). Cox regression analysis identified the use of MitraClip as a predictor of recurrence of MR ≥ 2+ [hazard ratio (HR) 5.2, 95% confidence interval (CI) 2.5-10.8, P = 0.0001] as well as of MR ≥ 3 (HR 3.5, 95% CI 0.9-13.1, P = 0.05).

Question: Optimal results immediately after MitraClip therapy or surgical edge-to-edge repair for functional mitral regurgitation: are they really stable at 4 years?

In patients with FMR and optimal mitral competence after MitraClip implantation, the recurrence of significant MR at 4 years is not uncommon. This study does not confirm previous observations reported in the Everest II randomized controlled trial indicating that, if the MitraClip therapy was initially successful, the results were sustained at 4 years. When compared with the surgical EE combined with annuloplasty, MitraClip therapy provides lower efficacy at 4 years.

Answer the question based on the following context: In the context of a master level programming practical at the computer science department of the Karlsruhe Institute of Technology, we developed and make available an open-source code for testing all 203 possible nucleotide substitution models in the Maximum Likelihood (ML) setting under the common Akaike, corrected Akaike, and Bayesian information criteria. We address the question if model selection matters topologically, that is, if conducting ML inferences under the optimal, instead of a standard General Time Reversible model, yields different tree topologies. We also assess, to which degree models selected and trees inferred under the three standard criteria (AIC, AICc, BIC) differ. Finally, we assess if the definition of the sample size (#sites versus #sites × #taxa) yields different models and, as a consequence, different tree topologies. We find that, all three factors (by order of impact: nucleotide model selection, information criterion used, sample size definition) can yield topologically substantially different final tree topologies (topological difference exceeding 10 %) for approximately 5 % of the tree inferences conducted on the 39 empirical datasets used in our study.

Question: Does the choice of nucleotide substitution models matter topologically?

We find that, using the best-fit nucleotide substitution model may change the final ML tree topology compared to an inference under a default GTR model. The effect is less pronounced when comparing distinct information criteria. Nonetheless, in some cases we did obtain substantial topological differences.

Answer the question based on the following context: To examine associations between sexual behaviour, sexual function and sexual health service use of individuals with depression in the British general population, to inform primary care and specialist services. British general population. 15,162 men and women aged 16-74 years were interviewed for the third National Survey of Sexual Attitudes and Lifestyles (Natsal-3), undertaken in 2010-2012. Using age-adjusted ORs (aAOR), relative to a comparator group reporting no treatment or symptoms, we compared the sexual health of those reporting treatment for depression in the past year. Sexual risk behaviour, sexual function, sexual satisfaction and sexual health service use. 1331 participants reported treatment for depression (5.2% men; 11.8% women). Relative to the comparator group, treatment for depression was associated with reporting 2 or more sexual partners without condoms (men aAOR 2.07 (95% CI 1.38 to 3.10); women 2.22 (1.68 to 2.92)), and concurrent partnerships (men 1.80 (1.18 to 2.76); women 2.06 (1.48 to 2.88)), in the past year. Those reporting depression treatment were more likely to be dissatisfied with their sex lives (men 2.32 (1.74 to 3.11); women 2.30 (1.89 to 2.79)), and to score in the lowest quintile on the Natsal-sexual function measure. They were also more likely to report a recent chlamydia test (men 1.92 (1.15 to 3.20)); women (1.27 (1.01 to 1.60)), and to have sought help regarding their sex life from a healthcare professional (men 2.92 (1.98 to 4.30); women (2.36 (1.83 to 3.04)), most commonly from a family doctor. Women only were more likely to report attending a sexual health clinic (1.91 (1.42 to 2.58)) and use of emergency contraception (1.98 (1.23 to 3.19)). Associations were broadly similar for individuals with depressive symptoms but not reporting treatment.

Question: Are depression and poor sexual health neglected comorbidities?

Depression, measured by reported treatment, was strongly associated with sexual risk behaviours, reduced sexual function and increased use of sexual health services, with many people reporting help doing so from a family doctor. The sexual health of depressed people needs consideration in primary care, and mental health assessment might benefit people attending sexual health services.

Answer the question based on the following context: Ultrasound-guided cervical nerve root block (US-CRB) is considered a safe and effective method for the treatment of radicular pain. However, previous studies on the spreading pattern of injected solution in US-CRB have reported conflicting results. The aim of this study was to investigate the spreading pattern in relation to injection volume. An institutional, prospective case series. A university hospital. Fifty-three patients diagnosed with mono-radiculopathy in C5, 6, or 7. US-CRB with fluoroscopic confirmation was performed. After the cervical roots were identified in ultrasound imaging, a needle was gently introduced toward the posterior edge of the root using an in-plane approach. The spread of 1 mL and 4 mL contrast medium, each injected in the same needle position, was examined with anteroposterior and lateral fluoroscopic views. After contrast injection, a mixture of local anesthetic and corticosteroid was injected. Clinical outcome was assessed using a numeric rating scale before and 2 weeks after the procedure. Contrast medium did not spread into the epidural space in any patients with 1 mL contrast medium injection, but it did spread into the intraforaminal epidural space in 13 patients (24.5%) with 4 mL. Pain improved in all patients. There was no significant difference in pain relief according to the spreading pattern.

Question: Ultrasound-Guided Cervical Nerve Root Block: Does Volume Affect the Spreading Pattern?

The spreading pattern of injected solution in US-CRB could be partially affected by the injectant volume. However, further studies are needed to assess the importance of other factors, such as needle position and physiological effects.

Answer the question based on the following context: Recent literature suggests that blood pressure variability (BPV) predicts outcome beyond blood pressure level (BPL) and that antihypertensive drug classes differentially influence BPV. We compared calcium channel blockers, angiotensin-converting enzyme inhibitors, and angiotensin receptor blockade for effects on changes in self-measured home BPL and BPV and for their prognostic significance in newly treated hypertensive patients. We enrolled 2484 patients randomly allocated to first-line treatment with a calcium channel blocker (n=833), an angiotensin-converting enzyme inhibitor (n=821), or angiotensin receptor blockade (n=830). Home blood pressures in the morning and evening were measured for 5 days off treatment before randomization and for 5 days after 2 to 4 weeks of randomized drug treatment. We assessed BPL and BPV changes as estimated by variability independent of the mean and compared cardiovascular outcomes. Home BPL response in each group was significant (P≤0.0001) but small in the angiotensin-converting enzyme inhibitor group (systolic/diastolic: 4.6/2.8 mm Hg) compared with the groups treated with a calcium channel blocker (systolic/diastolic: 8.3/3.9 mm Hg) and angiotensin receptor blockade (systolic/diastolic: 8.2/4.5 mm Hg). In multivariable adjusted analyses, changes in home variability independent of the mean did not differ among the 3 drug classes (P≥0.054). Evening variability independent of the mean before treatment significantly predicted hard cardiovascular events independent of the corresponding home BPL (P≤0.022), whereas BPV did not predict any cardiovascular outcome based on the morning measurement (P≥0.056). Home BPV captured after monotherapy had no predictive power for cardiovascular outcome (P≥0.22).

