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Answer the question based on the following context: Although the understanding of the health impact of hormone replacement therapy (HRT) is incomplete, even less is known about the attitudes, perceptions, and motivations of women faced with the decision to use HRT. The purpose of this study was to evaluate the relation between HRT use and women's perceptions of the risk and benefits associated with HRT use. A written questionnaire was administered to 387 women, aged 45 years and older, responding to a health plan invitation for free bone mineral density screening. Women were asked to estimate the lifetime probability of developing breast cancer, uterine cancer, osteoporosis, and myocardial infarction when taking HRT and when not taking HRT. Women rated their quality of life in their current state of health, with breast cancer, with uterine cancer, with osteoporosis, and after myocardial infarction. HRT users perceived a greater risk reduction using HRT compared with HRT nonusers for osteoporosis (-34.9% vs -17.8%, P<.001) and myocardial infarction (-20.7% vs -8.4%, P<.001). HRT nonusers perceived a greater risk increase using HRT compared with HRT nonusers for breast cancer (16.5% vs 3.3%, P<.001) and uterine cancer (9.2% vs 0.6%, P =.004). HRT users estimated a greater quality-of-life reduction compared with HRT nonusers for osteoporosis (-31.0 vs -24.5, P =.006).

Question: Do perceptions of risk and quality of life affect use of hormone replacement therapy by postmenopausal women?

Regardless of whether they used HRT, women in this study overestimated their risk for all four diseases. HRT users perceived greater benefit and less risk using HRT than nonusers. The results of our study show that continuing efforts are needed to help women understand the risks and benefits of HRT.

Answer the question based on the following context: Increasingly, surgical site infection (SSI) is being tied to quality of care. The incidence of SSI after colorectal surgery differs widely. We hypothesize that it is difficult to define SSI reliably and reproducibly when adhering to the U.S. Centers for Disease Control and Prevention (CDC) definitions. Elective intra-abdominal colorectal procedures via a clean-contaminated incision performed at a single institution between January 1 and May 1, 2011 were queried. Three attending surgeons examined all patients' records retrospectively for documentation of SSI. These data were compared with the institutional National Surgeon Quality Improvement Program (NSQIP) data with regard to deep and superficial incisional SSI. Seventy-one cases met the inclusion criteria. There were six SSIs identified by NSQIP, representing 8.4% of cases. Review of the three attending surgeons demonstrated a significantly higher incidence of SSI, at 27%, 38%, and 23% (p=0.002). The percent of overall agreement between all reviewers was 82.16 with a kappa of 0.64, indicating only modest inter-rater agreement. Lack of attending surgeon documentation and subjective differences in chart interpretation accounted for most discrepancies between the surgeon and NSQIP SSI capture rates.

Question: Can we define surgical site infection accurately in colorectal surgery?

This study highlights the difficulty in defining SSI in colon and rectal surgery, which oftentimes is subjective and difficult to discern from the medical record. According to these preliminary data from our institution, there is poor reliability between clinical reviewers in defining SSI on the basis of the CDC criteria, which has serious implications. The interpretation of clinical trials may be jeopardized if we cannot define SSI accurately. Furthermore, according to current CDC definitions and infection tracking strategies, these data suggest that the institutional incidence of SSI may not be a reliable measure by which to compare institutions. Better methods for defining SSI should be implemented if these data are made publicly available and tied to performance measures.

Answer the question based on the following context: Viral gastroenteritis is common, especially in young children. In adults, particularly amongst the elderly, it can lead to outbreaks at a time when demands on clinical services are at their peak.AIM: To evaluate seasonal screening of young children and elderly patients with suspected viral gastroenteritis using multiplex polymerase chain reaction (PCR) for enteric viruses within a general hospital setting. Stool samples from 200 children aged five years and under were screened for rotavirus, adenovirus, astrovirus, sapovirus and norovirus using multiplex PCR and a combined rotavirus/adenovirus immunochromatographic test (ICT) during the winter of 2012. Diarrhoeal samples submitted to the laboratory from 195 adults aged 65 years and over attending as inpatients were also evaluated by multiplex PCR. One or more enteric viruses were detected by PCR in 56% of children. Rotavirus was the most prevalent virus, found in 19% of samples. Enteric (diarrhoea-associated) adenovirus was detected in 5% of samples and non-enteric adenovirus was detected in 14% of samples. Astrovirus, norovirus and sapovirus were detected in 18%, 12% and 10% of samples, respectively. The ICT yielded a slightly lower rate for rotavirus and enteric adenovirus, but gave more rapid results. Norovirus, rotavirus and adenovirus were detected in 15%, 2.5% and 1% of elderly adults attending hospital as inpatients, respectively.

Question: Seasonal screening for viral gastroenteritis in young children and elderly hospitalized patients: is it worthwhile?

Rapid screening of young children (for rotavirus, adenovirus and norovirus) and symptomatic, elderly adults (for norovirus) during winter months may help to limit nosocomial spread.

Answer the question based on the following context: Chronic pain is common in persons with multiple sclerosis (MS), but the co-morbidity of fibromyalgia (FM) has yet to be investigated in MS. Objectives of the study were to evaluate, among the various types of chronic pain, the frequency of FM in MS and its impact on MS patients' health-related quality of life (HRQoL). 133 MS patients were investigated for the presence and characterization of chronic pain within 1 month of assessment. A rheumatologist assessed the presence FM according to the 1990 ACR diagnostic criteria. Depression, fatigue, and HRQoL were also assessed by means of specific scales. Chronic pain was present in 66.2% of patients (musculoskeletal in 86.3%; neuropathic in 13.7%; absent in 33.8% [called NoP]). Pain was diagnosed with FM (PFM+) in 17.3% of our MS patients, while 48.9% of them had chronic pain not FM type (PFM-); the prevalence of neuropathic pain in these 2 sub-groups was the same. PFM+ patients were prevalently females and had a higher EDSS than NoP. The PFM+ patients had a more pronounced depression than in the NoP group, and scored the worst in both physical and mental QoL.

Question: Chronic pain in multiple sclerosis: is there also fibromyalgia?

In our sample of MS patients we found a high prevalence of chronic pain, with those patients displaying a higher disability and a more severe depression. Moreover, FM frequency, significantly higher than that observed in the general population, was detected among the MS patients with chronic pain. FM occurrence was associated with a stronger impact on patients' QoL.

Answer the question based on the following context: There is growing interest in telehealth-the use of technology to support the remote delivery of health care and promote self-management-as a potential alternative to face-to-face care for patients with chronic diseases. However, little is known about what precipitates interest in the use of telehealth among these patients. This survey forms part of a research program to develop and evaluate a telehealth intervention for patients with two exemplar chronic diseases: depression and raised cardiovascular disease (CVD) risk. The survey was designed to explore the key factors that influence interest in using telehealth in these patient groups. Thirty-four general practices were recruited from two different regions within England. Practice records were searched for patients with (1) depression (aged 18+ years) or (2) 10-year risk of CVD ≥20% and at least one modifiable risk factor (aged 40-74 years). Within each general practice, 54 patients in each chronic disease group were randomly selected to receive a postal questionnaire. Questions assessed five key constructs: sociodemographics, health needs, difficulties accessing health care, technology-related factors (availability, confidence using technology, perceived benefits and drawbacks of telehealth), and satisfaction with prior use of telehealth. Respondents also rated their interest in using different technologies for telehealth (phone, email and Internet, or social media). Relationships between the key constructs and interest in using the three mediums of telehealth were examined using multivariable regression models. Of the 3329 patients who were sent a study questionnaire, 44.40% completed it (872/1740, 50.11% CVD risk; 606/1589, 38.14% depression). Overall, there was moderate interest in using phone-based (854/1423, 60.01%) and email/Internet-based (816/1425, 57.26%) telehealth, but very little interest in social media (243/1430, 16.99%). After adjusting for health needs, access difficulties, technology-related factors, and prior use of telehealth, interest in telehealth had largely no association with sociodemographic variables. For both patient groups and for each of the three technology mediums, the most important constructs related to interest in telehealth were having the confidence to use the associated technology, as well as perceiving greater advantages and fewer disadvantages from using telehealth. To illustrate, greater confidence using phone technologies (b=.16, 95% CI 0.002-0.33), while also perceiving more benefits (b=.31, 95% CI 0.21-0.40) and fewer drawbacks (b=-.23, 95% CI -0.28 to -0.17) to using telehealth were associated with more interest in using phone-based telehealth technologies for patients with depression.

Question: Are people with chronic diseases interested in using telehealth?

There is widespread interest in using phone-based and email/Internet-based telehealth among patients with chronic diseases, regardless of their health status, access difficulties, age, or many other sociodemographic factors. This interest could be increased by helping patients gain confidence using technologies and through highlighting benefits and addressing concerns about telehealth. While the same pattern exists for social media telehealth, interest in using these technologies is minimal.

Answer the question based on the following context: The halo orthosis is a treatment option currently used in Australia for cervical spine immobilisation following trauma, fracture and post surgical stabilisation. In a previous study, the authors reported halo pin replacement to be a common complication. The aim of this study was to investigate the potential correlation between routine halo pin re-torquing and the incidence of pin replacement. A retrospective case series study was undertaken. A total of 258 charts were reviewed, with 170 patients included in the study. Patients were fitted with a Bremer HALO System with the initial application torque maintained by routine re-torquing throughout the duration of wear. A total of 680 pins (4 per patient) were inserted during the initial application of the halo orthoses, with only six pins replaced (0.88%) throughout the duration of the study.

Question: Does routine pin re-torquing of patients wearing a halo-thoracic orthosis reduce the need for pin replacement?

The findings from this study demonstrate a potential correlation between routinely re-torquing halo pins and decreasing the incidence of pin replacement.

Answer the question based on the following context: Subtrochanteric fracture is a recognized complication following cannulated screw fixation of intracapsular hip fracture. We investigated the incidence of subtrochanteric fracture in a consecutive series of 304 patients and its association with screw entry point in the lateral femoral cortex. A retrospective consecutive case series of patients treated with internal fixation for intracapsular hip fracture by our unit between January 2003 and January 2010 were included. Two authors reviewed radiographs independently to determine distal screw entry point in the lateral femoral cortex. Hickey zone 1 was an entry point above the level of the upper border of the lesser trochanter. Hickey zone 2 was defined as an entry point between the upper and lower borders of the lesser trochanter. Hickey zone 3 was an entry point below the lower border of the lesser trochanter. Clinical notes were reviewed for subsequent subtrochanteric fracture. Association between subtrochanteric fracture and distal screw entry point in the lateral femoral cortex in relation to the upper border of the lesser trochanter was determined. Two hundred and fifty-six post-operative radiographs were available for analysis. Mean patient age was 73 years (30–98), 75% were women. There were 24 patients with screw entry point in Hickey zone 1, 225 in Hickey zone 2, and 7 in Hickey zone 3. Two patients sustained subtrochanteric fracture. No subtrochanteric fractures occurred in patients with Hickey zone two-screw entry.

Question: Is distal screw entry point associated with subtrochanteric fracture after intracapsular hip fracture fixation?

Subtrochanteric fracture is rare following cannulated screw fixation of intracapsular neck of femur fracture (0.78%). In this retrospective consecutive case series, no subtrochanteric fractures occurred when the entry point of the lowest screw in the lateral femoral cortex is between the levels of the upper and lower borders of the lesser trochanter.

Answer the question based on the following context: A significant minority of Australians engage in concurrent drug use (using more than one drug in a given period). We examined clusters and correlates of concurrent drug use using the latest available nationally representative survey data on Australian young adults. 3836 participants aged 18-29 years (mean age 24 years) from the 2010 National Drug Strategy Household Survey (NDSHS). Clusters were distilled using latent class analysis of past year use of alcohol, tobacco, cannabis, cocaine, hallucinogens, ecstasy, ketamine, GHB, inhalants, steroids, barbiturates, meth/amphetamines, heroin, methadone/buprenorphine, other opiates, painkillers and tranquillisers/sleeping pills. Concurrent drug use in this sample was best described using a 4-class solution. The majority (87.5%) of young adults predominantly used alcohol only (50.9%) or alcohol and tobacco (36.6%). 10.2% reported using alcohol, tobacco, marijuana, and ecstasy, and 2.3% reported using an extensive range of drugs.

Question: Is there any evidence of changes in patterns of concurrent drug use among young Australians 18-29 years between 2007 and 2010?

Most drug use clusters were robust in their profile and stable in their prevalence, indicating little meaningful change at the population level from 2007. The targeting of alcohol and tobacco use remains a priority, but openness to experiencing diverse drug-related effects remains a significant concern for 12.5% of young people in this age group.

Answer the question based on the following context: To analyze clinicopathologic parameters of oral squamous cell carcinoma (OSCC) in different age groups. We hypothesized that clinical and pathologic parameters of OSCCs will vary in different age groups. A retrospective cohort study was performed. All patients who were treated for a primary manifestation of OSCC at a single institution from 2001 to 2012 were reviewed and allocated to predefined age groups (predictor variable) as follows: young (≤40 years), middle-aged (40-80 years), and very elderly (≥80 years). The following outcome variables were recorded: demographic parameters, classic risk factors, tumor location and size, neck node involvement, histopathologic and therapeutic details, and association with human papillomavirus (HPV). The descriptive statistics were computed. Parametric and nonparametric tests were used for additional analysis. The significance level was set at P<.05. We reviewed 739 patients and identified 11 (1.4%) young (mean age 34.2 ± 2.8 years) and 17 (2.3%) very elderly patients (mean age 83.1 ± 1.2 years). The predilection site for OSCC was the oral tongue (63%) in young patients, the floor of the mouth (52%) in middle-aged patients, and the alveolar process (60%) in very elderly patients. One patient in the young group (9%) and 8 patients in the very elderly group (47%) had been exposed to risk factors; however, all of the examined middle-aged patients had had such exposure. The association of OSCC with HPV was distributed equally among the age groups. No age-related differences in the histopathologic parameters of OSCC were found.

Question: Clinicopathologic features of oral squamous cell carcinoma: do they vary in different age groups?

The features of OSCC that vary at different ages are the anatomic predilection site and the association with classic risk factors. HPV was not an age-related independent risk factor for OSCC development in the present study.

Answer the question based on the following context: To investigate possible associations of alexithymia with marital satisfaction and mutual attachment between the partners in a group of parents-to-be during pregnancy. The present study was conducted in a pregnancy cohort. Cross-sectional data were available for 151 mothers and 106 fathers, and altogether 102 couples. The 20-item Toronto Alexithymia Scale (TAS-20) was used to assess alexithymia, the Index of Marital Satisfaction (IMS) to assess romantic relationship satisfaction and the Experiences in Close Relationships Scale (ECR) to evaluate attachment-related anxiety and avoidance. Kruskal-Wallis test was used for categorized variable comparisons. For continuous variables, Spearman correlation analyses and linear regression analyses were conducted. The TAS-20 total score, as well as, two of its dimensions, difficulties in identifying and describing feelings, were significantly correlated (p<0.01) with both the IMS scores and the ECR anxiety and avoidance scores. In the regression analyses, the most significant predictive factor for the subjects' IMS scores was their partners' corresponding scores, although among fathers the IMS scores were partly explained by their own TAS-20 factor 1 scores (p=0.004). The subjects' own TAS-20 scores explained the ECR anxiety and avoidance scores to a significant extent, but the fathers' TAS-20 factor 3 scores were also associated with the mothers' avoidance scores (p=0.037).

Question: Is alexithymia linked with marital satisfaction or attachment to the partner?

Alexithymia was not directly related to marital satisfaction. However, alexithymia appears to have a significant effect on relationship-related anxiety and avoidance. This association should be further studied in parents and their offspring in a longitudinal setting.

Answer the question based on the following context: Adjuvant chemoradiotherapy (CRT) for patients with gastric cancer after D2 lymphadenectomy remains controversial. The objective of the present meta-analysis was to analyze efficacy and safety of postoperative CRT and establish a consensus on whether it is suitable for the patients. We searched PubMed, Ovid, Cochrane, and Web of Science. Statistical analysis was carried out by STATA version 12.0 software. The quality of evidence was assessed by Jadad and the Newcastle-Ottawa quality assessment scale. Six studies involving 2135 patients were included for the meta-analysis. The results showed that, compared with non-CRT, postoperative adjuvant CRT was associated with a significant improvement in 5-year overall survival (OS) (HR = 0.79, 95% CI 0.68-0.92, P = 0.002) and 5-year relapse-free survival (RFS) (HR = 0.81, 95% CI 0.70-0.93, P = 0.004). However, there were no differences in distant metastasis (RR = 0.93, 95% CI 0.82-1.06, P = 0.304) and treatment-related toxicity between the two groups.

Question: Is postoperative adjuvant chemoradiotherapy efficacious and safe for gastric cancer patients with D2 lymphadenectomy?

From the results of our study, postoperative adjuvant CRT may be associated with longer 5-year OS and 5-year RFS in patients with D2 lymphadenectomy, but might not improve 5-year disease-free survival compared to non-CRT. Methodologically high-quality comparative studies are needed for further evaluation.