Question: Does Antihypertensive Drug Class Affect Day-to-Day Variability of Self-Measured Home Blood Pressure?

Self-measured home evening BPV estimated by variability independent of the mean had prognostic significance, whereas antihypertensive drug classes had no significant impact on BPV changes. Home BPL should remain the primary focus for risk stratification and treatment.

Answer the question based on the following context: Acral melanoma is an uncommon type of melanoma in Caucasian patients. However, acral melanoma is the most common type of melanoma in African and Asian patients. Comparison analyses between hand-acral melanoma and foot-acral melanoma have been rarely reported in the literature. Acral melanoma is an uncommon melanocytic tumor characterized by an intrinsic aggressiveness, with specific histological and clinicopathological features. Acral melanoma involves the palms, soles and sub-ungueal sites. A total of 244 patients with acral melanoma were included in our analysis. The current study was performed in three different medical centers: Sapienza University of Rome, San Gallicano Institute of Rome and University of Magna Graecia (Italy). The Kaplan-Meier product was used to estimate survival curves for disease-free survival and overall survival. The log-rank test was used to evaluate differences between the survival curves. Assuming that the effects of the predictor variables are constant over time, the independent predictive factors were assessed by Spearman's test and subsequently data were analyzed performing Cox proportional-hazard regression. In both univariate and multivariate analyses Breslow thickness (p<0.0001) and ulceration (p = 0.003) remained the main predictors. General BRAF mutation was detected in 13.8% of cases. We found that median Breslow value and the percentage of recurrences were similar in hand-acral melanoma and foot-acral melanoma, as well as there were no differences in both short and long-term.

Question: Is the prognosis and course of acral melanoma related to site-specific clinicopathological features?

The absence of differences in survival between hand-acral melanoma and foot-acral melanoma shows that the aggressiveness of the disease is related to distinct mutational rate, as well as to anatomical site-specific features, rather than to the visibility of the primary lesion.

Answer the question based on the following context: The purpose was to evaluate economic benefit of calcium and vitamin D supplementation in orthopaedic trauma patients. We hypothesized that reduced nonunion rates could justify the cost of supplementing every orthopaedic trauma patient. Retrospective, economic model. Level 1 trauma center.PATIENTS/ Adult patients over 3 consecutive years presenting with acute fracture. Operative or nonoperative fracture management. Electronic medical records were queried for ICD-9 code for diagnosis of nonunion and for treatment records of nonunion for fractures initially treated within our institution. In our hospital, a mean of 92 (3.9%) fractures develop nonunion annually. A 5% reduction in nonunion risk from 8 weeks of vitamin D supplementation would result in 4.6 fewer nonunions per year. The mean estimate of cost for nonunion care is $16,941. Thus, the projected reduction in nonunions after supplementation with vitamin D and calcium would save $78,030 in treatment costs per year. The resulting savings outweigh the $12,164 cost of supplementing all fracture patients during the first 8 weeks of fracture healing resulting in a net savings of $65,866 per year.

Question: Economic Benefit of Calcium and Vitamin D Supplementation: Does It Outweigh the Cost of Nonunions?

Vitamin D and calcium supplementation of orthopaedic trauma patients for 8 weeks after fracture seems to be cost effective. Supplementation may also reduce the number of subsequent fractures, enhance muscular strength, improve balance in the elderly, elevate mood leading to higher functional outcome scores, and diminish hospital tort liability by reducing the number of nonunions.

Answer the question based on the following context: Fecal incontinence (FI) is a significant health problem among the elderly, with a devastating effect on their quality of life. The aim of the present study was to describe the prevalence and severity of FI among nursing home residents, and to investigate factors associated with FI. This was a cross-sectional study conducted in nursing homes in Ostrava, Czech Republic. Demographics and comorbidities were extracted from medical records of nursing homes. Data regarding incontinence were obtained via face-to-face interviews with residents or extracted from registered nurses' accounts (regarding residents with severe cognitive impairment). In total, 588 nursing home residents were enrolled into the study. FI was noted in 336 (57.1%) participating residents. The majority of FI residents (57.8%) reported FI episodes several times a week; daily FI episodes were found in 22.9% of the FI residents. The mean Cleveland Clinic Incontinence Score in FI residents was 17.2±1.8 (mean±SD). Factors associated with FI (statistically significant) were poor general health status (≥4 comorbidities), urinary incontinence, cognitive-function impairment (dementia), decreased mobility, and length of nursing home residency. There was no association between FI and age, sex, body mass index, or living with/without a partner.

Question: Fecal incontinence among nursing home residents: Is it still a problem?

Our data indicate that FI is still a serious health problem-FI currently affects more than half of the nursing home residents in Ostrava, Czech Republic. The study outcomes (revealed high prevalence and seriousness of FI) emphasize the importance of close monitoring and appropriately managing FI in nursing home residents.

Answer the question based on the following context: Patients may perceive resident procedural participation as detrimental to their outcome. Our objective is to investigate whether otolaryngology-head and neck surgery (OHNS) housestaff participation is associated with surgical morbidity and mortality. Case-control study. OHNS patients were analyzed from the American College of Surgeons National Surgical Quality Improvement Program 2006 to 2013 databases. We compared the incidence of 30-day postoperative morbidity, mortality, readmissions, and reoperations in patients operated on by resident surgeons with attending supervision (AR) with patients operated on by an attending surgeon alone (AO) using cross-tabulations and multivariable regression. There were 27,018 cases with primary surgeon data available, with 9,511 AR cases and 17,507 AO cases. Overall, 3.62% of patients experienced at least one postoperative complication. The AR cohort had a higher complication rate of 5.73% than the AO cohort at 2.48% (P<.001). After controlling for all other variables, there was no significant difference in morbidity (odds ratio [OR] = 1.05 [0.89 to 1.24]), mortality (OR = 0.91 [0.49 to 1.70]), readmission (OR = 1.29 [0.92 to 1.81]), or reoperation (OR = 1.28 [0.91 to 1.80]) for AR compared to AO cases. There was no difference between postgraduate year levels for adjusted 30-day morbidity or mortality.

Question: Does resident participation influence otolaryngology-head and neck surgery morbidity and mortality?

There is an increased incidence of morbidity, mortality, readmission, and reoperation in OHNS surgical cases with resident participation, which appears related to increased comorbidity with AR patients. After controlling for other variables, resident participation was not associated with an increase in 30-day morbidity, mortality, readmission, or reoperation odds. These data suggest that OHNS resident participation in surgical cases is not associated with poorer short-term outcomes.