Answer the question based on the following context: Indoleamine 2,3-dioxygenase (IDO) is an emerging immunomodulating factor in cancer. IDO expression in tumour-negative sentinel lymph nodes (SLNs) of patients with melanoma has a negative prognostic value. To analyse the expression pattern of IDO and associated immunological changes in corresponding primary melanomas (PMs), SLNs and metastases. In 120 patients with melanoma, PMs with corresponding SLNs (n = 85) and metastases (n = 18) were analysed by immunohistochemical staining for IDO and FoxP3. Tumour-infiltrating lymphocytes (TILs) were scored. IDO expression in stimulated peripheral blood mononuclear cells (PBMCs) was analysed in 27 patients. IDO expression in the sentinel node strongly correlated with endothelial IDO expression in the peritumoral stroma of the corresponding primary (P < 0·001) and metastatic melanoma (P < 0·05). Sentinel IDO positivity was inversely correlated with CD8+ lymphocytes (P = 0·01) and TILs (P = 0·05) in PM. Both IDO expression in the sentinel (P < 0·01) and the PM (P = 0·04) had a negative prognostic effect on overall survival, independent of Breslow thickness, sex, age, ulceration and sentinel invasion. IDO expression by PBMCs after stimulation with cytotoxic T-lymphocyte antigen 4 was not correlated with sentinel IDO expression but tended to correlate with disease stage (P = 0·04).

Question: Peritumoral indoleamine 2,3-dioxygenase expression in melanoma: an early marker of resistance to immune control?

Endothelial IDO expression is highly consistent in primary, sentinel and metastatic tissues of patients with melanoma, indicating that immune suppression in melanoma is determined very early in the disease course. This supports that IDO expression in melanoma is a marker of antitumour immune response with an independent prognostic value.

Answer the question based on the following context: Asthma and obesity are related diseases however the influence of obesity on asthma severity is not clear yet. Therefore, the aim of our study was to evaluate the association between obesity and asthma control evaluated on the basis of symptoms and asthma control questionnaire (ACQ). We enrolled 98 children with asthma aged 4 to 14 years consecutively and recorded their disease characteristics and severity parameters as well as the symptom scores. All children filled in the ACQ. Children were classified as obese and non-obese according to body mass index. Obesity was defined as body mass index over 90th percentile. Mean age of the children in the obese group (n= 27) was 8.1 ± 2.6 while that in the non-obese group (n= 71) was 8.6 ± 2.9 (p= 0.41). Asthma symptom score in obese and non-obese groups were not significantly different (p= 0.73). Children in the obese group had lower ACQ scores when compared to the non-obese group (1.2 ± 0.9 vs 1.7 ± 1.0, p= 0.04) however this significance was lost when controlled for age and gender in the regression model.

Question: Is obesity related to worse control in children with asthma?

The results of this study suggest that obesity is not significantly associated with worse asthma control when adjusted for age and gender.

Answer the question based on the following context: Von Willebrand disease (VWD) is the most common inherent bleeding disorder resulting in prolonged bleeding time. Gingival bleeding is a frequently reported symptom of VWD. However, gingival bleeding is also known as a leading symptom of plaque-induced gingivitis and untreated periodontal disease. Gingival bleeding in VWD patients (VWD) may be triggered by gingival inflammation and not a genuine symptom. Thus, this study evaluated whether type 1 VWD determines an increased susceptibility to gingival bleeding in response to the oral biofilm. Fifty cases and 40 controls were examined haematologically (VWF antigen, VWF Ristocetin cofactor, factor VIII activity) and periodontally [Gingival Bleeding Index (GBI), bleeding on probing (BOP), Plaque Control Record (PCR), periodontal inflamed surface area (PISA), vertical probing attachment level]. GBI was significantly higher in controls (12.2%) than in VWD (10%). The study failed to find a significant difference regarding BOP between VWD (17%) and controls (17.2%). Multiple regressions identified PCR and PISA to be associated with GBI and BOP. VWD was negatively associated with GBI. Smoking and number of remaining teeth was negatively associated with BOP.

Question: Is gingival bleeding a symptom of patients with type 1 von Willebrand disease?

VWD is not associated with a more pronounced inflammatory response to the oral biofilm in terms of GBI and BOP.

Answer the question based on the following context: To quantify the differences between the facial soft tissue morphology of severely obstructed mouth breathing (MB) and that of predominantly nasal breathing (NB) children. Soft tissue measurements were performed in the lateral cephalograms of 64 severely obstructed MB children (mean age 6.7 ± 1.6) compared with 64 NB children (mean age 6.5 ± 1.3). Groups were paired by age, gender, skeletal maturation status and sagittal skeletal pattern. Based on the assumption of normality and homoscedasticity, comparison of the means and medians of soft tissue measurements between the two groups was performed. The facial convexity and anterior facial height ratio of MB were similar to NB children. The upper lip of MB children was protruded, and its base was thinner compared with NB; however, the length was not affected. The lower lip was shorter and more protruded in MB children. The nasolabial angle, nasal prominence, and chin thickness were smaller in MB children.

Question: Facial soft tissues of mouth-breathing children: do expectations meet reality?

The facial soft tissue of severely obstructed MB children is different than in NB children. Changes in lips, nasolabial angle, nasal prominence, and chin thickness are associated with severe airway obstruction in children.

Answer the question based on the following context: Persons with Alzheimer's disease (AD) sometimes express themselves through behaviours that are difficult to manage for themselves and their caregivers, and to minimise these symptoms alternative methods are recommended. For some time now, animals have been introduced in different ways into the environment of persons with dementia. Animal-Assisted Therapy (AAT) includes prescribed therapy dogs visiting the person with dementia for a specific purpose.AIM: This study aims to illuminate the meaning of the lived experience of encounters with a therapy dog for persons with Alzheimer's disease. Video recorded sessions were conducted for each visit of the dog and its handler to a person with AD (10 times/person). The observations have a life-world approach and were transcribed and analysed using a phenomenological hermeneutical approach. The result shows a main theme 'Being aware of one's past and present existence', meaning to connect with one's senses and memories and to reflect upon these with the dog. The time spent with the dog shows the person recounting memories and feelings, and enables an opportunity to reach the person on a cognitive level.

Question: Can therapy dogs evoke awareness of one's past and present life in persons with Alzheimer's disease?

The present study may contribute to health care research and provide knowledge about the use of trained therapy dogs in the care of older persons with AD in a way that might increase quality of life and well-being in persons with dementia.

Answer the question based on the following context: Breast density and mammographic tumor features of breast cancer may carry prognostic information. The potential benefit of using the combined information obtained from breast density, mammographic tumor features, and pathological tumor characteristics has not been extensively studied. To investigate how mammographic tumor features relate to breast density and pathological tumor characteristics. This retrospective study was carried out within the Malmö Diet and Cancer Study: a population-based cohort study recruiting 17,035 women during 1991-1996. A total of 826 incident breast cancers were identified during follow-up. Mammography images were collected and analyzed according to breast density and tumor features at diagnosis. Pathological data were retrieved from medical reports. Mammographic tumor features in relation to invasiveness, tumor size, and axillary lymph node involvement were analyzed using logistic regression yielding odds ratios (OR) with 95% confidence intervals (CI) and adjusted for age at diagnosis, mode of detection, and breast density. Tumors presenting as an ill-defined mass or calcifications were more common in dense breasts than tumors presenting as a distinct mass or with spiculated appearance. Invasive cancer was more common in tumors with spiculated appearance than tumors presenting as a distinct mass (adjusted OR, 5.68 [1.81-17.84]). Among invasive tumors, an ill-defined mass was more often large (>20 mm) compared with a distinct mass, (adjusted OR, 3.16 [1.80-5.55]).

Question: Do mammographic tumor features in breast cancer relate to breast density and invasiveness, tumor size, and axillary lymph node involvement?

Tumors presenting as an ill-defined mass or calcifications were more common in dense breasts. Spiculated appearance was related to invasiveness, and ill-defined mass to larger tumor size, regardless of mode of detection and breast density. The potential role of mammographic tumor features in clinical decision-making warrants further investigation.

Answer the question based on the following context: Systemic right ventricular dysfunction and tricuspid regurgitation (TR) are frequently encountered in patients with congenitally corrected transposition of the great arteries (CCTGA). Studies using echocardiography have suggested a relationship between the degree of TR and systemic right ventricular dysfunction; however, assessment of systemic right ventricular function by echocardiography is limited. Cardiac MRI (CMR) is the gold standard for volumetric assessment of the systemic right ventricle. We performed a retrospective cohort study at our center evaluating all adult patients with CCTGA who underwent a CMR between 1/1999 and 1/2013 to determine the relationship between the degree of TR and systemic right ventricular function. Of the 33 patients identified, 12 had ≤ mild TR (37%), 13 had moderate TR (40%), and 8 had severe TR (24%). Mean age at CMR was 38 years (23-64). Mean right ventricular ejection fraction (45% vs. 41% vs. 42%, p=0.68) and mean indexed right ventricular end diastolic volume (122 ml/m(2) vs. 136 ml/m(2) vs. 138 ml/m(2)p=0.36) were not significantly different for patients with ≤ mild TR, moderate TR or severe TR. The degree of TR was not associated with additional congenital lesions, prior procedures, presence of an intraventricular conduction delay, or decreased left ventricular function.

Question: Is systemic right ventricular function by cardiac MRI related to the degree of tricuspid regurgitation in congenitally corrected transposition of the great arteries?

No association between the degree of TR and right ventricular volume or ejection fraction by CMR was identified. Failure to show worsening function or increased volume with greater degrees of TR suggests that the degree of regurgitation alone may not fully explain the heterogeneity in right ventricular size and function.

Answer the question based on the following context: This study examined possible income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention in the Netherlands in 2011. We used three waves of the International Tobacco Control (ITC) Netherlands Survey, a nationally representative longitudinal sample of smokers aged 15 years and older (n=1912). The main analyses tested trends and income differences in outcome measures (smokers' quit attempt rates, use of behavioral counseling, use of cessation medications, and quit success) and awareness variables (awareness of reimbursement possibilities, the media campaign, medications advertisements and other media attention) with generalized estimating equations analyses. In the first half of 2011, there was a significant increase in quit attempts (odds ratio (OR)=2.02, p<0.001) and quit success (OR=1.47, p<0.001). Use of counseling and medications remained stable at 3% of all smokers in this period. Awareness of reimbursement possibilities increased from 11% to 42% (OR=6.38, p<0.001). Only awareness of the media campaign was associated with more quit attempts at the follow-up survey (OR=1.95, p<0.001). Results were not different according to smokers' income level.

Question: Are there income differences in the impact of a national reimbursement policy for smoking cessation treatment and accompanying media attention?

The Dutch reimbursement policy with accompanying media attention was followed by an increase in quit attempts and quit success, but use of cessation treatment remained stable. The impact of the policy and media attention did not seem to have decreased or increased socioeconomic inequalities in quit attempts, use of cessation treatment, or quit success.

Answer the question based on the following context: To measure the effect of the insertion of less-difficult malignant cases on subsequent breast cancer detection by breast imaging radiologists. The research comprises two studies. Study 1: 8 radiologists read 2 sets of images each consisting of 40 mammographic cases. Set A contained four abnormal cases, and Set B contained six abnormal cases, including two priming cases (less difficult malignancies) placed at intervals of three and five subsequent cases before a subtle cancer. Study 2: 16 radiologists read a third condition of the same cases, known as Set C, containing six abnormal cases and two priming cases immediately preceding the subtle cancer cases. The readers were asked to localize malignancies and give confidence ratings on decisions. Although not significant, a decrease in performance was observed in Set B compared with in Set A. There was a significant increase in the receiver operating characteristic (ROC) area under the curve (z = -2.532; p = 0.0114) and location sensitivity (z = -2.128; p = 0.0333) between the first and second halves of Set A and a marginal improvement in jackknife free-response ROC figure of merit (z = -1.89; p = 0.0587) between the first and second halves of Set B. In Study 2, Set C yielded no significant differences between the two halves of the study.

Question: Assessing the effect of a true-positive recall case in screening mammography: does perceptual priming alter radiologists' performance?

Overall findings show no evidence that priming with lower difficulty malignant cases affects the detection of higher difficulty cancers; however, performance may decrease with priming.

Answer the question based on the following context: The precut timing during the biliary cannulation algorithm is a subject of controversy. Some studies suggest that early institution of precut is a safe and effective strategy even though the extent to which this approach may affect the duration of the ERCP is seldom addressed. To assess the success, safety, and procedure duration of an early precut fistulotomy (group A) versus a classic precut strategy after a difficult biliary cannulation (group B). Single-center, prospective cohort study. University-affiliated hospital. A total of 350 patients with a naïve papilla. Standard biliary cannulation followed by needle-knife fistulotomy (NKF). Biliary cannulation rate, NKF success, adverse events, and ERCP duration. The overall cannulation rate was similar, at 96% and 94% for groups A and B, respectively. The adverse event rate was 6.2% and 6.4%, respectively, with pancreatitis as the most frequent adverse event (group A, 3.9%; group B, 5.2%). The mean ERCP duration was, however, significantly shorter in group A, both when biliary cannulation was achieved without precutting (14 minutes vs 25 minutes, P <.001) as well as when biliary cannulation was attempted after NKF (18 minutes vs 31 minutes, P <.0001). Single-center study design, referral center.

Question: Early precut fistulotomy for biliary access: time to change the paradigm of "the later, the better"?

If the endoscopist is experienced in ERCP and precut techniques, an early precut strategy should be the preferred cannulation strategy because this approach is as safe and effective as the late fistulotomy approach and substantially reduces ERCP duration.

Answer the question based on the following context: As drug-eluting stent (DES) has almost overcome the disadvantage of frequent restenosis, off-pump coronary artery bypass grafting (OPCAB) has been introduced to avoid complications of cardiopulmonary bypass. However, which approach may promise better outcomes for patients with coronary artery disease remains controversial. Three databases were searched. The outcomes of interest were major adverse cardiac and cerebrovascular events (MACCE), all-cause death, target vessel revascularization (TVR), repeat revascularization (RRV), myocardial infarction (MI), and cerebrovascular events (CVE). The relative risk (RR) was calculated as the summary statistic. 11,452 patients from 22 studies were included, of which 4949 patients underwent OPCAB and 6503 patients received DES. The cumulative rates of MACCE (RR [95% CI]=0.43 [0.34, 0.54], P<0.00001), all-cause death (RR [95% CI]=0.56 [0.33, 0.96], P=0.03), TVR (RR [95% CI]=0.33 [0.21, 0.53], P<0.00001), RRV (RR [95% CI]=0.22 [0.11, 0.42], P<0.00001) and MI (RR [95% CI]=0.13 [0.05, 0.29], P<0.00001) at 3 years were all lower in OPCAB group. The incidences of in-hospital death (RR [95% CI]=1.31 [0.81, 2.13], P=0.27) and MI (RR [95% CI]=1.03 [0.60, 1.78], P=0.92) were not different between groups, but the rate of in-hospital CVE was lower (RR [95% CI]=2.6355 [1.0033, 6.9228], P=0.05) in DES group.

Question: Is off-pump coronary artery bypass grafting superior to drug-eluting stents for the treatment of coronary artery disease?

OPCAB presents better long-term outcomes of MACCE, all-cause mortality, TVR, RRV and MI but uncertain outcome of postoperative CVE without influencing the incidences of in-hospital death and MI.

Answer the question based on the following context: To evaluate whether medical personnel differ from the general population in obstetrical and perinatal outcomes. The participants comprised 46 physicians and 116 nurses employed at one medical center who gave birth in its maternity hospital. General medical and obstetrical data on their latest ("index") pregnancy and delivery were extracted from real-time computerized patient files. The control group included 162 women who gave birth during the same period in the same hospital. The study group had significantly more deliveries, cesarean sections, and terminations of pregnancy prior to the index pregnancy. The medical personnel conceived significantly more often with assisted reproductive technologies (ART) (18.8% vs. 8% for controls, P<0.05), and had significantly more obstetrical complications, i.e., premature contractions, gestational diabetes mellitus, preeclamptic toxemia, and 2nd/3rd trimester bleeding or chorioamnionitis (42.5% vs. 29% for controls, P<0.05). The rate of vaginal birth after cesarean delivery (VBAC) was lower in the study group (22.2% vs. 33.3% for controls, P=0.03). There was no difference in gestational age at delivery, birth weight, or adverse neonatal outcome.

Question: Personnel-itis: a myth or a pathology?

Medical personnel utilized ART more frequently and had more pregnancy complications as well as a lower incidence of VBAC than non-personnel. Neonatal outcomes were similar for both groups.

Answer the question based on the following context: (i) To examine the sustainability of an in-hospital quality improvement (QI) intervention, the American College of Cardiology's Guideline Applied to Practice (GAP) in acute myocardial infarction (AMI). (ii) To determine the predictors of physician adherence to AMI guidelines-recommended medication prescribing. Prospective observational study. Five mid-Michigan community hospitals. 516 AMI patients admitted consecutively 1 year after the GAP intervention. These patients were compared with 499 post-GAP patients. The main outcome was adherence to medication use guidelines. Predictors of medication use were determined using multivariable logistic regression analysis. 1 year after GAP implementation, adherence to most medications remained high. We found a significant increase in beta-blocker (BB) use in-hospital (87.9 vs. 72.1%, P<0.001) whereas cholesterol assessment within 24 h (79.5 vs. 83.6%, P>0.225) did not change significantly. However, discharge aspirin (83 vs. 90%, P<0.018) and BB prescriptions (84 vs. 92%, P<0.016) dropped to preintervention rates. Discharge angiotensin-converting enzyme inhibitor and treatment of patients with low-density lipoprotein of ≥ 100 were unchanged. Predictors of receiving appropriate medications were male gender (for aspirin and BBs) and treatment with percutaneous coronary intervention compared with coronary artery bypass graft. Notably, prescription rates for discharge medications differed significantly by hospital.

Question: Is quality improvement sustainable?

Early benefits of the Mid-Michigan GAP intervention on guideline use were only partially sustained at 1 year. Differences in guideline adherence by treatment modality and hospital demonstrate challenges for follow-up phases of GAP. Additional strategies to improve sustainability of QI efforts are urgently needed.

Answer the question based on the following context: Reliable measurement of FVIII inhibitor is critical in the follow-up of haemophilia A patients. We performed a multicentre study to evaluate whether the presence of von Willebrand factor (VWF) in FVIII-deficient plasma (FVIII-DP) influences FVIII inhibitor titres. Six French haematology laboratories participated in this study. Three samples with varying FVIII inhibitor titres (1, 5 and 15 BU/mL) and one sample without any detectable FVIII inhibitor were tested using four different procedures for FVIII inhibitor assay. The Nijmegen method and a modified assay with imidazole were performed using FVIII-DP with and without VWF in the control mixture and as substrate plasma in the FVIII one stage assay (OSA). Each mixture (reference and test) was incubated for two hours at 37 °C with buffered normal pool plasma. Higher inhibitor titres were measured in 5 and 15 BU/mL samples when assays were performed with the Nijmegen method and FVIII-DP without VWF. When samples were diluted in imidazole buffer, similar inhibitor titres, close to expected values, were measured whether VWF was present in the FVIII-DP or not. The data obtained were also more accurate when residual FVIII activity levels between 40% and 60% were used to calculate inhibitor titres, despite a linear type I reaction kinetics.

Question: Does the presence of von Willebrand factor in FVIII-deficient plasma influences the measurement of FVIII inhibitor titres in haemophilia A patients?

These results support the hypothesis that reliable FVIII inhibitor titres can be measured without the use of FVIII-DP containing VWF when an imidazole-modified assay is used.

Answer the question based on the following context: Borderline personality disorder (BPD) is characterized by a pervasive pattern of instability and impulsivity. There is a high prevalence of BPD patients among those admitted to the emergency department for suicide attempts. However, little empirical research exists to assist clinicians in deciding whether to hospitalize a suicidal patient. Some authors have argued that hospitalization does not prevent suicide and could actually harm these patients, thereby leading to psychosocial regression. Parasuicidal behaviors could be reinforced by the attention given during hospitalization. Our purpose was to determine whether the hospitalization of suicidal patients who have a high risk of BPD after discharge from the emergency department is associated with a recurrence of suicidal behavior at 6months. We designed a prospective study, acquiring patients from three emergency hospitals. The participants were suicidal subjects admitted for voluntary drug intoxication and were 18years of age or older. The participants completed the Personality Disorder Questionnaire (PDQ-4+) to assess BPD symptomatology. Information on the recurrence of suicidal behavior at 6months was obtained by interview of patients and the review of the charts from the 3 hospitals involved in the study. Other assessments included the BDI-13 (severity of depression), the Hopelessness Scale (hopelessness), the TAS-20 (alexythymia), the AUDIT (alcohol disorder) and the MINI (axis I disorders). A total of 606 subjects admitted for a suicide attempt participated in this study. A total of 320 (52.8 %) of the subjects completed the PDQ-4+. The sample was divided into three groups: participants at high risk of having at least one BPD (n=197), a group at high risk of having at least one non-BPD PD (n=84) and a group with low risk of having a PD (n=39). Hospitalization following an emergency was not associated with a recurrence of suicide attempts at 6months among patients at high risk of BPD. A logistical regression analysis showed pre-hospitalization antidepressant prescription to be associated with recidivism (OR=2.1, P=.037).

Question: Should hospitalization be required after the emergency discharge of patients with borderline personality disorder who have attempted suicide (FRENCH CRISIS cohort)?

Our exploratory study suggests that hospitalization may not increase suicide attempts among patients with BPD when the health organization does not include a specific device such as DBT.

Answer the question based on the following context: To examine the effects of the combined use of chlorhexidine and ethanol on the durability of resin-dentin bonds. Forty-eight flat dentin surfaces were etched (32% phosphoric acid), rinsed (15 s) and kept wet until bonding procedures. Dentin surfaces were blot-dried with absorbent paper and re-wetted with water (water, control), 1% chlorhexidine diacetate in water (CHD/water), 100% ethanol (ethanol), or 1% chlorhexidine diacetate in ethanol (CHD/ethanol) solutions for 30 s. They were then bonded with All Bond 3 (AB3, Bisco) or Excite (EX, Ivoclar-Vivadent) using a smooth, continuous rubbing application (10 s), followed by 15 s gentle air stream to evaporate solvents. The adhesives were light-cured (20 s) and resin composite build-ups constructed for the microtensile method. Bonded beams were obtained and tested after 24-h, 6-months and 15-months of water storage at 37°C. Storage water was changed every month. Effects of treatment and testing periods were analyzed (ANOVA, Holm-Sidak, p<0.05) for each adhesive. There were no interactions between factors for both etch-and-rinse adhesives. AB3 was significantly affected only by storage (p=0.003). Excite was significantly affected only by treatments (p=0.048). AB3 treated either with ethanol or CHD/ethanol resulted in reduced bond strengths after 15 months. The use of CHD/ethanol resulted in higher bond strengths values for Excite.

Question: Can 1% chlorhexidine diacetate and ethanol stabilize resin-dentin bonds?

Combined use of ethanol/1% chlorhexidine diacetate did not stabilize bond strengths after 15 months.

Answer the question based on the following context: Based on ethnographic investigations and mathematical models, older sexual partners are often considered a major risk factor for HIV for young women in sub-Saharan Africa. Numerous public health campaigns have been conducted to discourage young women from relationships with older men. However, longitudinal evidence relating sex partner age disparity to HIV acquisition in women is limited. Using data from a population-based open cohort in rural KwaZulu-Natal, South Africa, we studied 15- to 29-year-old women who were HIV seronegative at first interview between January 2003 and June 2012 (n = 2444). We conducted proportional hazards analysis to establish whether the age disparity of women's most recent sexual partner, updated at each surveillance round, was associated with subsequent HIV acquisition. A total of 458 HIV seroconversions occurred over 5913 person-years of follow-up (incidence rate: 7.75 per 100 person-years). Age disparate relationships were common in this cohort; 37.7% of women reported a partner 5 or more years older than themselves. The age disparity of women's partners was not associated with HIV acquisition when measured either continuously [hazard ratio (HR) for 1-year increase in partner's age: 1.00, 95% confidence interval (CI): 0.97 to 1.03] or categorically (man ≥5 years older: HR, 0.98; 95% CI: 0.81 to 1.20; man ≥10 years older: HR, 0.98; 95% CI: 0.67 to 1.43). These results were robust to adjustment for known sociodemographic and behavioral HIV risk factors and did not vary significantly by women's age, marital status, education attainment, or household wealth.

Question: Do age-disparate relationships drive HIV incidence in young women?

HIV incidence in young women was very high in this rural community in KwaZulu-Natal. Partner age disparity did not predict HIV acquistion. Campaigns to reduce age-disparate sexual relationships may not be a cost-effective use of HIV prevention resources in this setting.

Answer the question based on the following context: Serial electrophysiology has been suggested as essential for accurate diagnosis in Guillain-Barré syndrome (GBS). However, whether more adapted electrophysiological criteria may allow a single study to be sufficient is unknown. We retrospectively reviewed records of 365 consecutive patients with GBS from Birmingham, U.K., and Garches, France, admitted between 1998 and 2013. Electrophysiology was analysed using existing criteria as well as a set of modified criteria, developed using sensitive and specific cut-off values for demyelination and incorporating new knowledge on electrophysiology of axonal GBS. We compared diagnostic rates and classification changes using modified criteria with published literature relating to serial studies. With existing criteria, we found similar proportions of acute inflammatory demyelinating polyradiculoneuropathy (AIDP) (71.5% vs. 72%; p=1), axonal GBS (17.5% vs. 14.7%; p=0.62) and equivocal forms (9.9% vs. 13.3%; p=0.41) to the previous studies considered. With modified criteria, we identified comparable rates of AIDP (56.2% vs. 58.7%; p=0.70), axonal GBS (35.1% vs. 36%; p=0.89) and equivocal forms (7.7% vs. 5.3%; p=0.63) with a single nerve conduction study as compared with when serial electrophysiology was used in previous analyses. We observed an identical diagnostic shift from AIDP to axonal GBS with modified criteria as that described with serial studies (21.5% vs. 18.5%; p=0.72). Classification changes with modified criteria correlated significantly with performing of electrophysiology ≤7 days after symptom onset (p=0.045), indicating their greater usefulness in earlier disease stages.

Question: Electrophysiological diagnosis of Guillain-Barré syndrome subtype: could a single study suffice?

A single electrophysiological study may suffice to establish the ultimate electrodiagnosis of GBS subtype if the proposed modified electrodiagnostic criteria are used.

Answer the question based on the following context: Italy has a population of 60 million and a universal coverage single-payer healthcare system, which mandates collection of healthcare administrative data in a uniform fashion throughout the country. On the other hand, organization of the health system takes place at the regional level, and local initiatives generate natural experiments. This is happening in particular in primary care, due to the need to face the growing burden of chronic diseases. Health services research can compare and evaluate local initiatives on the basis of the common healthcare administrative data.However reliability of such data in this context needs to be assessed, especially when comparing different regions of the country. In this paper we investigated the validity of healthcare administrative databases to compute indicators of compliance with standards of care for diabetes, ischaemic heart disease (IHD) and heart failure (HF). We compared indicators estimated from healthcare administrative data collected by Local Health Authorities in five Italian regions with corresponding estimates from clinical data collected by General Practitioners (GPs). Four indicators of diagnostic follow-up (two for diabetes, one for IHD and one for HF) and four indicators of appropriate therapy (two each for IHD and HF) were considered. Agreement between the two data sources was very good, except for indicators of laboratory diagnostic follow-up in one region and for the indicator of bioimaging diagnostic follow-up in all regions, where measurement with administrative data underestimated quality.

Question: Can Italian healthcare administrative databases be used to compare regions with respect to compliance with standards of care for chronic diseases?

According to evidence presented in this study, estimating compliance with standards of care for diabetes, ischaemic heart disease and heart failure from healthcare databases is likely to produce reliable results, even though completeness of data on diagnostic procedures should be assessed first. Performing studies comparing regions using such indicators as outcomes is a promising development with potential to improve quality governance in the Italian healthcare system.

Answer the question based on the following context: The aim of this study was to investigate polymorphisms in the promoter region of the neutrophil elastase (ELANE) gene as potential modulators of the therapeutic response in children with idiopathic bronchiectasis. The study included 48 children between 5 and 17 years old who were diagnosed with idiopathic bronchiectasis based on high-resolution computed tomography of the thorax. In all patients therapy included administration of antibiotics, anti-inflammatory drugs, expectorants, and postural drainage. Response to therapy was evaluated by the change in FeNO levels before and after administration of therapy. The ELANE promoter region polymorphisms were analyzed by PCR-direct DNA sequencing. According to the predicted activity of ELANE genotypes, subjects were divided into two groups: low/intermediate activity (n = 18) and high activity (n = 30). Subjects in the group with high-activity genotype had higher initial FeNO levels and this difference was statistically significant (t = 2.906; p = 0.006). The difference between FeNO levels before and after therapy was also statistically significantly higher in children with high-activity genotype (t = 3.329; p = 0.002). Statistically significant correlation was observed between the change in FeNO levels and ELANE genotypes (r = 0.350; p = 0.015).

Question: Neutrophil elastase gene polymorphisms: modulators of response to therapy in childhood bronchiectasis?

Children with high-activity genotype had higher initial FeNO levels and showed better response to therapy than children with low/intermediate-activity genotypes.

Answer the question based on the following context: Hip dislocation as a result of neurogenic hip displacement is a common focal motor symptom in children with infantile cerebral palsy (ICP). In addition to contracture of the hip joint, in up to 65 % of cases patients suffer from pain which leads to further loss of function and often to limitations in important basic functions, such as lying, care, sitting, standing and transfer. In order to avoid hip dislocation and to be able to implement therapy at an early stage, screening programs have been developed in recent years which clearly demonstrate the risks of hip displacement in ICP depending on the ability to walk. An investigation of the natural course is practically impossible because as a rule patients with painful neurogenic hip displacement receive surgical therapy. In this study 96 patients with high hip dislocation grade IV on the Tönnis classification were included and 68 could be followed up. The average age at the time of surgery was 10.9 years and the mean follow-up period was 7.7 years. In the postoperative course 6 out of 91 reconstructed hips became redislocated and a proximal femoral resection was carried out in one female patient. The migration index according to Reimers was 14.0 % at the time of the follow-up examination.

Question: Long-term results of reconstructive surgery in infantile cerebral palsy patients with high hip dislocation: is hip screening necessary?

Revision procedures can be avoided by screening programs. These should be strived for so that the neuro-orthopedic treatment on operation planning is not first initiated when pain occurs and revision procedures, such as angulation osteotomy or proximal femoral resection can be avoided. The reconstruction should also involve minimal deformation of the femoral head. In order to implement this, the interdisciplinary cooperation between neuropediatricians, social pediatriatricians and neuro-orthopedists should be intensified in the future.

Answer the question based on the following context: Because the medial patellofemoral ligament (MPFL) is the primary restraint to lateral dislocation of the patella, we aimed, in this controlled study, to verify whether the MPFL with different measurements could be considered another predisposing factor for patellar dislocation. A group of 100 consecutive individuals without the criteria for patellar dislocation (trochlear dysplasia, patella alta and lateral patellar tilt) was recruited as a control group and underwent magnetic resonance imaging (MRI) study and another group of 50 patients with patellar instability. Femoral condyles, interepicondylar distance, length and thickness of the MPFL were measured. In the control group, the MPFL was 38-60 mm long. Individuals with patellar instability who had no episode of patellar dislocation had a 4.11-mm longer ligament than controls (p = 0.032), while patients with instability with a previous history of dislocation had a 13.54-mm longer MPFL than controls (p < 0.001). Thickness of the MPFL at the patellar insertion was lower in individuals with patellar instability with a history of dislocation (p < 0.001). An instability coefficient (IC) less than 1.3 indicates that the MPFL is insufficient.

Question: Medial patellofemoral ligament anatomy: is it a predisposing factor for lateral patellar dislocation?

Individuals with patellar instability and previous patellar dislocation present with longer MPFL when compared to controls, and an associated IC less than 1.3 can be considered a predisposing factor for patellar dislocation. Treatment of patellar instability is a challenge, and it is difficult to identify what is the predisposing factor. This study has verified the measurements of the MPFL for the first time and presents values of thickness and length that can be considered as indications for surgical reconstruction.

Answer the question based on the following context: Interventions that improve HbA1c levels do not necessarily improve health-related quality of life (QoL). This issue may be particularly relevant in asymptomatic diabetes patients detected earlier in the course of the disease. HbA1c , diabetes-specific QoL (ADDQoL) and health status were measured in 510 screen-detected diabetes patients from the ADDITION-Cambridge trial at 1 and 5 years post diagnosis. Multivariable logistic/linear regression was used to quantify the longitudinal association between change in HbA1c from 1 to 5 years and ADDQoL and health status at 5 years, adjusting for age, sex, education and trial group; alcohol consumption, smoking, physical activity, plasma vitamin C, HbA1c , ADDQoL or health status at 1 year, and glucose-lowering medication at 5 years. From 1 to 5 years, median HbA1c interquartile range increased from 6.3% (5.9-6.8) to 6.8% (6.4-7.4); the median ADDQoL score and mean health status physical health summary score decreased from -0.4 (-1 to -0.08) to -0.5 (-1.08 to -0.09) (suggesting an adverse impact of diabetes on QoL) and by -0.79 (8.94) points, respectively. Increases in HbA1c were independently associated with reporting a negative impact of diabetes on QoL (OR = 1.38, 95% CI: 1.03 to 1.85) but not with the health status summary scores.