Answer the question based on the following context: Maximum urethral closure pressure (MUCP) provides an objective assessment of urethral integrity, but its role in predicting outcome after midurethral sling (MUS) placement is debatable and current practice in the UK is variable. The study was carried out to determine if lower preoperative MUCP is associated with poor outcome following MUS. The study was a retrospective review of the British Society of Urogynaecology (BSUG) database and urodynamics (UDS) data. Patients who reported outcome as "no improvement", "worse" or "much worse" on the Patient Global Impression of Improvement (PGII) scale were identified as having a poor outcome. Patients who reported "a little improvement", "improved" and "very much improved" on the PGII were thought to have a good outcome. The preoperative demographics, UDS findings and quality of life (International Consultation of Incontinence questionnaires [ICIQ-SF]) data of the two groups were compared. A total of 236 women were identified for the study. Of these, 24 women (10.2 %) had a poor outcome. Of the remaining women reporting a good outcome, 50 cases were randomly selected. All urodynamic parameters, including mean functional urethral length (FUL), bladder capacity, and Qmax, were similar, except for mean MUCP 37.05 cm H2O, which was significantly lower in group 1 (poor outcome 37.05 cm H2O) compared with a mean MUCP of 50.6 cm H2O in group 2 (good outcome; p = 0.005).

Question: Should maximal urethral closure pressure be performed before midurethral sling surgery for stress incontinence?

We conclude that failure following MUS is associated with preoperatively lower MUCP, which can be used as a predictor of failure.

Answer the question based on the following context: We aimed to compare three surgical techniques (open approach for diverticulectomy with cricopharyngeal myotomy [OA], endoscopic laser-assisted diverticulotomy [ELD], and endoscopic stapler-assisted diverticulotomy [ESD]) for treatment of Zenker's diverticulum with regard to validated swallowing outcomes, radiographic outcomes, complications, and revision rates. We statistically analyzed whether the size of residual postoperative party wall or the specific surgical technique correlates with swallowing outcomes. Retrospective chart review and radiographic study analysis. A retrospective chart review and radiographic analysis of preoperative and postoperative contrast swallow studies were conducted on patients undergoing surgery for Zenker's diverticulum between 2002 and 2014 at our institution. A follow-up validated swallowing outcome questionnaire, the Eating Assessment Tool-10, was administered to measure and compare patients' symptomatic outcomes. Seventy-three patients were reviewed and grouped according to technique. Median follow-up was 1.6 years. ESD resulted in a significantly larger residual party wall than ELD and OA but yielded comparative swallowing outcomes. OA had the highest complication rate and ESD had the highest revision rate. There were no revisions after ELD nor OA.

Question: Does residual wall size or technique matter in the treatment of Zenker's diverticulum?

Despite the predictably larger residual postoperative party wall following ESD, this technique produced statistically comparable swallowing outcomes. Given its low complication rate and comparable results, ESD should be considered first line therapy for medically high-risk patients with Zenker's diverticulum, while acknowledging a higher risk of symptom recurrence. ELD, with its slightly greater risk profile but low recurrence rate, is well suited for most in revision cases. OA may best be reserved for those patients in whom endoscopic approach is not feasible.

Answer the question based on the following context: The aim of this study was to compare the efficacy and safety of minimally invasive percutaneous nephrolithotomy (MIP) and conventional percutaneous nephrolithotomy (PCNL) in the treatment of patients with large renal stone burden. MIP has proven its efficacy and safety in the management of small renal calculi. However, conventional PCNL is still considered the standard method for treatment of large renal stones in the upper urinary tract. A search of two longitudinal databases in two tertiary referral centres for complex stone disease identified 133 consecutive patients who were treated by either MIP or PCNL for renal stones 20 mm or larger between January 2009 and August 2012. Clinical data and outcome measures of the two methods were compared by Student's t test, chi-squared test or Fisher's exact test. A p value less than 0.05 was considered statistically significant. Operative time was significantly shorter and hospital stay was significantly longer in conventional PCNL compared to MIP (p = 0.002 and < 0.001, respectively). There were no significant differences in primary stone-free rate or complication rate between the two methods. Only higher graded complications (above Clavien grade II) were significantly more common in conventional PCNL (p = 0.02).

Question: Minimally invasive versus conventional large-bore percutaneous nephrolithotomy in the treatment of large-sized renal calculi: Surgeon's preference?

MIP is equally effective as conventional PCNL in the treatment of large renal calculi. Both methods have a similar complication rate. The shorter operative time in PCNL may be based on the larger diameter and quicker retrieval of large fragments; the longer mean hospital stay may be caused by the handling of the nephrostomy tube. The current data suggest that the choice of the method mainly depends on the surgeon's preference.

Answer the question based on the following context: Prior studies suggest that cohesion among members of military units has a positive impact on behavioral and mental health sequelae of combat deployment. However, these studies have not distinguished variation in cohesion across units from variation in perception of cohesion across individuals within units. A sample of U.S. Marines was assessed before and after deployment to Iraq or Afghanistan in 2010 or 2011. Within-group centering was used to distinguish unit-level from individual-level associations of cohesion with four behavioral and mental health outcomes assessed after deployment: alcohol misuse, violation of the Uniform Code of Military Justice (UCMJ), probable posttraumatic stress disorder (PTSD) and a positive screen for depression. Unit-level cohesion is associated positively with alcohol misuse (OR=1.86, 95% CI 1.05-3.29) and negatively with UCMJ violations (OR=0.41, 95% CI 0.20-0.83) but not with probable PTSD (OR=1.00, 95% CI 0.60-1.6) or a positive screen for depression (OR=1.00 95% CI 0.58-1.72). Lower perception of cohesion relative to the other members of the same unit is associated with higher likelihood of UCMJ violations, probable PTSD and a positive screen for depression. Data on all members of the studied units were not available.

Question: Is cohesion within military units associated with post-deployment behavioral and mental health outcomes?

Distinguishing unit-level from individual-level variation in cohesion among military unit members reveals more varied associations with behavioral and mental health outcomes of deployment than have been reported in previous studies, in which these levels have been collapsed. Associations between individual-level variation in cohesion and mental health outcomes may result from pre-existing traits related to both perception of cohesion and risk for psychiatric disorders.

Answer the question based on the following context: To evaluate the extracranial venous anatomy with contrast-enhanced MR venogram (CE-MRV) in patients without multiple sclerosis (MS), and assess the prevalence of various venous anomalies such as asymmetry and stenosis in this population. We prospectively recruited 100 patients without MS, aged 18-60 years, referred for contrast-enhanced MRI. They underwent additional CE-MRV from skull base to mediastinum on a 3T scanner. Exclusion criteria included prior neck radiation, neck surgery, neck/mediastinal masses or significant cardiac or pulmonary disease. Two neuroradiologists independently evaluated the studies to document asymmetry and stenosis in the jugular veins and prominence of collateral veins. Asymmetry of internal jugular veins (IJVs) was found in 75 % of subjects. Both observers found stenosis in the IJVs with fair agreement. Most stenoses were located in the upper IJV segments. Asymmetrical vertebral veins and prominence of extracranial collateral veins, in particular the external jugular veins, was not uncommon.

Question: Extracranial Venous abnormalities: A true pathological finding in patients with multiple sclerosis or an anatomical variant?

It is common to have stenoses and asymmetry of the IJVs as well as prominence of the collateral veins of the neck in patients without MS. These findings are in contrast to prior reports suggesting collateral venous drainage is rare except in MS patients.