Question: Are changes in glycaemic control associated with diabetes-specific quality of life and health status in screen-detected type 2 diabetes patients?

Increases in HbA1c from 1 to 5 years post-diagnosis were independently associated with increased odds of reporting a negative impact of diabetes on QoL. While our results suggest that efforts to reduce HbA1c do not adversely affect health-related QoL, large numbers of participants still report a negative impact of diabetes on their QoL 5 years post-diagnosis.

Answer the question based on the following context: Rootless carnivorous plants of the genus Utricularia are important components of many standing waters worldwide, as well as suitable model organisms for studying plant-microbe interactions. In this study, an investigation was made of the importance of microbial dinitrogen (N2) fixation in the N acquisition of four aquatic Utricularia species and another aquatic carnivorous plant, Aldrovanda vesiculosa. 16S rRNA amplicon sequencing was used to assess the presence of micro-organisms with known ability to fix N2. Next-generation sequencing provided information on the expression of N2 fixation-associated genes. N2 fixation rates were measured following (15)N2-labelling and were used to calculate the plant assimilation rate of microbially fixed N2. Utricularia traps were confirmed as primary sites of N2 fixation, with up to 16 % of the plant-associated microbial community consisting of bacteria capable of fixing N2. Of these, rhizobia were the most abundant group. Nitrogen fixation rates increased with increasing shoot age, but never exceeded 1·3 μmol N g(-1) d. mass d(-1). Plant assimilation rates of fixed N2 were detectable and significant, but this fraction formed less than 1 % of daily plant N gain. Although trap fluid provides conditions favourable for microbial N2 fixation, levels of nif gene transcription comprised<0·01 % of the total prokaryotic transcripts.

Question: Dinitrogen fixation associated with shoots of aquatic carnivorous plants: is it ecologically important?

It is hypothesized that the reason for limited N2 fixation in aquatic Utricularia, despite the large potential capacity, is the high concentration of NH4-N (2·0-4·3 mg L(-1)) in the trap fluid. Resulting from fast turnover of organic detritus, it probably inhibits N2 fixation in most of the microorganisms present. Nitrogen fixation is not expected to contribute significantly to N nutrition of aquatic carnivorous plants under their typical growth conditions; however, on an annual basis the plant-microbe system can supply nitrogen in the order of hundreds of mg m(-2) into the nutrient-limited littoral zone, where it may thus represent an important N source.

Answer the question based on the following context: In order to prevent recurrent deformity, overcorrection in Blount's disease has been a common practice by most paediatric orthopaedic surgeons. However, some patients have persistent valgus alignment resulting in awkward deformity. The femoro-tibial angle (FTA) was measured in this series of cases to determine the necessity of such practice. During 1998-2010, patients with Blount's disease stage 2 by Langenskiold, aged from 30 to 40 months who had failed from bracing and underwent valgus osteotomy were included. Seventeen legs had postoperative FTA 7-13° (group 1) and 48 legs had postoperative FTA more than 13° (group 2). ROC curve was used to determine the appropriate FTA that was suitable to prevent recurrence. Four legs had recurrence (28.6%) in group 1 and six legs (12.5%) had recurrence in group 2. Chi-square test between two groups were not statistically significant in recurrence (p = 0.434). Age and BMI were not statistically significant between recurrent and non-recurrent groups. The ROC curve shows that overcorrection more than 15° did not show benefit to prevent the recurrence in Blount's stage 2.

Question: Do we need to do overcorrection in Blount's disease?

Our study showed that the overcorrection group had non-statistically significant recurrence compared to the non-overcorrection group, and overcorrection more than valgus 15° has no benefit to prevent recurrence.

Answer the question based on the following context: In our study we explored the need to define a core outcome set for primary frozen shoulder. We investigated the outcomes used by studies included in a systematic review of the management of primary frozen shoulder; surveyed which primary outcome measures health care professionals considered important; and re-examined papers previously obtained for a systematic review of patients' views of interventions for frozen shoulder to investigate their views on outcomes. Thirty-one studies investigated the outcomes range of movement (28 studies), pain (22), function and disability (22), adverse events (13), quality of life (7) and other outcomes (5). Many different types of pain and ranges of movement were measured. Function and disability was measured using fifteen instruments, the content of which varied considerably. Function and disability, pain and range of movement (132, 108 and 104 respondents, respectively) were most often cited by health care professionals as the primary outcome measure that should be used. Searches identified one paper that included patients' views. Outcomes of importance to patients were pain at night, general pain, reduced mobility (resulting in modification of activities) and the emotional impact of frozen shoulder.

Question: Exploring the outcomes in studies of primary frozen shoulder: is there a need for a core outcome set?

We identified a diverse range of outcomes that have been used or are considered to be important. The development of a core outcome set would improve the design and reporting of studies and availability of data for evidence synthesis. Methods used to develop a core outcome set should be robust, transparent and reflect the views of all stakeholders.

Answer the question based on the following context: Patients with postbariatric bacterial overgrowth were reinvestigated after a follow-up of 15 years. It was hypothesized that systemic associations analogous to those reported for whole gut microbiome would be revealed. Patients (n = 37, 70.3 % females, 42.4 ± 9.9 years old, preoperative BMI 53.5 ± 10.6 kg/m(2), current BMI 32.8 ± 10.8 kg/m(2)), all submitted to RYGB on account of morbid obesity, were followed during 176.8 ± 25.7 months. Blood tests included fasting blood glucose, HbA1c, liver and pancreatic enzymes, and lipid fractions. Bacterial overgrowth was diagnosed by quantitative culture of gastric fluid in both the excluded remnant and the gastric pouch, with the help of double-balloon enteroscopy. Absolute counts of aerobes and anaerobes in both gastric reservoirs were correlated with nutritional and biochemical measurements, aiming to identify clinically meaningful associations. Patients denied diarrhea, abdominal pain, weight loss, or other symptoms related to bacterial overgrowth. Biochemical profile including enzymes was also acceptable, indicating a stable condition. Positive correlation of bacterial count in either segment of the stomach was demonstrated for BMI and gamma-glutamyl transferase, whereas negative correlation occurred regarding fasting blood glucose.

Question: Asymptomatic gastric bacterial overgrowth after bariatric surgery: are long-term metabolic consequences possible?

An antidiabetic role along with deleterious consequences for weight loss and liver function are possible in such circumstances. Such phenotype is broadly consistent with reported effects for the whole gut microbiome. Prospective controlled studies including molecular analysis of gastrointestinal fluid, and simultaneous profiling of the entire microbiome, are necessary to shed more light on these findings.

Answer the question based on the following context: Incomplete tears of the hip abductor insertion can coexist with primary hip osteoarthritis. The aim of this investigation was to test the hypotheses that: (1) the outcome of patients undergoing primary THA using a direct anterior approach would be inferior when hip abductor pathology was present; and (2) in the presence of incomplete tears, the transgluteal approach with hip abductor repair delivers a superior outcome compared to the direct anterior approach. Forty patients underwent MR imaging of the hip abductor insertion prior to THA. The grade of abductor tears was assessed, the approach used for THA was recorded, and pre- and postoperative one-year outcome scores (WOMAC, HHS) were recorded. Twenty patients showed a normal appearance of the hip abductor insertion and THA was performed using the direct anterior approach (group 1). In 20 patients partial tears of the hip abductor insertion were recognized. Eight of them had THA through a direct anterior approach (group 2) and twelve through a transgluteal approach with repair (group 3).All patients improved after surgery. Overall the WOMAC improved from 6.1 to 2.1 points and the HHS from 46 to 87 points. A significantly higher benefit in terms of the HHS was achieved in patients of group 1 (p = 0.045). No significant differences were recorded between group 2 and group 3.

Question: Primary total hip arthroplasty (THA) in patients with incomplete hip abductor tears: does hip abductor repair improve outcome?

Improvement in outcome scores after THA using the direct anterior approach was inferior in the presence of partial hip abductor tears. The repair of partial hip abductor tears was not associated with superior clinical results.

Answer the question based on the following context: Chemotherapy near the end of life is frequently considered as an indicator of inappropriate aggressiveness. We were interested in revising our prescribing habits and in analyzing the reasons for offering active treatment to patients with advanced cancer. We examined the electronic medical records of all the cancer patients died in the Italian Region of Valle d'Aosta in a 1-year period and extracted all the available clinical data. From the 350 deceased patients, we selected the 141 to whom active treatment had been given during the natural history of their disease. Among the patients undergoing any active treatment, the median number of days from the last administration to death was 75. Thirty-seven patients (26.2 %) had their last treatment administration during the 4 weeks before death and 20 (14.2 %) during the last 2 weeks. Fourteen patients (9.9 %) started treatment during the last 4 weeks. When the patients undergoing treatment in the last 4 weeks of life were compared with those subject to earlier withdrawal, only age and pretreatment were statistically significantly different. Most of the treatment choices were considered appropriate, and earlier treatment withdrawal could have been advised only in a minority of the cases.

Question: Active treatment given in the last weeks of life: poor quality cancer care or justifiable behavior?

Our data were at the lower range when compared with the available literature. Uncertainties in prognostication and the possibility of response to treatment can justify chemotherapy prescriptions in selected cases. We suggest that the focus should move to the provision of adequate and timely supportive care.

Answer the question based on the following context: Some conflicting results have been published about the relationship between TNF-α-308 gene polymorphism and chronic obstructive pulmonary disease (COPD). The aim of this study was to determine whether TNF-α-308 gene polymorphism was associated with smoking-related COPD and whether it was associated with pulmonary function parameters (PFTs), body mass index (BMI), and prognosis. We studied the frequencies of TNF-α-308 gene polymorphism in 90 male subjects (60 subjects with COPD and 30 healthy smokers) in a Caucasian population. There was no significant difference in the frequency of G/G and G/A gene polymorphisms in the COPD group compared with control subjects (p>0.05). We compared COPD patients as G/A gene polymorphism and G/G gene polymorphism; the PFTs and BMI before and after one year were not statistically significant (p>0.05). Also, the exacerbation and hospitalization data of COPD patients were not significant between these groups.

Question: Is TNF-α gene polymorphism related to pulmonary functions and prognosis as determined by FEV1, BMI, COPD exacerbation and hospitalization in patients with smoking-related COPD in a Turkish population?

In conclusion, there was no difference between smoking-related COPD and the control group according to TNF α-308 gene polymorphism in a Caucasian population. In addition, it was shown that important determinants of prognosis of COPD such as FEV1, BMI, COPD exacerbation and hospitalization were not associated with TNF-α-308 gene polymorphism.

Answer the question based on the following context: In this study, we aimed to research the relation between breast arterial calcifications (BACs) detected on mammography and two well-known markers of cardiovascular diseases-carotid artery intima-media thickness (C-IMT) and haemodynamics parameters like carotid peak-systolic velocity (PSV), end-diastolic velocity (EDV) and resistive index (RI). The study group consisted of 50 consecutive BAC (+) women and the control group consisted of 55 BAC (-) women. In all participants, BAC was diagnosed using mammography and C-IMT was measured using B-mode and Doppler ultrasonography. BAC was defined as two linear calcification depositions in a conical periphery or as calcific rings at the mammographic evaluation. Doppler spectrum samples were obtained from 2 cm proximal to the main carotid artery bifurcation. Postmenopausal female patients ranging in age from 40 to 86 included in this study. When the groups were adjusted for age, a statistically significant difference was found between mean C-IMT of BAC (+) and BAC (-) groups (0.81 ± 0.2 vs. 0.69 ± 0.2 mm; p<0.001). No significant differences were observed between BAC (+) and BAC (-) groups in terms of PSV, EDV, RI.

Question: Breast arterial calcifications and carotid intima-media thickness and haemodynamics: Is there any association?

The findings of the present study suggest that BAC, diagnosed by mammography, is independently associated with C-IMT. C-IMT measurement is suggested as a useful tool to detect early atherosclerotic changes. However, haemodynamic variables (PSV, EDV, RI) were not statistically different between the BAC (+) and BAC (-) groups. Prospective larger cohort studies are needed to further elucidate whether BAC is an independent risk factor for cardiovascular disease.

Answer the question based on the following context: CT temporal bone scans are often performed to aid in surgical planning and management of cholesteatomas. With improvements in the resolution of CT scans today, it is now possible to obtain more information from these scans than before. The aim of this study is to compare findings on high resolution CT (HRCT) temporal bone scans to intra-operative findings, so as to determine how well various middle ear structures are assessed by HRCT scanning. Retrospective study. Otology clinic of a tertiary otolaryngology centre. 32 mastoidectomies performed by a single otologist for clinically confirmed cholesteatoma were included. Correlation of CT and intra-operative findings on the status of structures including the ossicles, semicircular canals, facial canal and tegmen was analysed using kappa and AC1 statistics. In all patients, a soft tissue mass with bony erosion in keeping with a cholesteatoma was seen on CT. Radiosurgical agreement was excellent for the presence of semicircular canal erosion (k=0.89, AC1=0.96), facial canal dehiscence (k=0.74, AC1=0.76), tegmen erosion (k=0.76, AC1=0.92) and malleus erosion (k=0.76, AC1=0.85). It was good for incus erosion (k=0.71, AC1=0.92) and stapes erosion (k=0.63, AC1=0.73).

Question: Pre-operative high resolution computed tomography scans for cholesteatoma: has anything changed?

There was good to excellent radiosurgical agreement in the assessment of the status of various middle ear structures. Improvement in radiosurgical agreement from existing studies in the literature was noted. This was especially true for features such as facial canal dehiscence. With technological advancements, CT temporal bone scans appear even more valuable for evaluation of patients prior to cholesteatoma surgery.

Answer the question based on the following context: Two surgical techniques for performing a transtibial amputation include a traditional approach and a bone bridge approach. To date, there is no conclusive evidence of superiority of either technique in terms of temporal-spatial, kinetic, and mechanical work parameters.QUESTIONS/ We sought to compare instrumented three-dimensional gait parameters and mechanical work measurements of patients who had undergone a traditional or bone bridge amputation at the transtibial level. Residual limb length and its effect on those functional outcomes was a secondary interest irrespective of amputation type. This retrospective comparative study included 14 active-duty military men with a mean age of 25 years (range, 20-28 years). Comparisons were made between seven patients with traditional and seven patients with bone bridge amputations at the transtibial level. The patients walked at self-selected and fast paces while three-dimensional gait analysis data were collected and comparisons were made between patients with the two amputation types as well as by length of the residual limb. With the numbers available, we observed no differences between the two surgical groups at either speed for the temporal-spatial parameters or mechanical work metrics. However, the bone bridge group did demonstrate greater rolloff vertical ground reaction force during the fast walking condition with a median 1.02% of body weight compared with 0.94% (p = 0.046), which suggests a more stable platform in terminal stance. When the two groups were combined into one to test the effect of residual limb length, the linear regression resulted in an R(2) value of 0.419 (p = 0.012), in which patients with longer residual limbs had improved F3 force values during self-selected walking.

Question: Do patients with bone bridge amputations have improved gait compared with patients with traditional amputations?

Overall, limited functional differences were found between the two groups in this small pilot study, so a superior surgical technique could not be determined; whereas our limited sample size prevents a firm conclusion of no difference, our data can be considered hypothesis-generating for future, larger studies. Although some evidence indicated that patients with a bone bridge have improved loading at higher speeds, a regression of all patients walking at self-selected speed indicates that as residual limb length increases, loading increases regardless of amputation type. Thus, our data suggest it is important to preserve residual limb length to allow for improved loading in terminal stance.

Answer the question based on the following context: This study aims to estimate and test temporal differences in mental health (MH) need and service use among adult cancer survivors nationally before and after important policy recommendations for psychosocial cancer care. Adults (n = 58,585) from the National Health Interview Survey, 2005 and 2010, were categorized as having (1) no chronic disease, (2) chronic disease other than cancer, (3) cancer without other chronic disease, and (4) cancer with other chronic disease. In these groups, we compared psychological distress, MH visits, and unmet need for MH services. Survey-weighted logistic regression was used to model these variables as functions of disease status and sociodemographic covariates and the interactions of disease status and survey year. Whereas the proportion of individuals with psychological distress and MH visits was significantly higher in 2010 versus 2005 for the no chronic disease group, the only group with significantly lower unmet need in 2010 versus 2005 was the cancer with other chronic disease group (5.3% vs. 3.0%, p < 0.05). In adjusted models, cancer survivors with other chronic disease had significantly lower odds of unmet need in 2010 (odds ratio 1.38; 95% confidence interval 0.85, 2.25) than in 2005 (odds ratio 3.32; 95% confidence interval 2.28, 4.83).

Question: Mental health needs and service use in a national sample of adult cancer survivors in the USA: has psychosocial care improved?

We find evidence of MH care quality improvement among cancer survivors between 2005 and 2010, a period that coincides with policy and clinical attention to psychosocial cancer care. These efforts may have reduced, but not eliminated, unmet need for MH services among cancer survivors.

Answer the question based on the following context: Numerous molecular markers have been investigated as potential predictors of tumor responses to preoperative chemoradiotherapy (preCRT) for rectal cancer. To develop a system in which biomarkers are used to predict the likelihood of a pathologic complete response (pCR) to preCRT.DESIGN & This is a retrospective analysis of tumor specimens collected prior to preCRT from 81 patients who underwent curative resection for primary rectal adenocarcinoma between June 2008 and February 2012. Using tissue microarrays and immunohistochemistry, expression levels of twelve candidate biomarkers (p53, p21, Bcl2, Bax, EGFR, Cox-2, MLH-1, MSH-2, Ku70, VEGF, TS, Ki-67) were evaluated in paraffin-embedded tumor samples collected before preCRT. The correlation between biomarker expression levels and the pathologic response to preCRT was assessed based on histopathological staging (pTNM) and tumor regression grade (TRG). Expression levels of 4 biomarkers (p53, VEGF, p21, Ki67) correlated with pCR. Patients showing low expression of p53 and/or high expression of VEGF, p21, and Ki67 exhibited a significantly greater pCR rate. A scoring system devised so that one point was given for each biomarker whose expression level correlated with pCR (score range: 0-4) showed that 1 of 26 patients with scores of 0 to 1 achieved pCR, whereas 26 of 55 patients with scores of 2 to 4 achieved pCR (3.8% vs. 47.3%, p<0.001). For prediction of pCR, the scoring system showed 96.3% sensitivity, 46.3% specificity, a 47.3% positive predictive value, and a 96.2% negative predictive value. Immunohistochemistry has limitations related to reproducibility and the ability to provide quantitative information. In addition, this study lacks test and validation sets.

Question: Can a biomarker-based scoring system predict pathologic complete response after preoperative chemoradiotherapy for rectal cancer?

Expression levels of 4 biomarkers correlated with pCR after preCRT for rectal cancer. A scoring system based on levels of biomarker expression showed good sensitivity and negative predictive value for pCR.

Answer the question based on the following context: Transanal stapled procedures are increasingly being used. Several postoperative complications can be referred to their application, including those related to the presence of retained staples at the level of the staple line. This study was conducted to assess whether the removal of the retained staples is a useful approach to improve some of the most common postoperative complications of these surgical techniques. This is a retrospective study. The study was conducted at the One-Day Surgery Unit of St. Andrea Hospital. All of the patients who underwent a stapled transanal procedure from January 2003 to December 2011 were included in the study. Patients included in the study were followed postoperatively for 1 year after surgery to identify the presence of retained staples. If identified, the retained staples were removed endoscopically or transanally. After the staple removal, patients were followed with biweekly office visit for 2 months to evaluate the progression of symptoms. From the 566 patients included in the study, 165 experienced postoperative complications, and in 66 of these cases, retained staples were found and removed. With the removal of retained staples, symptoms were almost all resolved or improved. In only 1 case did the retained staples removal not modify the symptoms. The study design may have introduced potential selection bias. In addition, the study was limited by the lack of a specific questionnaire for the evaluation of symptoms improvement.

Question: Does the removal of retained staples really improve postoperative chronic sequelae after transanal stapled operations?

The removal of the retained staples is an efficacious and safe procedure to solve or improve postoperative complications and should be always considered.

Answer the question based on the following context: The aim of this study was to verify if gait speed can be an incremental predictor for mortality and/or major morbidity in combination with EuroSCORE II. A single center prospective study cohort of 150 patients aged 70 years or older and undergoing cardiac surgery between August 2012 and April 2013. Slow gait speed was defined as a time taken to walk 5 meters of ≥6 second. The logistic EuroSCORE and EuroSCORE II were used for risk stratification. The studied group had a mean age of 77.7±5.2 years and mean gait speed was 4.9±1.01 (3.0-8.6) seconds. Slow gait speed was recorded in 21 patients (14%), indicated as frail, the other 129 patients (86%) as active. The logistic EuroSCORE risk (P=0.528), was not significantly different between the two groups. The EuroSCORE II risk, however, was significantly higher (P=0.023) for the frail group. There was no mortality and no statistically significant difference in percentage of major morbidity between the frail (28.6%) versus 17.1% for the active group (P=0.209) and slow gait speed could not be identified as independent predictor. Nevertheless frailty demonstrated an incremental value to improve performance of the logistic EuroSCORE model to predict early mortality and/or major morbidity in this elderly patient population. This was not so for EuroSCORE II.

Question: Is gait speed improving performance of the EuroSCORE II for prediction of early mortality and major morbidity in the elderly?

We confirm the incremental value of frailty, evaluated by gait speed, to improve mortality and morbidity prediction of the logistic EuroSCORE model in elderly undergoing cardiac surgery. We could not confirm this for the new EuroSCORE II model.

Answer the question based on the following context: To evaluate the relationship between hepatic steatosis and increase in liver size and resolution of shunting after surgical attenuation of congenital extrahepatic portosystemic shunts in dogs. Prospective study. Dogs (n = 20) with congenital extrahepatic portosystemic shunts. Shunts were attenuated using ameroid ring constrictors. Portal blood flow and liver volume were evaluated using computed tomography before and ≥8 weeks after surgery. Hepatic steatosis was quantified by stereological point counting of lipid droplets and lipogranulomas (LG) in liver biopsies stained with Oil-red-O. Associations between steatosis and preoperative liver volume, liver growth after surgery, and development of acquired shunts were evaluated. Acquired shunts developed in 2 dogs (10%). Dogs with larger preoperative liver volumes relative to bodyweight had fewer lipid droplets per tissue point (P = .019). LG per tissue point were significantly associated with age: 0.019 ± 0.06 for dogs<12 months versus 0.25 ± 0.49 for dogs>12 months (P = .007). There was a significant positive association between liver growth after surgery and the number of LG/month of age in dogs>12 months (P = .003). There was no association between steatosis, presence of macrosteatosis, the number of LG or development of acquired shunts.

Question: Does hepatic steatosis have an impact on the short term hepatic response after complete attenuation of congenital extrahepatic portosystemic shunts?

This preliminary study suggests that the presence of hepatic lipidosis and LG has no demonstrable effect on development of acquired shunts or the magnitude of increase in liver volume after attenuation of congenital extrahepatic portosystemic shunts in dogs.

Answer the question based on the following context: Both gestational diabetes mellitus (GDM) and late-preterm delivery at 34-36 weeks' gestation are independently associated with neonatal respiratory complications, but it is unknown whether their combination increases further its risk. We therefore appraised the independent effect of GDM on the respiratory outcome of late-preterm infants. In a retrospective cohort study, respiratory outcome of 911 infants delivered at 34-36 weeks' gestation between 1 January 2009 and 30 August 2012 from mothers with GDM (study group, n=130) was compared with infants delivered at the same gestation by mothers without GDM (control group, n=781). The study group had significantly higher incidence of transient tachypnoea of newborn (TTN, p=0.02) and air leak (p=0.012), and required more respiratory support, including oxygen, continuous positive airway pressure (CPAP), mechanical ventilation and neonatal intensive care, with a longer length of hospital stay, but not duration on respiratory support. On logistic regression analysis, GDM is an independent risk factor for TTN (aOR=1.5, 95% C.I.1.0-2.4), CPAP (aOR=2.37, 95% C.I. 1.05-4.89), mechanical ventilation (aOR=4.02 95% C.I. 1.57-10.32) and neonatal intensive care (aOR 1.83, 95% C.I. 1.05-3.87).

Question: Does gestational diabetes mellitus affect respiratory outcome in late-preterm infants?

Our results demonstrated an independent effect of GDM on the risk of severe respiratory complications in late-preterm infants. Additional close monitoring and timely intervention are necessary in the management of these infants.

Answer the question based on the following context: The study was conducted between November 2008 and April 2009 on consecutive psoriatic outpatients referred to a service of dermatological consultations, on indication of other hospital specialists. Participants were affected by mild skin psoriasis, in particular with nail dystrophies and/or scalp and/or intergluteal/perianal lesions. The questionnaire provided by the Classification of Psoriatic Arthritis (CASPAR) study group was proposed to all patients and we added a question about the time of psoriasis onset. Eighty-seven subjects (34 males and 53 females) aged between 18 and 91 years (mean age 48 years) with such psoriatic features were recruited. Other 30 refused to take part to the study. Forty-seven per cent of these participants were found to suffer from PsA, in particular 83% of those with nail and scalp psoriasis, 40% of subjects with intergluteal/perianal involvement and 37% of patients with just scalp lesions. We present the first exploratory and observational study focused on a population with mild skin psoriasis, in order to evaluate if nail dystrophies, scalp or intergluteal/perianal psoriatic lesions might be indicative of a higher risk of PsA even in cases with mild skin psoriasis.

Question: Nail dystrophies, scalp and intergluteal/perianal psoriatic lesions: risk factors for psoriatic arthritis in mild skin psoriasis?

Nail psoriasis is probably a suggestive feature of joint involvement. The scalp psoriasis, as well as intergluteal/perianal psoriatic lesions, is likely to be less associated to PsA, but may be an important comorbidity factor for the development of PsA. Further investigations in a larger population are encouraged to assess a potential link between PsA, site-specific and mild skin psoriasis.

Answer the question based on the following context: A total of 182 patients were enrolled in 2 cohorts: the first included 144/182 patients (79.1%) evaluated after 6 months from clinical remission, and the second 116/182 (63.7%) evaluated for at least 12 months after clinical remission. Patients were previously treated with topical diclofenac 3% in hyaluronic acid, cryotherapy, photodynamic, curettage or imiquimod cream. Subjects with history of malignant skin diseases showed an increased number of new lesions at 16 months from baseline (12 months from remission) compared to patients without history of cancers (mean 1.58 versus 1.17). Hyperkeratotic lesions healed more rapidly but relapsed at 6 months more frequently than non-hyperkeratotic ones (32.9% versus 20.7%). The results showed gender-related differences: male patients recovered better and independently from the treatment used; in contrast, men showed a higher recurrence (32% at 6 months and 6.6% between 6 and 12 months versus 16% at 6 months and 5.9% between 6 and 12 months for females) and a higher average number of new lesions after 12 months from remission (1.6 versus 0.88 for females).

Question: Relapsed actinic keratosis evaluation: an observational Italian multicenter prospective study. Does gender have a role?

The results may suggest a lower adherence to photoprotection in male patients. Hyperkeratotic lesions recurred mostly at 6 months in comparison to non-hyperkeratotic lesions.

Answer the question based on the following context: New concentrated laundry pods, available on the European market for approximately 10 years, are associated with more severe intoxications compared to classic laundry detergents.AIM: To compare symptoms and severity after exposure to classic laundry detergents and new laundry pods in a pediatric population. Retrospective study conducted between 1st January 2002 and 30th June 2013 including all laundry detergent exposure patients admitted to our tertiary level pediatric emergency unit. Collected data were age, sex, date, time and location of exposure, type of product (powder, liquid, tablets, pods), estimated ingested quantity, time of admission, clinical symptoms, severity, complications, and progression. Descriptive analysis: eighty-nine children were included. The mean age was 2.1 ± 1.5 years (range, 36 days to 10 years), 65% of patients were aged less than 2 years. The male:female ratio was 1.5 (males, 60%). After exposure, 57% of children were symptomatic and most frequently developed digestive symptoms (75%). Comparative analysis: compared to classic laundry detergent, children exposed to laundry pods were more symptomatic (96% versus 51%, P<0.0001), had more digestive signs (P=0.003), more frequently had bronchospasm (P=0.02), had a higher risk of ocular lesions (P=0.04), and exposure was more severe (poisoning severity score grade 2, 92% versus 59%, P<0.0001). Laundry pod toxicity is more severe. The chemical composition of laundry pods has a higher concentration of surfactants and ethoxylated alcohols; they have a higher viscosity and hydrotropic power. The addition of water seems to modify the alkalinity, which explains the severity of ENT, gastric, and corneal lesions.

Question: Pediatric exposures to laundry pods or capsules: more toxic than traditional laundry products?

The declaration to national poison centers of these intoxications should be pursued by emergency pediatricians, physicians, and pediatric intensivists. Family physicians can encourage parents to declare adverse effects to the National Consumer Product Safety Commission. Parents need to be better informed of the risk of laundry pods and strictly keep this type of product out of the reach of children. Given that it took 7 years after the first warning by the French poison centers to obtain safety recommendations for manufacturers, it is important to maintain pressure on companies to obtain the necessary modification of the physicochemical properties and child-resistant packaging.

Answer the question based on the following context: The presented study explored health beliefs and experiences as well as health education needs of low-educated employees (LEEs) (incomplete primary, primary, lower secondary and basic vocational education) in comparison to those with higher education (secondary and tertiary education) in four European countries: Latvia, Poland, Slovenia and Spain. The main aim was to identify a specificity of low-educated employees (LEEs) by capturing their opinions, experiences, attitudes and needs concerning health education. The sample consisted of 1691 individuals with the status of an employee (approximately 400 respondents in each of 4 countries participating in the project). The respondents were aged 25-54 (both the control group and the target group consisted in 1/3 of the following age groups: 25-34, 35-44 and 45-54). The respondents were interviewed during the years 2009 and 2010 with a structured questionnaire concerning their health, health behaviours as well as educational needs concerning health education. The study revealed substantial differences in the attitudes of people from this group concerning methodology of health education. LEEs prefer more competitions and campaigns and less written educational materials in comparison to those with higher education. Additionally, they more often perceive a fee, longer time, necessity to take part in a knowledge test and a concern that their health will be checked as factors that can discourage them from taking part in a health training. On the other hand, LEEs can by encouraged to take part in such a training by a media broadcast concerning the event, snacks or lottery during the training, or financial incentives.

Question: Should we adjust health education methodology to low-educated employees needs?

The results of the study proved the need for specific health education guidelines to conduct health education for low-educated employees. These guidelines should take in account the sources of health education preferred by LEEs as well as the factors that can encourage/discourage their participation in trainings concerning health.

Answer the question based on the following context: The management of patients with differentiated thyroid cancer (DTC) who have elevated serum thyroglobulin (Tg) levels and negative (131)I or (123)I scans is problematic, and the decision regarding whether or not to administer (131)I therapy (a "blind" therapy) is also problematic. While (124)I positron emission tomography (PET) imaging has been shown to detect more foci of residual thyroid tissue and/or metastases secondary to DTC than planar (131)I images, the utility of a negative (124)I PET scan in deciding whether or not to consider performing blind (131)I therapy is unknown. The objective of this study was to determine whether a negative (124)I pretherapy PET scan in patients with elevated serum Tg levels and negative (131)I or (123)I scans predicts a negative (131)I posttherapy scan. Several prospective studies have been performed to compare the radiopharmacokinetics of (124)I PET versus (131)I planar imaging in patients who 1) had histologically proven DTC, 2) were suspected to have metastatic DTC (e.g., elevated Tg, positive recent fine-needle aspiration cytology, suspicious enlarging mass), and 3) had (131)I planar and (124)I PET imaging performed. Using these criteria, we retrospectively identified patients who had an elevated Tg, a negative diagnostic (131)I/(123)I scan, a negative diagnostic (124)I PET scan, therapy with (131)I, a post-therapy (131)I scan, and a prior (131)I therapy with a subsequent positive post-(131)I therapy scan. For each scan, two readers categorized every focus of (131)I and (124)I uptake as positive for thyroid tissue/metastases or physiological. Twelve patients met the above criteria. Ten of these 12 patients (83%) had positive foci on (131)I posttherapy scan.

Question: Do negative 124I pretherapy positron emission tomography scans in patients with elevated serum thyroglobulin levels predict negative 131I posttherapy scans?

In our selected patient population, (131)I posttherapy scans are frequently positive in patients with elevated serum Tg levels, a negative diagnostic (131)I or (123)I scan, and a negative (124)I PET scan. Thus, for a patient with elevated serum Tg level, negative diagnostic (131)I planar scan, and a prior post-(131)I therapy scan that was positive, a negative (124)I PET scan will have a low predictive value for a negative post-(131)I therapy scan and should not be used to exclude the option of blind (131)I therapy.

Answer the question based on the following context: Among all postoperative complications, cardiac arrest after cardiac surgical operations has the greatest association with mortality. However, hospital variation in the ability to rescue after cardiac arrest is unknown. The purpose of this study was to characterize the impact of cardiac arrest on mortality and determine the relative impact of patient, operative, and hospital factors on failure to rescue (FTR) rates and surgical mortality after cardiac arrest. A total of 79,582 patients underwent operations at 17 different hospitals (2001 through 2011), including 5.2% (n=4,138) with postoperative cardiac arrest. Failure to rescue was defined as mortality after cardiac arrest. Patient risk, operative features, and outcomes were compared among hospitals. Overall FTR rate was 60% with significant variation among hospitals (range, 50% to 83%; p<0.001). Failure-to-rescue patients were slightly older, presented with increased preoperative risk, and underwent more emergent operations (all p<0.05). After risk adjustment, the variable "individual hospital" demonstrated the strongest association with likelihood for FTR (likelihood ratio=39.1; p<0.001). Overall risk-adjusted mortality, cardiac arrest, and FTR rates varied across hospitals and did not correlate. High-performing hospitals with lowest FTR rates accrued longer postoperative and intensive care unit stays after the index operation (2 to 3 days; p<0.001).