Answer the question based on the following context: To assess modifications in baseline specific IgE- and anti-IgE- and antigen-specific-mediated basophil activation in egg-allergic children. The values were compared before and after the children completed specific oral tolerance induction (SOTI) with egg. We studied 28 egg-allergic children who completed SOTI with egg. The basophil activation test and specific IgE determinations with egg white, ovalbumin, and ovomucoid were performed in all 28 children. A decrease in antigen-specific activation with egg white, ovalbumin, and ovomucoid was observed only at the 2 lowest concentrations used (5 and 0.05 ng/mL). Baseline activation was higher in patients with multiple food allergies and in those who developed anaphylaxis during SOTI; this activation decreased in both groups after completion of SOTI. A significant decrease was also observed in specific IgE values for egg white, ovalbumin, and ovomucoid after tolerance induction.

Question: Is the Quantification of Antigen-Specific Basophil Activation a Useful Tool for Monitoring Oral Tolerance Induction in Children With Egg Allergy?

Food tolerance induction is a specific process for each food that can be mediated by immunologic changes such as a decrease in specific IgE values and in specific and spontaneous basophil activation.

Answer the question based on the following context: Component-based diagnosis on multiplex platforms is widely used in food allergy but its clinical performance has not been evaluated in nut allergy. To assess the diagnostic performance of a commercial protein microarray in the determination of specific IgE (sIgE) in peanut, hazelnut, and walnut allergy. sIgE was measured in 36 peanut-allergic, 36 hazelnut-allergic, and 44 walnut-allergic patients by ISAC 112, and subsequently, sIgE against available components was determined by ImmunoCAP in patients with negative ISAC results. ImmunoCAP was also used to measure sIgE to Ara h 9, Cora 8, and Jug r 3 in a subgroup of lipid transfer protein (LTP)-sensitized nut-allergic patients (positive skin prick test to LTP-enriched extract). sIgE levels by ImmunoCAP were compared with ISAC ranges. Most peanut-, hazelnut-, and walnut-allergic patients were sensitized to the corresponding nut LTP (Ara h 9, 66.7%; Cor a 8, 80.5%; Jug r 3, 84% respectively). However, ISAC did not detect sIgE in 33.3% of peanut-allergic patients, 13.9% of hazelnut-allergic patients, or 13.6% of walnut-allergic patients. sIgE determination by ImmunoCAP detected sensitization to Ara h 9, Cor a 8, and Jug r 3 in, respectively, 61.5% of peanut-allergic patients, 60% of hazelnut-allergic patients, and 88.3% of walnut-allergic patients with negative ISAC results. In the subgroup of peach LTP-sensitized patients, Ara h 9 sIgE was detected in more cases by ImmunoCAP than by ISAC (94.4% vs 72.2%, P<.05). Similar rates of Cora 8 and Jug r 3 sensitization were detected by both techniques.

Question: Is Microarray Analysis Really Useful and Sufficient to Diagnose Nut Allergy in the Mediterranean Area?

The diagnostic performance of ISAC was adequate for hazelnut and walnut allergy but not for peanut allergy. sIgE sensitivity against Ara h 9 in ISAC needs to be improved.

Answer the question based on the following context: Urinalysis is the third major test in clinical laboratory. Manual technique imprecision urges the need for a rapid reliable automated test. We evaluated the H800-FUSIOO automatic urine sediment analyzer and compared it to the manual urinalysis technique to determine if it may be a competitive substitute in laboratories of central hospitals. 1000 urine samples were examined by the two methods in parallel. Agreement, precision, carryover, drift, sensitivity, specificity, and practicability criteria were tested. Agreement ranged from excellent to good for all urine semi-quantitative components (K>0.4, p = 0.000), except for granular casts (K = 0.317, p = 0.000). Specific gravity results correlated well between the two methods (r = 0.884, p = 0.000). RBCS and WBCs showed moderate correlation (r = 0.42, p = 0.000) and (r = 0.44, p = 0.000), respectively. The auto-analyzer's within-run precision was>75% for all semi-quantitative components except for proteins (50% precision). This finding in addition to the granular casts poor agreement indicate the necessity of operator interference at the critical cutoff values. As regards quantitative contents, RBCs showed a mean of 69.8 +/- 3.95, C.V. = 5.7, WBCs showed a mean of 38.9 +/- 1.9, C.V. = 4.9). Specific gravity, pH, microalbumin, and creatinine also showed good precision results with C.Vs of 0.000, 2.6, 9.1, and 0.00 respectively. In the between run precision, positive control showed good precision (C.V. = 2.9), while negative control's C.V. was strikingly high (C.V. = 127). Carryover and drift studies were satisfactory. Manual examination of inter-observer results showed major discrepancies (<60% similar readings), while intra-observer's results correlated well with each other (r = 0.99, p = 0.000).

Question: Urinalysis: The Automated Versus Manual Techniques; Is It Time To Change?

Automation of urinalysis decreases observer-associated variation and offers prompt competitive results when standardized for screening away from the borderline cutoffs.

Answer the question based on the following context: Diagnosis of neonatal sepsis is difficult because of the nonspecific nature of the clinical presentation. Inflammation and coagulation can activate each other. Coagulation activation can occur in the early phase of sepsis. The main purposes of this study were to investigate the value of platelet parameters and coagulation parameters in predicting neonatal sepsis. The study included 650 patients: 490, Group I (330 proven and 160 clinical sepsis cases), and 160, Group II (control group). Platelet count (PLT), mean platelet volume (MPV), platelet distribution width (PDW), thrombocytocrit, prothrombin time (PT), and activated partial thromboplastin time (APTT) were measured. The parameters were determined before diagnosis of sepsis. Receiver-operating characteristic (ROC) curves were analyzed to determine the optimal thresholds. The optimum cutoff value, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated for each potential marker. The MPV, PDW, PT, and CRP values were found to be increased while PLT decreased significantly in sepsis patients. ROC curve analysis showed that PT and PLT were better than PDW and MPV for the diagnosis of sepsis. Further, combining PT (17.85 s) and CRP (8.5 mg/L) can enhance the diagnostic accuracy of sepsis, with a sensitivity, specificity, PPV, and NPV of 77.9, 83.1, 58.2, and 92.6%, respectively.

Question: Are Global Coagulation and Platelet Parameters Useful Markers for Predicting Late-Onset Neonatal Sepsis?

PT has a potential to be an additional indicator for neonatal sepsis, the combined use of PT and other markers such as CRP should be considered in the early diagnosis of neonatal sepsis.