Question: Hospital variation in mortality from cardiac arrest after cardiac surgery: an opportunity for improvement?

Significant hospital variation exists in cardiac surgical mortality and FTR rates after cardiac arrest. Institutional factors appear to confer the strongest influence on the likelihood for mortality after cardiac arrest compared with patient and operative factors. Identifying best practice patterns at the highest performing centers may serve to improve surgical outcomes after cardiac arrest and improve patient quality.

Answer the question based on the following context: Bone morphogenetic protein-7 (BMP-7) is a key protein in organogenesis and liver development. The protein has been studied in the context of liver fibrosis and regeneration. The aim of the present study was to explore any possible association between fibrosis levels (as revealed by liver biopsy) and serum BMP-7 levels. A total of 189 patients with chronic hepatitis B and 51 healthy controls were enrolled in the study. The study group contained 120 (63.5%) males and 69 (36.5%) females, and the control group contained 25 males (49.0%) and 26 females (51%). In general, serum BMP-7 values of patients were higher than those of controls (p = 0.001). Serum BMP-7 values of patients with liver fibrosis of stages 1, 2, 3, or 4 were higher than control values (all p values = 0.01), but the serum BMP-7 levels of patients with stage 5 fibrosis were similar to that of controls. Associations between fibrosis stage and the serum levels of BMP-7, ALT, HBVDNA, platelets, and albumin were all statistically significant (p = 0.001). The AUROC for the BMP-7 level in advanced stage fibrosis was found to be 0.23. The data were analyzed using the binary logistic regression analysis (backward stepwise method) and BMP-7, HBVDNA, and platelet levels were found to be risk factors associated with fibrosis (p values 0.031, 0.040, and 0.001, respectively).

Question: Are bone morphogenetic protein-7 (BMP-7) serum levels correlated with development of hepatic fibrosis?

BMP-7 may play anti-inflammatory and anti-fibrogenic roles in the pathogenesis of chronic hepatitis B infection.

Answer the question based on the following context: With recent changes in the economy and the drive for cost-effective health care, current practices in the NHS need to be reviewed and revised. In light of this, the aim of this study is to investigate the perceived benefits of routine follow-up of patients with prostate cancer and to examine perceptions of prostate cancer patients and health professionals about who should follow-up patients and where and when this should take place. A service evaluation was carried out on a sample of patients receiving follow-up assessment following radical treatment for prostate cancer and health professionals in a specialist cancer urology unit in an acute NHS trust in south-east England. Data were collected through patient (n=47) and health professional (n=17) questionnaires and through a group discussion with a sample of patients (n=52). There was agreement between patients and professionals that the main purpose of follow-up consultation was to review the prostate-specific antigen (PSA) blood test and assess urinary symptoms. The majority of patients and professionals wanted follow-up in the hospital with face-to-face consultation. There was general agreement that assessments should be carried out every six months. An overwhelming majority of patients (95%) felt that it was important to have easy access to the urology cancer nurses and doctors.

Question: Prostate cancer follow-up needs: do patients and professionals agree?

Patients want to maintain the traditional model of hospital based follow-up in specialist urology cancer clinics. However, this approach is not economically sustainable. If this is to change we need to work with our patients to develop a service that meets their needs. For a new approach to follow-up to meet the needs of patients, they need to be confident that they have access to expert advice and support, and are assured of referral back to the urology team if required. Nurses are ideally placed to play a key role in the development of such a service.

Answer the question based on the following context: (1) To assess the use and practice of the clock face among surgeons who routinely perform anterior cruciate ligament (ACL) reconstructions, and (2) to assess the accuracy, precision, and reliability of 3 commonly used clock-face schemes in ACL reconstruction. First, 9 surgeons completed a questionnaire assessing the use and definition of the clock-face technique. Next, to assess the accuracy, precision, and reliability of the clock face, each surgeon estimated the "time" of 8 artificial femur models with a black dot located on the posterior aspect of the lateral condylar wall. The estimates were performed using 3 different clock-face schemes and were repeated 10 months later. Solutions for each specimen were obtained by use of a computer graphical interface. More than half of the respondents (55%) use the clock face in ACL reconstructions, with the reported mean ideal "time" for a femoral tunnel in a right knee of 10:05 (SD, 31 minutes). When we accounted for the different clock definitions, this ideal position was found along the entire lateral condylar wall. In the assessment of the performance of the clock face, the mean error was 32 to 40 minutes (which translates to 3 to 4 mm) among the 3 clock schemes. The maximum error was 4 hours 0 minutes, and the range of responses was 1 hour 0 minutes to 4 hours 0 minutes depending on the specimen and clock scheme. Regardless of the clock scheme used, the intrarater and inter-rater reliabilities were similar-measuring, on average, 0.78 and 0.68, respectively.

Question: Is the clock face an accurate, precise, and reliable measuring tool for anterior cruciate ligament reconstruction?

The clock face continues to be commonly used in ACL reconstruction. Different clock-face definitions affect the position for the same "time." When the clock-face parameters were strictly defined, there was good reliability with borderline accuracy and poor precision.

Answer the question based on the following context: Magnetic resonance imaging (MRI) showing an "intact" anterior cruciate ligament (ACL) graft may not correlate well with examination findings. Reasons for an ACL graft dysfunction may be from malpositioned tunnels, deficiency of secondary stabilizers, repeat injuries, or a combination of factors. To evaluate the concordance/discordance of an ACL graft assessment between an arthroscopic evaluation, physical examination, and MRI and secondarily to evaluate the contributing variables to discordance. Case series; Level of evidence, 4. A total of 50 ACL revisions in 48 patients were retrospectively reviewed. The ACL graft status was recorded separately based on Lachman and pivot-shift test data, arthroscopic findings from operative reports, and MRI evaluation and was categorized into 3 groups: intact, partial tear, or complete tear. Two independent evaluators reviewed all of the preoperative radiographs and MRI scans, and interrater and intrarater reliability were evaluated. Concordance and discordance between a physical examination, arthroscopic evaluation, and MRI evaluation of the ACL graft were calculated. Graft position and type, mechanical axis, collateral ligament injuries, chondral and meniscal injuries, and mechanism of injury were evaluated as possible contributing factors using univariate and multivariate analyses. Sensitivity and specificity of MRI to detect a torn ACL graft and meniscal and chondral injuries on arthroscopic evaluation were calculated. The interobserver and intraobserver reliability for the MRI evaluation of the ACL graft were moderate, with combined κ values of .41 and .49, respectively. The femoral tunnel position was vertical in 88% and anterior in 46%. On MRI, the ACL graft was read as intact in 24%; however, no graft was intact on arthroscopic evaluation or physical examination. The greatest discordance was between the physical examination and MRI, with a rate of 52%. An insidious-onset mechanism of injury was significantly associated with discordance between MRI and arthroscopic evaluation of the ACL (P = .0003) and specifically with an intact ACL graft on MRI (P = .0014). The sensitivity and specificity of MRI to detect an ACL graft tear were 60% and 87%, respectively.

Question: A Radiographic Assessment of Failed Anterior Cruciate Ligament Reconstruction: Can Magnetic Resonance Imaging Predict Graft Integrity?

Caution should be used when evaluating a failed ACL graft with MRI, especially in the absence of an acute mechanism of injury, as it may be unreliable and inconsistent.

Answer the question based on the following context: To compare the strength of the association between depression and mortality between elderly and younger individuals with diabetes mellitus. A survival analysis conducted in a longitudinal cohort study of persons with diabetes mellitus to test the association between depression and mortality in older (≥ 65) and younger (18-65) adults. Managed care. Persons aged 18 and older with diabetes mellitus who participated in the Wave 2 survey of the Translating Research Into Action for Diabetes (TRIAD) Study (N = 3,341). The primary outcome was mortality risk, which was measured as days until death using linked data from the National Death Index. Depression was measured using the Patient Health Questionnaire. After controlling for age, sex, race and ethnicity, income, and other comorbidities, mortality risk in persons with diabetes mellitus was 49% higher in those with depression than in those without, although results varied according to age. After controlling for the same variables, mortality risk in persons aged 65 and older with depression was 78% greater than in those without. For those younger than 65, the effect of depression on mortality was smaller and not statistically significant.

Question: Depression and all-cause mortality in persons with diabetes mellitus: are older adults at higher risk?

This analysis suggests that the effect of depression on mortality in persons with diabetes mellitus is most significant for older adults. Because there is evidence in the literature that treatment of depression in elderly adults can lead to lower mortality, these results may suggest that older adults with diabetes mellitus should be considered a high-priority population for depression screening and treatment.

Answer the question based on the following context: The aim of this study was to assess whether changes in Cystatin C (CyC) after 48 h post contrast media exposure was a reliable indicator of acute kidney injury and the validity of a risk scoring tool for contrast-induced acute kidney injury (CI-AKI). We enrolled 121 patients for whom diagnostic coronary angiography were planned. The risk score for CI-AKI was calculated and serum creatinine (sCr) and CyC were measured before and 48 h post coronary angiography. CyC and sCr based AKI was calculated as a 25% increase from baseline within 48 h from contrast media exposure. Mean serum CyC and creatinine concentrations were 0.88 ± 0.27 mg/dL and 0.79 ± 0.22 mg/dL, respectively before the procedure and 1.07 ± 0.47 mg/dL and 0.89 ± 0.36 mg/dL, respectively 48 h after contrast media exposure (P<0.001). CyC based AKI occurred in 45 patients (37.19 %) and sCr based AKI occurred in 20 patients (16.52%) after the procedure. Mean risk score was found to be 4.00 ± 3.478 and 3.60 ± 4.122 for CyC based AKI and sCr based AKI, respectively and was significantly increased in CyC based AKI group (P<0.001).

Question: Is cystatin-C superior to creatinine in the early diagnosis of contrast-induced nephropathy?

CyC measured 48 h after contrast media exposure may be a more sensitive indicator of CI-AKI relative to creatinine and Mehran risk scoring is in good correlation with CyC increase.

Answer the question based on the following context: In patients with obesity, intramuscular injections may be deposited subcutaneously due to an increase in gluteal fat. We aimed to use abdominal CT done in our institute for gluteal fat thickness to test our hypothesis. After IRB approval, CT scans of the abdomen and pelvis of the past 6 months were analyzed. The thickness of gluteal region subcutaneous fat was measured in a standardized manner. Out of 700 CT scans, studied, 476 were males and 224 were females. The average gluteal fat thickness was 2.34 cm +/- 1 cm. The average fat thickness in males was 1.98 cm +/- 0.98 cm whereas in females was 3.0 cm +/- 1.2 cm. Subcutaneous granulomas were seen in 17 cases and one injection granuloma in the intramuscular plane.

Question: Intended intramuscular gluteal injections: are they truly intramuscular?

A significant number of female patients had increased gluteal fat thickness beyond the reach of routinely used needles. The medications in these patients will thus be unintentionally injected to subcutaneous plane, possibly altering the pharmacokinetics.

Answer the question based on the following context: Geographical variations in adult obesity rates have been attributed in part to variations in social and economic inequalities. Insecurity is associated with obesity at the cross-national level, but there is little empirical evidence to show that insecurity contributes to the structuring of adult obesity rates at the subnational level. This is examined in this study across local authorities in England, using a recently developed social classification for the British population. Modelled obesity rates from the Health Survey for England 2006-2008 were related to social class (as estimated from the BBC's Great British Class Survey of 2011 and a nationally representative sample survey), across 320 local authorities in England. Comparisons of mean obesity rates across Z score categories for seven latent social classes were carried out using one-way analysis of variance. Pooled ordinary least square regression analyses of obesity rates by local authorities according to the proportion of different social classes within each of them were performed to determine the extent of geographical variations in obesity rates among the classes that were more greatly based on insecurity (emergent service workers, precariat), and those more closely based on inequality (elite, established middle class, technical middle class, new affluent workers, traditional working class). Adult obesity rates vary negatively across local authorities according to the proportion of people in the elite (F=39.06, p<0.001) and technical middle class (F=8.10, p<0.001) and positively with respect to the proportion of people of the established middle class (F=26.36, p<0.001), new affluent workers (F=73.03, p<0.001), traditional working class (F=23.00, p<0.001) and precariat (F=13.13, p<0.001). Social classes more closely based on inequality show greater association with adult obesity rates across local authorities than social classes more closely based on insecurity.

Question: Do adult obesity rates in England vary by insecurity as well as by inequality?

Both insecurity and inequality are associated with the geographical patterning of adult obesity rates across England.

Answer the question based on the following context: The goal of this study was to identify anterior spinal artery (ASA) occlusion by CT angiography in cervical spondylotic myelopathy (CSM) and amyotrophy (CSA) with T2-weighted hyperintensity of MR image of documented small intramedullary high signal intensity known as "snake-eye appearance" (SEA). One hundred and six patients with CSM were admitted to the investigator group between June 2010 and June 2013. Intramedullary high signal intensity was found in 42 cases and was divided into two types, SEA and non-SEA. SEA was observed in 10 patients, including seven CSM patients and three CSA patients. All SEA patients were performed CT angiography of ASA after admission. The ASA was visualized in all 10 patients. ASA incomplete occlusion was found in one CSA patient and one CSM patient. No ASA occlusion was found in other CSA and CSM patients with SEA.

Question: Is the "snake-eye" MRI sign correlated to anterior spinal artery occlusion on CT angiography in cervical spondylotic myelopathy and amyotrophy?

ASA occlusion is not commonly seen in CSM and CSA patients with SEA. Pathological changes about SEA in CSM and CSA have no close correlation with ASA occlusion, but may be with anterior radiculomedullary arteries.

Answer the question based on the following context: We report on a 17-year-old boy with elevated blood glucose levels, elevated liver enzymes and obesity (BMI 32.3 kg/m2). Clinical examination showed acanthosis nigricans and a vitiligo. The rest of the physical examination was without pathological findings. The HbA1c value was 8.6 % (71 mmol/mol), and postprandial C-peptide showed a maximum level of 1.3 nmol/l. The type 1 diabetes-associated autoantibodies against protein tyrosine phosphatase IA-2 and zinc-transporter-8 were positive, while autoantibodies to glutamic acid decarboxylase and insulin were negative. There was no ketonuria. Ultrasound showed steatohepatitis. Under therapy with metformin up to 2×1 g, blood glucose levels and liver enzymes normalized after a few weeks. After two months, the HbA1c value was 6.0 % (42.1 mmol/mol), and a weight loss of 5 kg was recorded.

Question: Difficult diagnosis in a 17-year-old patient: Type 1 diabetes?

In obese adolescent patients with diabetes, a clear classification right from the beginning is not always possible. Characteristic findings of type 1 and type 2 diabetes may be present simultaneously. In the presented patient, monotherapy with metformin was sufficient in the first year. Close monitoring is essential to detect the transition to insulin dependence in time.

Answer the question based on the following context: The Endocuff is a new colonoscopy accessory that has been designed to improve both the adenoma detection rate and endoscope tip control. A total of 50 Endocuff-assisted colonoscopies were analyzed retrospectively with regard to safety, procedural success, and complications. The cecal intubation rate was 98 %, and the mean intubation time was 6.0 minutes (95 % confidence interval 5.3 - 6.6 minutes). The ileal intubation rate was 76 %. In 30 % of patients, the Endocuff caused small, superficial, "scratch-like" mucosal lesions. In all other patients, no Endocuff-associated complications were observed. A total of 36 adenomas were detected in 50 patients. The adenoma detection rate was 34 %.

Question: Endocuff-assisted colonoscopy: a new accessory to improve adenoma detection rate?

Endocuff-assisted colonoscopy showed good procedural success rates in terms of cecal intubation rate and time, and a promising adenoma detection rate. Endocuff seems to improve endoscope tip control, especially during polypectomy. Endocuff may be a useful device for colorectal adenoma screening, and should be investigated in larger trials.

Answer the question based on the following context: The purpose of this study was to investigate the timing of surgical intervention for fractures of the acetabulum and its influence on perioperative factors. Retrospective review. Level I trauma center. Two hundred eighty-eight consecutive patients who sustained either posterior wall (PW), associated both column (ABC), or anterior column posterior hemitransverse (ACPHT) acetabulum fractures were included in the study. One hundred seventy-six PW fractures were treated through a Kocher-Langenbeck approach, and 112 ABC/ACPHT fractures were treated through an anterior intrapelvic approach. Estimated blood loss (EBL), operative time. EBL (800 vs. 400 mL), operative time (270 vs.154 minutes), and hospital stay (11 vs. 7 days) were greater for the ABC/ACPHT fractures compared with the PW fractures. When comparing early (≤48 hours) versus late (>48 hours) treatment of PW fractures, there was no difference in EBL (400 vs. 400 mL, P = 0.37) or operative time (150 vs. 156 minutes, P = 0.50). In comparison of early versus late treatment of ABC/ACPHT fractures, no significant difference was noted in EBL (725 vs. 800 mL, P = 0.30) or operative time (258.5 vs. 272 minutes, P = 0.21).