Answer the question based on the following context: Data demonstrating the outcome of transcatheter aortic valve replacement (TAVR) in the very elderly patients are limited, as they often represent only a small proportion of the trial populations. The purpose of this study was to compare the outcomes of nonagenarians to younger patients undergoing TAVR in current practice. We analyzed data from the Society of Thoracic Surgeons/American College of Cardiology TVT (Transcatheter Valve Therapy) Registry. Outcomes at 30 days and 1 year were compared between patients ≥90 years versus<90 years of age using cumulative incidence curves. Quality of life was assessed with the 12-item Kansas City Cardiomyopathy Questionnaire. Between November 2011 and September 2014, 24,025 patients underwent TAVR in 329 participating hospitals, of which 3,773 (15.7%) were age ≥90 years. The 30-day and 1-year mortality rates were significantly higher among nonagenarians (age ≥90 years vs.<90 years: 30-day: 8.8% vs. 5.9%; p<0.001; 1 year: 24.8% vs. 22.0%; p<0.001, absolute risk: 2.8%, relative risk: 12.7%). However, nonagenarians had a higher mean Society of Thoracic Surgeons Predicted Risk of Operative Mortality score (10.9% vs. 8.1%; p<0.001) and, therefore, had similar ratios of observed to expected rates of 30-day death (age ≥90 years vs.<90 years: 0.81, 95% confidence interval: 0.70 to 0.92 vs. 0.72, 95% confidence interval: 0.67 to 0.78). There were no differences in the rates of stroke, aortic valve reintervention, or myocardial infarction at 30 days or 1 year. Nonagenarians had lower (worse) median Kansas City Cardiomyopathy Questionnaire scores at 30 days; however, there was no significant difference at 1 year.

Question: Should Transcatheter Aortic Valve Replacement Be Performed in Nonagenarians?

In current U.S. clinical practice, approximately 16% of patients undergoing TAVR are ≥90 years of age. Although 30-day and 1-year mortality rates were statistically higher compared with younger patients undergoing TAVR, the absolute and relative differences were clinically modest. TAVR also improves quality of life to the same degree in nonagenarians as in younger patients. These data support safety and efficacy of TAVR in select very elderly patients.

Answer the question based on the following context: Iron overload and hepatitis C virus (HCV) infection together can lead to chronic liver damage in thalassemia major (TM) patients. We investigated viral, genetic, and disease factors influencing sustained virological response (SVR) after peg-interferon and ribavirin therapy in TM patients with HCV infection. We analyzed 230 TM patients with HCV infection (mean age 36.0±6.3 years; 59.1% genotype 1; 32.2% genotype 2; 3.4% genotype 3; and 5.3% genotype 4; 28.7% carried CC allele of rs12979860 in IL28B locus; 79.6% had chronic hepatitis and 20.4% cirrhosis; 63.5% naive and 36.5% previously treated with interferon alone) treated in 14 Italian centers. By multivariate regression analysis SVR was independently associated with CC allele of IL28B SNP (OR 2.98; CI 95% 1.29-6.86; p=0.010) and rapid virologic response (OR 11.82; CI 95% 3.83-36.54; p<0.001) in 136 genotype 1 patients. Combining favorable variables the probability of SVR ranged from 31% to 93%. In genotype 2 patients, only RVR (OR 8.61; CI 95% 2.85-26.01; p<0.001) was associated with SVR higher than 80%. In 3 patients with cirrhosis a decompensation of liver or heart disease were observed. Over 50% of patients increased blood transfusions.

Question: Dual therapy with peg-interferon and ribavirin in thalassemia major patients with chronic HCV infection: Is there still an indication?

Dual therapy in TM patients with chronic HCV infection is efficacious in patients with the best virological, genetic and clinical predictors. Patients with cirrhosis have an increased risk of worsening liver or heart disease.

Answer the question based on the following context: To study hyperglycaemia in acute medical admissions to Irish regional hospital. From 2005 to 2007, 2061 white Caucasians, aged>18 years, were admitted by 1/7 physicians. Those with diabetes symptoms/complications but no previous record of hyperglycaemia (n=390), underwent OGTT with concurrent HbA1c in representative subgroup (n=148). Comparable data were obtained for 108 primary care patients at risk of diabetes. Diabetes was diagnosed immediately by routine practice in 1% (22/2061) [aged 36 (26-61) years (median IQ range)/55% (12/22) male] with pre-existing diabetes/dysglycaemia present in 19% (390/2061) [69 (58-80) years/60% (235/390) male]. Possible diabetes symptoms/complications were identified in 19% [70 (59-79) years/57% (223/390) male] with their HbA1c similar to primary care patients [54 (46-61) years], 5.7 (5.3-6.0)%/39 (34-42)mmol/mol (n=148) vs 5.7 (5.4-6.1)%/39 (36-43)mmol/mol, p=0.35, but lower than those diagnosed on admission, 10.2 (7.4-13.3)%/88 (57-122)mmol/mol, p<0.001. Their fasting plasma glucose (FPG) was similar to primary care patients, 5.2 (4.8-5.7) vs 5.2 (4.8-5.9) mmol/L, p=0.65, but 2hPG higher, 9.0 (7.3-11.4) vs 5.5 (4.4-7.5), p<0.001. HbA1c identified diabetes in 10% (15/148) with 14 confirmed on OGTT but overall 32% (48/148) were in diabetic range on OGTT. The specificity of HbA1c in 2061 admissions was similar to primary care, 99% vs 96%, p=0.20, but sensitivity lower, 38% vs 93%, p<0.001 (63% on FPG/23% on 2hPG, p=0.037, in those with possible symptoms/complications).

Question: Can HbA1c detect undiagnosed diabetes in acute medical hospital admissions?

HbA1c can play a diagnostic role in acute medicine as it diagnosed another 2% of admissions with diabetes but the discrepancy in sensitivity shows that it does not reflect transient/acute hyperglycaemia resulting from the acute medical event.

Answer the question based on the following context: A database search yielded 79 women with early-stage cervical cancer who underwent radical hysterectomy and preoperative MRI. The sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of MRI in assessment of ≤5 and>5 mm IO involvement were calculated with histopathological surgical specimen findings considered to be the reference standard. A main and subset analysis was performed. The subset analysis included only those patients who would have been considered for radical trachelectomy. For predicting a distance between the tumour and the IO of ≤5 mm, MRI had a sensitivity of 73%, a specificity of 98.3%, a PPV of 95%, a NPV of 88.1%, and an accuracy of 89.8% for the main analysis, and sensitivity of 81.8%, a specificity of 93.2% a PPV of 69.2% a NPV of 96.5% and an accuracy of 91.4% for the subset analysis.

Question: Is MRI helpful in assessing the distance of the tumour from the internal os in patients with cervical cancer below FIGO Stage IB2?

MRI has high specificity, NPV, and accuracy in detecting tumour from the IO, making MRI suitable for treatment planning in patients desiring trachelectomy to preserve fertility.

Answer the question based on the following context: Posterior communicating artery (PComA) aneurysm seems to behave uniquely compared with other intracranial aneurysms at different locations. The association between the morphology of the carotid siphon and PComA aneurysms is not well known. This study aimed to investigate whether the anatomical characteristics of the carotid siphon are associated with the formation and rupture of PComA aneurysms. One hundred and thirty-two patients were retrospectively reviewed in a monocentric case-control study. Sixty-seven consecutive patients with PComA aneurysms were included in the case group, and 65 patients with anterior circulation aneurysm situated in other intracranial locations were included in the control group, matched by age and sex. Morphological characteristics of the carotid siphon were analyzed using angiography images. A univariate analysis was used to investigate the association between the morphological characteristics and the formation of PComA aneurysms. Furthermore, a subgroup analysis within the case group compared ruptured and non-ruptured PComA aneurysms. Patients with PComA aneurysm had a significantly (1.31 ± 0.70 vs. 0.82 ± 0.46; P < 0.001) larger PComA. No association was observed between the morphological characteristics of the carotid siphon and the presence of a PComA aneurysm. Likewise, subgroup analysis showed no significant association between morphological characteristics of the carotid siphon and aneurysm rupture.

Question: Carotid siphon morphology: Is it associated with posterior communicating aneurysms?

This case-control study shows that the carotid siphon morphology seems not to be related to PComA aneurysm formation or rupture.

Answer the question based on the following context: To verify whether or not heart rate is maintained below the calculated submaximal level in healthy, sedentary subjects when they perform the 6-minute step test (6MST) and the 6-minute walking test (6MWT), and to compare the maximal heart rate achieved by the subjects at the end of each test. Observational, cross-sectional study. One tertiary centre. Two hundred and fifty-three participants from a pool of 330 healthy and sedentary subjects between 20 and 80 years of age. Both the 6MWT and the 6MST were performed in accordance with the American Thoracic Society's statement. Dyspnoea, blood pressure, oxygen saturation and heart rate were measured before and after each test. Mean heart rate immediately after the 6MST was significantly higher than mean heart rate immediately after the 6MWT {125 [standard deviation (SD) 19] vs 111 (SD 17) beats/minute; mean difference 13 (95% confidence interval of the difference 10 to 16); P<0.001}. Moreover, mean heart rate during (3minutes after commencement) the 6MST [118 (SD 18) beats/minute] was statistically higher than mean heart rate at the end of the 6MWT [111 (SD 18) beats/minute; P<0.001]. None of the subjects achieved the calculated submaximal heart rate.

Question: Can we use the 6-minute step test instead of the 6-minute walking test?

The 6MST and 6MWT are safe and produce submaximal effort in healthy participants. However, they are not interchangeable, and the 6MST requires more energy than the 6MWT.

Answer the question based on the following context: The use of the dipstick urinalysis has been validated for the diagnosis of symptomatic urinary infections, cystitis and pyelonephritis thanks to an excellent negative predictive value. For prostatitis, it is rather its positive predictive value that is interesting. The aim of this study is to validate its use in the screening of urinary colonizations in the preoperative assessment in urology. A monocentric prospective study was carried out for one year in 2011 comparing the data from the urine dipstick test with a fresh-voided midstream urinary examination and culture performed on the day of admission with the same urine sample in 598 asymptomatic patients programmed for a urological procedure. The gold standard to diagnose a microbiological-confirmed urinary tract infection or colonization was uropathogen growth of ≥10(3) colony-forming units per ml (cfu/mL) with or without leucocyturia. The study disclosed 5% of colonized patients. The urine dipstick test had a 65% sensitivity and a 97% negative predictive value. However, the low sensitivity of the urine dipstick test entailed 34% of false negatives.

Question: Can the urine dipstick be used in the diagnosis of urinary bacterial colonizations in a preoperative urological assessment?

In spite of a good negative predictive value linked to a low prevalence of colonized patients (5%), the low sensitivity of the urine dipstick test entails a non-negligible number of false negatives. Its use as a single test of preoperative screening would expose colonized patients to the prospect of an operation, which seems to be unacceptable for some of them, notably endoscopic ones.

Answer the question based on the following context: Strategies to optimize the development of sunscreens include the use of theoretical sunscreen simulators to predict sun protection factor (SPF) and UVA protection factor (UVA-PF) and in vitro measurements of UVA-PF. The aims of this study were to assess the correlations between (1) SPF and UVA-PF results obtained in a theoretical sunscreen simulator with those observed in vivo (SPF and UVA-PF) and in vitro (UVA-PF) and (2) the results of UVA-PF observed in vitro and in vivo for products in different galenic forms containing or not pigments. BASF Sunscreen Simulator software was used to evaluate the theoretical performance of formulations regarding SPF and UVA protection. In vitroUVA-PF and in vivoSPF were determined for all formulations. UVA-PFin vivo measurements were carried out only on products for which the galenic forms (compact foundations and lip balms) or the presence of dye or pigments could make the results of UVA-PFin vitro less reliable (due to a possible uneven film formation). The results of the SPF calculated by the BASF Sunscreen Simulator presented a very good correlation with SPF observed in vivo in the absence of pigments (r = 0.91; P<0.05) and a good correlation in the presence of pigments (r = 0.70; P<0.05). The UVA-PF calculated by the BASF Sunscreen Simulator also exhibited a very good correlation with UVA-PF measured in vitro (r = 0.88; P<0.05) for the formulations not containing pigment and a good correlation (r = 0.75; P<0.05) for the formulations containing pigment. The correlation of same UVA-PF calculated by BASF Sunscreen Simulator with UVA-PF measured in vivo for the formulations containing pigment was r = 0.74 (P<0.05), which is considered good. In addition, the measurements of UVA-PFin vivo presented a good correlation with the values obtained in vitro (r = 0.74; P<0.05).

Question: SPF and UVA-PF sunscreen evaluation: are there good correlations among results obtained in vivo, in vitro and in a theoretical Sunscreen Simulator?

In the present study, the use of BASF Sunscreen Simulator and in vitroUVA tests showed good correlations with in vivo results and could be considered as valuable resources in the development of sunscreens.

Answer the question based on the following context: Guidelines and text-book descriptions of the Rinne test advise orienting the tuning fork tines in parallel with the longitudinal axis of the external auditory canal (EAC), presumably to maximise the amplitude of the air conducted sound signal at the ear. Whether the orientation of the tuning fork tines affects the amplitude of the sound signal at the ear in clinical practice has not been previously reported. The present study had two goals: determine if (1) there is clinician variability in tuning fork placement when presenting the air-conduction stimulus during the Rinne test; (2) the orientation of the tuning fork tines, parallel versus perpendicular to the EAC, affects the sound amplitude at the ear. To assess the variability in performing the Rinne test, the Canadian Society of Otolaryngology - Head and Neck Surgery members were surveyed. The amplitudes of the sound delivered to the tympanic membrane with the activated tuning fork tines held in parallel, and perpendicular to, the longitudinal axis of the EAC were measured using a Knowles Electronics Mannequin for Acoustic Research (KEMAR) with the microphone of a sound level meter inserted in the pinna insert. 47.4 and 44.8% of 116 survey responders reported placing the fork parallel and perpendicular to the EAC respectively. The sound intensity (sound-pressure level) recorded at the tympanic membrane with the 512 Hz tuning fork tines in parallel with as opposed to perpendicular to the EAC was louder by 2.5 dB (95% CI: 1.35, 3.65 dB; p < 0.0001) for the fundamental frequency (512 Hz), and by 4.94 dB (95% CI: 3.10, 6.78 dB; p < 0.0001) and 3.70 dB (95% CI: 1.62, 5.78 dB; p = .001) for the two harmonic (non-fundamental) frequencies (1 and 3.15 kHz), respectively. The 256 Hz tuning fork in parallel with the EAC as opposed to perpendicular to was louder by 0.83 dB (95% CI: -0.26, 1.93 dB; p = 0.14) for the fundamental frequency (256 Hz), and by 4.28 dB (95% CI: 2.65, 5.90 dB; p < 0.001) and 1.93 dB (95% CI: 0.26, 3.61 dB; p = .02) for the two harmonic frequencies (500 and 4 kHz) respectively.