Question: Open reduction and internal fixation of acetabulum fractures: does timing of surgery affect blood loss and OR time?

We found no advantage or disadvantage in terms of EBL or operative time for early (≤48 hours) versus late (>48 hours) fixation for either PW or ABC/ACPHT acetabular fractures.

Answer the question based on the following context: This study included 225 singleton pregnancies attending Canakkale Onsekiz Mart University Obstetrics and Gynecology clinic for all monitoring and examinations, and gave birth at our clinic between January 2011 and December 2012. Data sources were clinical records and the hospital's automation system, and the study was planned as retrospective cohort. NT measurement was made between 10 weeks 3 days and 13 weeks 6 days gestation. For data analysis, the chi-square, Mann-Whitney U test and Spearman correlation were used. Of pregnancies, in the study, 5 (2.2%) developed GDM, 6 (2.6%) developed GHT, 2 (0.89%) developed IUGR and 10 (4.4%) developed oligohydramnios. There was no correlation identified between NT measurements and development of GDM, GHT, IUGR and oligohydramnios.

Question: Is there any relationship between adverse pregnancy outcome and first trimester nuchal translucency measurements in normal karyotype fetuses?

There was no relationship found between first trimester NT measurements and complications that could develop in pregnancy. For the first time in the literature, NT and oligohydramnios were studied and no relationship was observed.

Answer the question based on the following context: Pancreatic fistula (PF) is the most dreadful complication of patients after pancreatic resection. The use of operative site drains is considered routine all along in pancreatic surgery in order to remove any collections and to act as a warning of hemorrhage or anastomotic leakage. To date few studies investigated the potential benefit and safety of routine drainage compared with no drainage after pancreatic resection and the evidence by literature is not clear. A systematic review of the literature was carried out performing an unrestricted search in MEDLINE, EMBASE and Cochrane Library up to 28th February 2014. Reference lists of retrieved articles and review articles were manually searched for other relevant studies. The currently available data regarding the incidence of post-operative short-term outcomes after pancreatic resection were meta-analyzed according to the presence or absence of the intra-abdominal drainage. Overall 7 studies were included in the meta-analysis, that is 2 randomized controlled trials (RCTs) and 5 non-RCTs resulting in 2704 patients totally. Intra-abdominal drainage showed to increase the PF (OR 2.31, 95% CI 1.52-3.51), the total post-operative complications (OR 1.52, 95% CI 1.30-1.78) and the re-admission (OR 1.30, 95% CI 1.06-1.61) rates. A non-significant correlation was found with the presence/absence of the drainage about biliary and enteric fistula, post-operative hemorrhage, intra-abdominal infected collection, wound infection and overall mortality rates.

Question: Intra-abdominal drainage after pancreatic resection: is it really necessary?

The meta-analysis shows that the presence of an intra-abdominal drainage does not improve the post-operative outcome after pancreatic resection.

Answer the question based on the following context: To report the epidemiology of obesity in a pediatric surgical population and determine whether obesity is a risk factor for longer anesthesia duration. Childhood obesity is a significant public health problem in the United States. Epidemiologic studies on pediatric surgical populations have been limited to states with very high prevalence of adult obesity (Michigan, Texas). Data from other states and more recent data since 2006 are unavailable. We examined anesthesia records for surgical patients age 2-18 years at Columbia University Medical Center from January 2009 to December 2010. Patients undergoing bariatric surgery or those with records missing preoperative height or weight data were excluded. Body mass index (BMI) was calculated as weight (kg)/height (m(2) ). BMI ≥95th percentile according to national growth charts were considered obese. We reviewed 9522 patients of which 1639 were obese (17.2%). The sex-age category interaction on obesity was not significant using logistic regression (P = 0.11). Among surgical groups, the otolaryngology (ENT) cohort had the highest obesity rate (21.7%, 360/1656). Obese children who had tonsillectomy, adenoidectomy, or both did not have a prolonged anesthetic (P = 0.33) or surgical duration (P = 0.61) compared with nonobese children, adjusting for surgeon, season, surgical procedure code, and ASA status.

Question: Does obesity prolong anesthesia in children undergoing common ENT surgery?

Children presenting for surgery, particularly the ENT cohort, have a high prevalence of obesity. Obese and nonobese children who had tonsillectomy, adenoidectomy, or both had comparable durations of anesthesia. Therefore, obesity did not lead to longer anesthetic duration.

Answer the question based on the following context: To determine the relationship between obesity and febrile urinary tract infection (UTI) in young children. We reviewed all medical records of children aged <3 years who visited our institution for febrile UTIs and infant national health checkups (controls) between January 2008 and February 2012. All subjects were subcategorized into 3 groups of lean, overweight, and obese using weight-for-length measurements. The effect of obesity on UTI risk was evaluated and odds ratios were calculated. We analyzed 465 patients with UTIs and 812 controls. The proportion of overweight and obese children was higher in patients with UTIs (22.8%) and acute pyelonephritis (APN; 31.1%) compared with those in the control (11.7%; P <.05). After adjusting for age and gender, the odds ratio (OR) of UTI in obese relative to lean children was 1.84 (95% confidence interval [CI], 1.11-3.05) and that of APN was 2.43 (95% CI, 1.27-4.62). The OR of APN in overweight relative to lean children was 1.96 (95% CI, 1.11-3.46). After adjusting for age, the OR of APN in obese relative to lean boys was 2.74 (95% CI, 1.11-6.77) and that in overweight to lean girls was 2.48 (95% CI, 1.05-5.83). Within patients with UTIs, compared with lean children, the obese showed a longer duration of fever and a higher frequency of APN and the overweight had a higher incidence of hydronephrosis (P <.05).

Question: Obesity and a febrile urinary tract infection: dual burden for young children?

Obesity may be associated with higher odds of a febrile UTI and APN in young children.

Answer the question based on the following context: Churches occupy an important social and cultural position in Madagascar. The sexual transmission of HIV raises controversies about the role that Churches can play in preventing HIV/AIDS. This cross-sectional survey investigated recommendations by religious leaders for condom use and other preventive strategies in the context of international guidelines. A questionnaire was self-administered to a random sample of religious leaders. The questions related to preventive methods against HIV/AIDS such as: condom use, marital fidelity, sexual abstinence before marriage, and HIV-testing. Associations with recommendations for condom use were evaluated using univariate and multivariate logistic regression analyses. Of 231 religious leaders, 215 (93.1%) were willing to share their knowledge of HIV/AIDS with their congregations. The majority received their information from the media (N=136, 58.9%), a minority from their church (N=9, 3.9%), and 38 (16.4%) had received prior training on HIV. Nearly all (N=212, 91.8%) knew that HIV could be sexually transmitted though only a few (N=39, 16.9%) were aware of mother-to-child transmission or unsafe injections (N=56, 24.2%). A total of 91 (39.4%) were willing to, or had recommended (N=64, 27.7%), condom use, while 50 (21.6%) had undergone HIV testing. Only nine (3.9%) had ever cared for a person living with HIV/AIDS (PLHIV). Multivariable logistic regression shows that condom use recommendations by religious leaders were negatively associated with tertiary level education (OR: 0.3, 95% CI 0.1-0.7), and positively associated with knowing a person at risk (OR: 16.2, 95% CI 3.2-80.2), knowing of an ART center (OR: 2.6, 95% CI 1.4-4.8), and receiving information about HIV at school (OR: 2.6, 95% CI 1.2-5.6).

Question: Can churches play a role in combating the HIV/AIDS epidemic?

Malagasy church leaders could potentially become key players in HIV/AIDS prevention if they improved their knowledge of the illness, their commitment to international recommendations, and extended their interaction with people most at risk.

Answer the question based on the following context: Many adolescents are having sex and adolescents with life-limiting illnesses are no exception. It is therefore important for health care professionals to take a sexual history and provide advice about sexually transmitted diseases, unintended pregnancies, and ways of reducing high-risk sexual behaviors. Consultations should provide a forum for discussion and education. A literature review revealed no previous studies on this topic. Our aim was to review medical consultations between adolescents with life-limiting illnesses and pediatricians to establish whether sex was discussed. The clinical medical notes of 25 adolescents aged 12 to 18 years, under the care of a community team specializing in patients with nonmalignant life-limiting conditions at a District General Hospital in the United Kingdom (UK) were selected at random. Researchers retrospectively reviewed handwritten notes and typed letters in the medical records with a view to establishing whether a sexual history was taken on any occasion. None of the health care professionals took a sexual history from any of the adolescents on any occasion despite multiple clinic attendances.

Question: Sexual history taking: a dying skill?

Sexual health is described by the World Health Organization as a basic human right. Clinicians may struggle to accept that adolescents with life-limiting illnesses may want to talk about sex, and this study has highlighted it as a topic that is generally ignored. Health professionals should include sexual health in routine palliative assessments. Adolescents with life-limiting illnesses should not be denied the right to holistic health care.

Answer the question based on the following context: In this retrospective study, we aimed to analyze the frequency of thyroid cancer in patients who underwent thyroidectomy for hyperthyroidism. A total number of 177 patients, who underwent surgery for hyperthyroidism between August 2005 and March 2010, were included in this study. Demographic, clinical, radiologic, and laboratory data were collected retrospectively.Results. Postoperative histopathological examinations revealed thyroid malignancy in 13 (7.3%) patients. Among these 13 patients presenting thyroid malignancy, 53.9% were diagnosed with multinodular toxic goiter (MTG), 38.5% with uninodular toxic goiter (UTG) and 7.6% with Graves' disease.

Question: Thyroid cancer in hyperthyroid patients: is it different clinical entity?

Thyroid carcinoma is common in hyperthyroidism and thyroid fine-needle aspiration biopsy (TFNAB) is a reliable method in the diagnosis of the thyroid malignancy in these patients. We suggest that it is reasonable to evaluate nodules with TFNAB in hyperthyroid patients prior to surgical intervention.

Answer the question based on the following context: Observational cohort study. To determine the accuracy of the Revised Cardiac Risk Index (RCRI) in predicting major adverse cardiac events in patients undergoing spine fusion surgery of 3 levels or more. Preoperative cardiac testing is extensively guided by the RCRI, which was developed and validated in thoracic, abdominal, and orthopedic surgical patients. Because multilevel spine fusion surgery is often associated with major transfusion, we hypothesize that the RCRI may not accurately characterize the risk of cardiovascular morbidity in these patients. After institutional review board approval, perioperative data were collected from 547 patients who underwent 3 or more levels of spinal fusion with instrumentation. Postoperative cardiac morbidity was defined as any combination of the following: arrhythmia requiring medical treatment, myocardial infarction (either by electrocardiographic changes or troponin elevation), or the occurrence of demand ischemia. The surgical complexity was categorized as anterior surgery only, posterior cervical and/or thoracic fusion, posterior lumbar fusion, or any surgery that included transpedicular osteotomies. Logistic regression analysis was performed to determine RCRI performance. The RCRI performed no better than chance (area under the curve = 0.54) in identifying the 49 patients (9%) who experienced cardiac morbidity.

Question: Predicting major adverse cardiac events in spine fusion patients: is the revised cardiac risk index sufficient?

The RCRI did not predict cardiac morbidity in our patients undergoing major spine fusion surgery, despite being extensively validated in low-risk noncardiac surgical patients. Preoperative testing and optimization decisions, previously based on the RCRI, may need to be revised to include more frequent functional cardiac imaging and more aggressive implementation of pharmacologic modalities that may mitigate cardiac morbidity, similar to the preoperative evaluation for major vascular surgery.

Answer the question based on the following context: The goal of individualized anatomic anterior cruciate ligament reconstruction (ACL-R) is to reproduce each patient's native insertion site as closely as possible. The amount of the native insertion site that is recreated by the tunnel aperture area is currently unknown, as are the implications of the degree of coverage. As such, the goals of this study are to determine whether individualized anatomic ACL-R techniques can maximally fill the native insertion site and to attempt to establish a crude measure to evaluate the percentage of reconstructed area as a first step towards elucidating the implications of complete footprint restoration. This is a prospective pilot study of 45 patients who underwent primary single-bundle anatomic ACL-R from May 2011 to April 2012. Length and width of the native insertion site were measured intraoperatively. Using published guidelines, reconstruction technique and graft choice were determined to maximize the percentage of reconstructed area. Native femoral and tibial insertion site area and femoral tunnel aperture area were calculated using the formula for area of an ellipse. On the tibial side, tunnel aperture area was calculated with respect to drill diameter and drill guide angle. Percentage of reconstructed area was calculated by dividing total tunnel aperture area by the native insertion site area. The mean areas for the native femoral and tibial insertion sites were 83 ± 20 and 125 ± 20 mm(2), respectively. The mean tunnel aperture area for the femoral side was 65 ± 17, and 86 ± 17 mm(2) for the tibial tunnel aperture area. On average, percentage of reconstructed area was 79 ± 13 % for the femoral side, and 70 ± 12 % for the tibial side.

Question: Is the native ACL insertion site "completely restored" using an individualized approach to single-bundle ACL-R?

Anatomic ACL-R does not restore the native insertion site in its entirety. Percentage of reconstructed area serves as a rudimentary tool for evaluating the degree of native insertion site coverage using current individualized anatomic techniques and provides a starting point from which to evaluate the clinical significance of complete footprint restoration.

Answer the question based on the following context: The incidence of pubic lice infestations is estimated to be between 1.3% and 4.6%, with an average incidence of 2% worldwide. It is also estimated that 70% to 80% of adults now remove pubic hair in part or entirety, using a variety of methods. It is hypothesized that the destruction of this pubic hair habitat may account for the falling incidence of pubic lice and may possibly lead to its eradication or atypical presentation.AIM: To report the changing incidence of pubic lice infestation from our unit over the last 10 years and assess its association, if any, with pubic hair removal of any kind. Assessment of medical records and questionnaires were used to identify the incidence of hair removal and pubic lice infestation over a 10-year period. Data were anonymized and analyzed to identify any correlation. A significant and strong correlation between the falling incidence of pubic lice infections and increase in pubic hair removal was observed, with a Pearson correlation r value of 0.9686 (95% confidence intervals, 0.88-0.992). The P value is less than 0.0001.

Question: Pubic lice: an endangered species?

The increased incidence of hair removal may lead to atypical patterns of pubic lice infestations or its complete eradication as the natural habitat of this parasite is destroyed.

Answer the question based on the following context: The aim of this study was to identify the patient-related risk factors for post-dural puncture headache with same standardized procedures. The inclusion criteria were patients (i) who underwent lumbar puncture for diagnostic purposes, (ii) with ≥10 years of age, and (iii) with no structural lesions that could cause headache from brain-computed tomography or magnetic resonance images. The primary endpoint for this study was post-dural-puncture headache as a dependent variable. The differences were analyzed with demographic and cerebrospinal fluid profiles as independent variables. Four hundred and thirteen patients met the inclusion criteria for this study, and 36 patients developed post-dural puncture headache. Patients with post-dural puncture headache were younger, had lower body mass index, and had less diabetes and hypertension. In cerebrospinal fluid profile, the counts of white blood cell and protein, and cerebrospinal fluid pressure were lower in patients with post-dural puncture headache than those without post-dural puncture headache, but glucose ratio was higher. Interestingly, patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime. After adjusting the clinical variables, multiple logistic regression analysis showed that younger age, lower cerebrospinal fluid pressure, and puncture at daytime were independently significant variables for predicting post-dural puncture headache.

Question: Does lumbar puncture at night prevent post-dural puncture headache?

We confirmed the risk factor for post-dural puncture headache such as young age, and newly found that patients who underwent puncture at daytime developed more post-dural puncture headache than those who were performed puncture at nighttime.

Answer the question based on the following context: High rates of vitamin D insufficiency are usually found in obese patients, even before any malabsorptive bariatric surgery. It is not clear whether they lack vitamin D because of different food intake, different solar exposure, or different storage pathways or bioavailability in adipose tissue. To better understand vitamin D deficiency, we studied different categories of inpatients. We collected clinical and biological data from 457 consecutive inpatients during a year: 217 nonobese diabetic patients, 159 obese nonsurgical diabetic patients, 46 obese surgical nondiabetic patients, and 35 obese surgical diabetic patients. Statistically significant differences between two mean 25-hydroxyvitamin D (25(OH)D) levels were defined at the 5 % level using a Z-test. Vitamin D deficiency was found in 69 % of the patients, while 24 % had a normal level and 7 % an optimal level. A significant difference was found between obese (25(OH)D = 40.3 nmol/l) and nonobese patients (25(OH)D = 46.8 nmol/l). Patients undergoing bariatric surgery were not different from the other obese patients.