Question: Rinne test: does the tuning fork position affect the sound amplitude at the ear?

Clinicians vary in their orientation of the tuning fork tines in relation to the EAC when performing the Rinne test. Placement of the tuning fork tines in parallel as opposed to perpendicular to the EAC results in a higher sound amplitude at the level of the tympanic membrane.

Answer the question based on the following context: To evaluate how body mass index (BMI) affects rates of 30-day complication, hospital readmissions, and mortality in patients undergoing knee arthroscopy. Patients undergoing knee arthroscopy procedures between 2006 and 2013 were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Patient demographics and preoperative risk factors including BMI were analyzed for postoperative complications within 30 days. Cochran-Armitage testing was performed to detect differences in complication rates across BMI categories according to World Health Organization classification. The independent risk of BMI was assessed using multivariate regression analysis. Of 41,919 patients with mean age 48 years undergoing knee arthroscopy, 20% were classified as normal weight (BMI 18.5 to 24), 35% overweight (BMI 25 to 29), 24% obese class I (BMI 30 to 34), 12% class II (BMI 35 to 40), and 9% class III (BMI ≥40). Risk of complication increased significantly with increasing BMI (normal: 1.5%, overweight: 1.6%, obese class I: 1.7%, obese class II: 1.8%, obese class III: 1.9%, P = .043). On multivariate analysis, there was no increased risk of postoperative complication directly attributed to patient BMI. Independent risk factors for medical and surgical complications after knee arthroscopy included American Society of Anesthesiologists (ASA) rating (class 4 v class 1 odds ratio [OR]: 5.39 [95% confidence interval: 3.11-9.33], P<.001), functional status for activities of daily living (dependent v independent OR: 2.13 [1.42, 3.31], P<.001), history of renal comorbidity (presence v absence OR: 5.10 [2.30, 11.29], P<.001), and previously experienced history of wound infection prior to current surgery (presence v absence OR: 4.91 [2.88, 8.39], P<.001).

Question: Is Obesity a Risk Factor for Adverse Events After Knee Arthroscopy?

More than 40% of knee arthroscopy patients qualify as obese. Although univariate analysis suggests that obesity is associated with increased postoperative complications within 30 days of surgery, BMI alone does not predict complications. Independent predictors of complications include patients with high ASA classification, dependent functional status, renal comorbidities, and a recent history of wound infection.

Answer the question based on the following context: Prominent hypointense cerebral vessels on susceptibility-weighted imaging (SWI) and the hyperintense vessel sign (HVS) on fluid-attenuated inversion recovery (FLAIR) imaging are considered as markers of compromised tissue perfusion in cerebral ischemia. In this study, we aimed to identify the correlation between HVS on FLAIR and hypointense vessels on SWI, and to determine whether these imaging features provide independent prognostic information in patients with ischemic stroke. We retrospectively analyzed consecutive ischemic stroke patients with proximal middle cerebral artery (MCA) occlusion who underwent SWI and FLAIR within 24 h of symptom onset. The presence of hypointense vessels on SWI and hyperintense vessels on FLAIR in>4 of 10 slices encompassing the MCA territory were considered to represent prominent hypoperfusion. Among 50 patients, 62% had a prominent HVS on FLAIR and 68% had prominent hypointense vessels on SWI. There was a moderate but significant correlation between the number of slices with HVS on FLAIR and prominent hypointense vessels on SWI (r=0.425, P = 0.002). In multivariate analyses, the prominence of hypointense vessels on SWI, but not HVS on FLAIR, was significantly associated with a higher discharge NIHSS score (P = 0.027), mRS score (P = 0.021), and lesion growth (P = 0.050).

Question: Bright and dark vessels on stroke imaging: different sides of the same coin?

The significant, albeit moderate, correlation between markers of compromised tissue perfusion on FLAIR and SWI suggests that these imaging features reflect different but interrelated aspects of cerebral hemodynamics during ischemic stroke. Our findings highlight that while HVS on FLAIR denotes the presence of leptomeningeal collaterals, hypointense vessels on SWI signify the sufficiency of cerebral blood flow at the tissue level and are therefore more critical in terms of prognosis.

Answer the question based on the following context: Nipple-sparing mastectomy (NSM) preserves the native skin envelope, including the nipple-areolar skin, and has significant benefits including improved aesthetic outcome and psychosocial well-being. Patients with prior breast scars undergoing NSM are thought to be at increased risk for postoperative complications, such as skin and/or nipple necrosis. This study describes our experience performing NSM in patients who have had prior breast surgery and aims to identify potential risk factors in this subset of patients. A retrospective review of all patients undergoing nipple sparing mastectomy at The University of Utah from 2005 to 2011 was performed. Fifty-two patients had prior breast scars, for a total of 65 breasts. Scars were categorized into 4 groups depending on scar location: inframammary fold, outer quadrant, periareolar, and circumareolar. Information regarding patient demographics, social and medical history, treatment intent, and postoperative complications were collected and analyzed. Eight of the 65 breasts (12%) developed a postoperative infection requiring antibiotic treatment. Tobacco use was associated with an increased risk of infection in patients with prior breast scars (odds ratio [OR], 7.95; 95% confidence interval [CI], 1.37-46.00; P = 0.0206). There was a 13.8% rate of combined nipple and skin flap necrosis and receipt of chemotherapy (OR, 5.00; CI, 1.11-22.46; P = 0.0357) and prior BCT (OR, 12.5; CI, 2.2-71.0; P = 0.004) were found to be associated with skin flap or NAC necrosis.

Question: Nipple Sparing Mastectomy in Patients With Prior Breast Scars: Is It Safe?

Nipple-sparing mastectomy is a safe and viable option for patients with a prior breast scar. Our results are comparable to the published data in patients without a prior scar. Caution should be exercised with patients who have a history of tobacco use or those requiring chemotherapy because these patients are at increased risk for infection and NAC/skin flap necrosis, respectively, when undergoing NSM in the setting of a prior breast scar.

Answer the question based on the following context: The use of prehospital blood transfusion (PBT) in air medical transport has become more widespread. However, the effect of PBT remains unknown. The aim of this study was to examine the impact of PBT on 24-hour and overall in-hospital mortality. This is a retrospective cohort study of all trauma patients carried by air medical transport from the scene to a Level I trauma center from 2007 to 2013. We excluded patients who died on the helipad or in the emergency department. Primary outcomes measured were 24-hour and overall in-hospital mortality. Multivariable logistic regressions using all available patient data or the propensity score (for receiving PBT)-matched patient data were performed to study the effect of PBT on these outcomes. Of the 5,581 patients included in the study, 231 (4%) received PBT. Multivariable regression analyses did not show evidence of PBT effect on 24-hour in-hospital mortality (odds ratio [OR], 1.22; 95% confidence interval [CI], 0.61-2.44) and on overall in-hospital mortality (OR, 1.20; 95% CI, 0.55-1.79). In addition, using 1:1 propensity score-matched data, the analysis did not show evidence of PBT effect on 24-hour in-hospital mortality (OR, 1.04; 95% CI, 0.54-1.98) and on overall in-hospital mortality (OR, 1.05; 95% CI, 0.56-1.96). Factors associated with increased 24-hour mortality were advanced age, penetrating injury, increased blood transfusion requirement in the first 24 hours, and decreased Glasgow Coma Scale (GCS) score (p<0.05). These factors were also associated with overall mortality, in addition to increased Injury Severity Score (ISS) (p<0.05).

Question: Blood transfusion: In the air tonight?

This is the largest study to date of trauma patients who received PBT and were transported from the scene by air medical transport. Our results show no effect of PBT on 24-hour and overall in-hospital mortality. Previous studies also suggest no benefit of PBT, which is counterintuitive to damage-control resuscitation. Prospective data on PBT are needed to assess risk, cost, and benefit.

Answer the question based on the following context: We compared the predictive abilities of the Abbott Real Time hepatitis C virus (HCV) assay (ART) with those of standard serum HCV ribonucleic acid (RNA) detection methods in patients undergoing triple therapy, which involves treatment with a protease inhibitor combined with pegylated interferon and ribavirin. In this study, 28 patients underwent triple therapy. The hepatitis C virus ribonucleic acid (HCV RNA) level of each patient was measured at weeks 0, 4, 8, and 12 after the initiation of therapy using the Roche COBAS AmpliPrep/COBAS TaqMan HCV assay version 1.0 (CAP/CTM v1.0) and ART. At week 8 after the initiation of therapy, the sustained virological response (SVR) rate among patients who tested negative and positive for HCV RNA using CAP/CTM v1.0, was 80.0% (20/25) and 33.3% (1/3), and using ART, it was 91.3% (21/23) and 0.0% (0/5), respectively. Although at week 8, the predictive capability of CAP/CTM v1.0 was 78.5%, ART was found to be a more accurate predictor of future SVR status with a rate of 92.9%.

Question: Can the Abbott RealTime hepatitis C virus assay be used to predict therapeutic outcomes in hepatitis C virus-infected patients undergoing triple therapy?

These results indicate that the presence or absence of serum HCV RNA, evaluated using ART at week 8 after the initiation of therapy, may be useful for predicting therapeutic outcomes in patients receiving triple therapy.

Answer the question based on the following context: Prior research has documented the inadequacy of pain management for trauma patients in the emergency department (ED), with rates of pain assessment and opioid administration averaging about 50%. Such rates, however, may be misleading and do not adequately capture the complexity of pain management practices in a trauma population. The goal of the study was to determine if pain was undertreated at the study hospital or if patient acuity explained the timing and occurrence of pain treatment in the prehospital setting and the ED. A retrospective study was performed at a Level 1 adult trauma centre in the Midwest. The trauma registry was used to identify patients who received a trauma activation during the study period (June-November 2012; N=313). Using the first set of patient vitals and ISS, patients were grouped into three categories: physiologically stable with low injury severity (n=132); physiologically stable with moderate to severe injury (n=122); and physiologically unstable with severe injury (n=56). Differences were assessed with Kruskal-Wallis and chi-square tests. Patients who were physiologically unstable were the least likely to receive a standardised pain assessment and the least likely to receive an opioid in the ED. Patients who were physiologically stable at entry to the ED but sustained a severe injury were the most likely to receive an opioid. Time to first pain assessment and time to first opioid did not differ by patient acuity.

Question: Is pain really undertreated?

Results confirm that patient acuity greatly affects the ability to effectively and appropriately manage pain in the initial hours after injury. This study contributes to the literature by noting areas for improvement but also in explaining why delaying pain treatment may be appropriate in certain patient populations.

Answer the question based on the following context: Scabies, or mange as it is called in animals, is an ectoparasitic contagious infestation caused by the mite Sarcoptes scabiei. Sarcoptic mange is an important veterinary disease leading to significant morbidity and mortality in wild and domestic animals. A widely accepted hypothesis, though never substantiated by factual data, suggests that humans were the initial source of the animal contamination. In this study we performed phylogenetic analyses of populations of S. scabiei from humans and from canids to validate or not the hypothesis of a human origin of the mites infecting domestic dogs. Mites from dogs and foxes were obtained from three French sites and from other countries. A part of cytochrome c oxidase subunit 1 (cox1) gene was amplified and directly sequenced. Other sequences corresponding to mites from humans, raccoon dogs, foxes, jackal and dogs from various geographical areas were retrieved from GenBank. Phylogenetic analyses were performed using the Otodectes cynotis cox1 sequence as outgroup. Maximum Likelihood and Bayesian Inference analysis approaches were used. To visualize the relationship between the haplotypes, a median joining haplotype network was constructed using Network v4.6 according to host. Twenty-one haplotypes were observed among mites collected from five different host species, including humans and canids from nine geographical areas. The phylogenetic trees based on Maximum Likelihood and Bayesian Inference analyses showed similar topologies with few differences in node support values. The results were not consistent with a human origin of S. scabiei mites in dogs and, on the contrary, did not exclude the opposite hypothesis of a host switch from dogs to humans.

Question: Are humans the initial source of canine mange?

Phylogenetic relatedness may have an impact in terms of epidemiological control strategy. Our results and other recent studies suggest to re-evaluate the level of transmission between domestic dogs and humans.

Answer the question based on the following context: Previous injury is a well-documented risk factor for football injury. The time trends and patterns of recurrent injuries at different playing levels are not clear.AIM: To compare recurrent injury proportions, incidences and patterns between different football playing levels, and to study time trends in recurrent injury incidence. Time-loss injuries were collected from injury surveillance of 43 top-level European professional teams (240 team-seasons), 19 Swedish premier division teams (82 team-seasons) and 10 Swedish amateur teams (10 team-seasons). Recurrent injury was defined as an injury of the same type and at the same site as an index injury within the preceding year, with injury<2 months defined as an early recurrence, and>2 months as a delayed recurrence. Seasonal trend for recurrent injury incidence, expressed as the average annual percentage of change, was analysed using linear regression. 13 050 injuries were included, 2449 (18.8%) being recurrent injuries, with 1944 early (14.9%) and 505 delayed recurrences (3.9%). Recurrence proportions were highest in the second half of the competitive season for all cohorts. Recurrence proportions differed between playing levels, with 35.1% in the amateur cohort, 25.0% in the Swedish elite cohort and 16.6% in the European cohort (χ(2) overall effect, p<0.001). A decreasing trend was observed in recurrent injury incidence in the European cohort, a -2.9% average annual change over the 14-year study period (95% CI -5.4% to -0.4%, p=0.026). Similarly, a decreasing tendency was also seen in the Swedish premier division.

Question: Injury recurrence is lower at the highest professional football level than at national and amateur levels: does sports medicine and sports physiotherapy deliver?

Recurrence proportions showed an inverse relationship with playing level, and recurrent injury incidence has decreased over the past decade.