Question: High vitamin D deficiency rate in metabolic inpatients: is bariatric surgery planning found guilty?

No significant difference in 25(OH) vitamin D level could be demonstrated between obese patients before bariatric surgery and obese patients with no obesity surgery project. No difference was found between our Parisian obese population and a Spanish obese population, which benefits from a better solar exposure. Both findings suggest that obesity itself is the link with vitamin D deficiency, independently from behavioral differences.

Answer the question based on the following context: The prospective memory (PM) construct is aimed at capturing cognitive operations involved in the successful accomplishment of delayed intentions. It is generally agreed that PM impairment occurs in patients with prefrontal lobes damage. To evaluate if there is a causal role of a deficit of executive abilities (failures of planning, set-shifting, selective attention, or working memory) over the PM impairment. We report a detailed investigation of PM and executive abilities in two patients with posttraumatic damage to prefrontal lobes who complained from a reduced compliance with appointments and daily routines. Laboratory tests confirmed a difficulty in fulfilling delayed intentions in response to the occurrence of critical events and elapsed time. In one patient, PM impairment was associated with poor performance on tests investigating planning, working memory, and mental shifting. The other patient performed in the normal range on all executive tests.

Question: Prospective memory impairment and executive dysfunction in prefrontal lobe damaged patients: is there a causal relationship?

Despite the frequent claim of a dependence of PM deficits from executive dysfunction, the reported cases demonstrate that this is not necessarily the case. The results are discussed in the light of current hypotheses relating PM impairment to other deficits that commonly occur as a result of damage to the prefrontal lobes.

Answer the question based on the following context: Region-specific types of neglect (peripersonal and extrapersonal) have been dissociated, yet, differential behavioural consequences are unknown. The aim of the current study was to investigate behavioural consequences at the level of basic activities of daily living of region-specific neglect, using the Catherine Bergego Scale (CBS). 118 stroke patients were screened within the first two weeks after admission to the rehabilitation center for inpatient rehabilitation. Patients with peripersonal neglect and patients with neglect for both regions had significantly higher total score on the CBS compared to nonneglect patients. Total scores for patients with extrapersonal neglect were comparable to non-neglect patients. ADL impairments were found across activities (e.g., looking towards one side, forgetting body parts, colliding) for both patients with peripersonal neglect and patients with neglect for both regions. Patients with extrapersonal neglect were only impaired on the item on way finding.

Question: Functional assessment of region-specific neglect: are there differential behavioural consequences of peripersonal versus extrapersonal neglect?

When diagnosing neglect, it is relevant to distinguish the type of region-specific neglect and, where needed, to adjust the rehabilitation program accordingly. As the CBS is not developed to typically measure ADL in extrapersonal neglect, it would be of importance to add other (instrumental) activities that heavily rely on processing information in farther space.

Answer the question based on the following context: This study aimed to evaluate associations between endoscopic ultrasound (EUS) criteria for chronic pancreatitis (CP) and coexisting pancreatic intraepithelial neoplasia (PanIN) lesions. Patients with known or suspected CP who underwent pancreatic resection within a year of EUS were selected. Histology slides and EUS images were reviewed for evidence of pancreatic fibrosis. Ninety-seven (51 men; mean age, 53 [12] years) underwent EUS within a 1 year or less of EUS. Pancreatic intraepithelial neoplasia lesions were found in 84 (87%) patients. Pancreatic intraepithelial neoplasia 1, 2, and 3 lesions were seen in 71 (83%), 10 (14%), and 1 (2%), respectively. Two patients had more than 1 PanIN grade (one had PanIN 1 and 2 and the other had PanIN 1 and 3). The mean number of EUS criteria for PanIN 1, 2, and 3 lesions were 3.9, 4.5, and 5.5, respectively. The odds ratio for the association between PanIN 2 and hyperechoic foci without shadowing in the pancreas head was 8.5 (P = 0.05). The odds ratio for the association between PanIN 2 and lobularity with honeycombing was 2.7 (P = ns). Advanced PanIN lesions had greater than or equal to 4 EUS criteria for CP.

Question: Can endoscopic ultrasound predict pancreatic intraepithelial neoplasia lesions in chronic pancreatitis?

Pancreatic intraepithelial neoplasia lesions were highly prevalent in CP resections. Increasing PanIN grade is observed with increasing fibrosis score and increasing number of EUS criteria for CP.

Answer the question based on the following context: Chronic pain patients referred to a pain treatment facility have no guarantee that they will receive a proper diagnostic procedure or treatment. To obtain information about organizational aspects of pain treatment facilities and the content of their daily pain practice, we performed a questionnaire survey. The aim of the study was to evaluate the amount of pain treatment facilities, the content of organized specialized pain care and adherence to the criteria of the internationally accepted guidelines for pain treatment services. The University Pain Centre Maastricht in the Department of Anaesthesiology and Pain Management at Maastricht University Medical Centre developed a questionnaire survey based on the Recommendations for Pain Treatment Services of the International Association for the Study of Pain (IASP). The questionnaire was sent to the medical boards of all hospitals in the Netherlands (n=94). The response rate was 86% (n=81). Of all hospitals, 88.9% (n=72) reported the provision of organized specialized pain care, which was provided by a pain management team in 86.1% (n=62) and by an individual specialist in 13.9% (n=10). Insight was obtained from pain treatment facilities in five different domains: the organizational structure of pain management, composition of the pain team, pain team practice, patient characteristics, and research and education facilities.

Question: Pain treatment facilities: do we need quantity or quality?

Although 88.9% of all hospitals stated that organized specialized pain care was provided, only a few hospitals could adhere to the criteria for pain treatment services of the IASP. The outcome of the questionnaire survey may help to define quality improvement standards for pain treatment facilities.

Answer the question based on the following context: Informed Consent was obtained from all study subjects. 40 adult HIV infected patients (experimental group) and 40 adult non-infected volunteers (control group) participated. Age, occupation, and relevant medical history were recorded. The following laboratory tests reports were recorded: complete blood cell counts, blood glucose levels, serum iron and erythrocyte sedimentation rate. Oral smears were collected from normal appearing tongue and buccal mucosa of the individuals by exfoliative cytology. The cells were morphologically analysed and the nuclear area (NA), the cytoplasmic area (CA) and the nucleus-to-cytoplasm area ratio (NA/CA) were calculated. Cell yield, cell cohesion, presence/absence of inflammatory cells and candida were observed. The cytological smears of HIV patients showed abundant cell yield and the epithelial cells were found to be in close cohesive clusters and both findings were found to be statistically significant. Nuclear cytoplasmic ratio was seen to be increased in 93.8% of HIV positive patientsand Mild to moderate pleomorphism was observed in 17.9% of HIV positive patients. HIV positive patients had a diminished inflammatory response and this was found to be statistically significant.

Question: Oral Cytology for HIV: A New Diagnostic Tool?

Statistically significant deviations from normal oral epithelium were found in the study conducted. With further research, oral exfoliative cytology may form a new, painless, inexpensive diagnostic method for HIV infections.

Answer the question based on the following context: Gadolinium-enhanced magnetic resonance imaging (MRI) is the gold standard for cerebral staging in thoracic oncology. We hypothesize that a minimalist examination, consisting of a single contrast-enhanced T1-weighted three-dimensional gradient-echo sequence (CE 3D-GRE), would be sufficient for the cerebral staging of nonsymptomatic lung cancer patients. Seventy nonsymptomatic patients (50 % men; 62 years ± 10.2) referred for cerebral staging of a lung cancer were retrospectively included. All underwent a standard 3 T MRI examination with T1, FLAIR, T2* GRE, diffusion, and CE 3D-GRE sequences, for a total examination time of 20 min. The sole CE 3D-GRE (acquisition time: 6 min) was extracted and blindly interpreted by two radiologists in search of brain metastases. Hemorrhagic features of potential lesions and relevant incidental findings were also noted. Discrepant cases were reviewed by a third reader. The full MRI examination and follow-up studies were used as a reference to calculate sensitivity and specificity of the sole CE 3D-GRE. Thirty-eight point six percent (27 out of 70) of the patients had brain metastases. Performances and reader's agreement with the sole CE 3D-GRE sequence were excellent for the diagnosis of brain metastases (sensitivity=96.3 %, specificity=100 %, κ=0.91) and incidental findings (sensitivity=85.7 %, specificity=100 %, κ=0.62) but insufficient for the identification of hemorrhages within the metastases (sensitivity=33.3 %, specificity=85.7 %, κ=0.47).

Question: Cerebral staging of lung cancer: is one single contrast-enhanced T1-weighted three-dimensional gradient-echo sequence sufficient?

In the specific case of lung cancer, cerebral staging in nonsymptomatic patients can be efficiently achieved with a minimalistic protocol consisting of a single CE 3D-GRE sequence, completed if positive with a T2* sequence for hemorrhagic assessment, thus halving appointment delays.

Answer the question based on the following context: To investigate whether equal access to bortezomib has been achieved under the Dutch policy regulations that guarantee equal access to expensive inpatient drugs. We investigated accessibility to bortezomib treatment at national and regional levels by (i) conducting interviews with stakeholders in the Dutch healthcare system to explore prescription barriers and (ii) tabulating sales data from 2004-2009 and trial participation rates. Interviews revealed awareness of the high treatment costs, although prescription barriers were not encountered. National use of bortezomib increased slowly (treating 2% of patients in 2004 to 17% in 2009), indicating a long adjustment period. Furthermore, use remains below the rate estimated by the professional association of haematologists (27%). Regional differences were found for both daily practice use (e.g. ranging from 13-27% in 2009) and clinical trial participation (e.g. ranging from 1-12% in 2006).

Question: Access to expensive cancer drugs in Dutch daily practice: should we be concerned?

Our results were somewhat conflicting: interviews did not reveal any prescription barriers, but quantitative methods showed regional differences, signs of underutilisation, and access inequality. Investigating use and accessibility, based on data triangulation, provides valuable feedback which can enhance evidence-based decision making for both physicians and policymakers. This could improve appropriate and efficient use and ensure equal access to expensive drugs.

Answer the question based on the following context: This study examines the awareness and self-report knowledge of physical activity (PA) guidelines among adults with rheumatic conditions and evaluates rates of adherence to PA recommendations. Secondary aims include (i) investigating perceived benefits and barriers to exercise and (ii) exploring correlates associated with PA. This cross-sectional study involved adults attending an outpatient rheumatology clinic completing a questionnaire. Closed- and open-ended questions enquired about awareness and knowledge of PA guidelines, and a single-item self-report measure of PA was included. Perceptions of exercise were assessed using the Exercise Benefits and Barriers Scale. Descriptive statistics described participant characteristics and age-adjusted bivariate analyses explored associations between socio-demographic and condition-related factors and PA. A total of 401 adults (134 males, 267 females) completed the questionnaire. Only 17.6% of respondents were aware of national PA guidelines and 17.4% accurately identified the frequency and duration of the recommendations. A quarter of respondents (26.7%) reported adherence to the guidelines, while 30.5% reported no weekly PA. Higher perceived benefits and lower perceived barriers to exercise were positively associated with PA behaviour.

Question: Physical activity guidelines: is the message getting through to adults with rheumatic conditions?

A large majority of respondents were not aware of PA guidelines and self-report knowledge of PA recommendations was largely inaccurate. Despite the role of PA in health promotion and in the management of rheumatic conditions, adherence to PA recommendations was low. Level of education, perceived benefits and barriers to exercise, and awareness and self-report knowledge of PA guidelines are associated with PA behaviour.

Answer the question based on the following context: Acute type A aortic dissection (AADA) is a surgical emergency. In patients with aortic arch and descending aorta (DeBakey type I) involvement, performing a total aortic arch replacement with frozen elephant trunk (FET) for supposedly better long-term results is controversial. We hereby present our results. From February 2004 to August 2013, 52 patients with acute aortic dissection DeBakey type I received a FET procedure at our centre (43 males, age 59.21 ± 11.67 years). All patients had an intimal tear in the aortic arch and/or proximal descending aorta. Concomitant procedures were Bentall (n = 15) and aortic valve repair (n = 30). Cardiopulmonary bypass (CPB), X-clamp and cardiac arrest times were 262 ± 64, 159 ± 45 and 55 ± 24 min, respectively. The 30-day mortality rate was 13% (n = 7). Stroke and re-thoracotomy for bleeding were 12% (n = 6) and 23% (n = 12), respectively. Postoperative recurrent nerve palsy and spinal cord injury rates were 10% (5 of 52) and 4% (2 of 52), respectively. Follow-up was 40 ± 24 months. During follow-up, no patient died and no patient required a reoperation for the aortic arch.

Question: Total aortic arch replacement with frozen elephant trunk in acute type A aortic dissections: are we pushing the limits too far?

Our results with FET in AADA show acceptable results. Total aortic arch replacement with an FET in AADA patients does demand high technical skills. In spite of this, we believe FET improves long-term outcomes in cases of AADA with intima tear or re-entry in the aortic arch or the descending aorta (DeBakey type I). Modern grafts with four side branches as well as sewing collars for the distal anastomosis have helped to further 'simplify' the FET implantation. However, such a strategy is not appropriate in all AADA cases; it should be implemented only in experienced centres and only if absolutely necessary.

Answer the question based on the following context: Psychological interventions show greater efficacy when evaluated with distressed patients. We report on the feasibility of implementing screening for recruiting distressed cancer patients to a randomized controlled trial of problem-solving therapy (PST), characteristics associated with enrolment, and time investment and challenges of implementing screening. Three medical settings implemented screening of patients, directly after cancer treatment (T1) and 2 months later (T2), using Hopkins Symptom Checklist-25 and one question about need for services. Distressed patients indicating need for services were interviewed. Eligible patients were offered the possibility to participate in the trial. Consenting patients were randomized to PST or waitlist. At T1, 366 of 970 screened patients (37%) scored above the cutoff and at T2, 208 of 689 screened patients (30%). At either or both T1 and T2, 423 patients reported distress, of whom 215 indicated need for services. Only 36 (4% of 970) patients consented to trial participation. Twenty-seven patients needed to be screened to recruit a single patient, with 17 h required for each patient recruited. Barriers to screening were time constraints and negative attitudes of oncology staff towards screening.

Question: Is implementing screening for distress an efficient means to recruit patients to a psychological intervention trial?

Implementing screening proved inefficient for recruiting distressed cancer patients post-treatment to a randomized controlled trial on PST, with need for services being much less than anticipated. Consecutively screening patients did not result in a sample representative of the larger pool of distressed patients, which may lower generalizability. An adequately powered intervention trial using screening requires a feasibility study establishing recruitment rates and dedicated, funded staff assistance.

Answer the question based on the following context: The incremental prognostic value of plasma levels of C-reactive protein (CRP) in relation to GRACE score has not been established in patients with acute coronary syndrome (ACS) with non-ST segment elevation. To test the hypothesis that CRP measurements at admission increases the prognostic value of GRACE score in patients with ACS. A total of 290 subjects, consecutively admitted for ACS, with plasma material obtained upon admission CRP measurement using a high-sensitivity method (nephelometry) were studied. Cardiovascular outcomes during hospitalization were defined by the combination of death, nonfatal myocardial infarction or nonfatal refractory angina. The incidence of cardiovascular events during hospitalization was 15% (18 deaths, 11 myocardial infarctions, 13 angina episodes) with CRP showing C-statistics of 0.60 (95% CI = 0.51-0.70, p = 0.034) in predicting these outcomes. After adjustment for the GRACE score, elevated CRP (defined as the best cutoff point) tended to be associated with hospital events (OR = 1.89, 95% CI = 0.92 to 3.88, p = 0.08). However, the addition of the variable elevated CRP in the GRACE model did not result in significant increase in C-statistics, which ranged from 0.705 to 0.718 (p = 0.46). Similarly, there was no significant reclassification of risk with the addition of CRP in the predictor model (net reclassification = 5.7 %, p = 0.15).

Question: Does C-reactive protein add prognostic value to GRACE score in acute coronary syndromes?

Although CRP is associated with hospital outcomes, this inflammatory marker does not increase the prognostic value of the GRACE score.

Answer the question based on the following context: To investigate the modulatory effects that dynamic hyperinflation (DH), defined as a reduction in inspiratory capacity (IC), has on exercise tolerance after bronchodilator in patients with COPD. An experimental, randomized study involving 30 COPD patients without severe hypoxemia. At baseline, the patients underwent clinical assessment, spirometry, and incremental cardiopulmonary exercise testing (CPET). On two subsequent visits, the patients were randomized to receive a combination of inhaled fenoterol/ipratropium or placebo. All patients then underwent spirometry and submaximal CPET at constant speed up to the limit of tolerance (Tlim). The patients who showed ΔIC(peak-rest)<0 were considered to present with DH (DH+). In this sample, 21 patients (70%) had DH. The DH+ patients had higher airflow obstruction and lower Tlim than did the patients without DH (DH-). Despite equivalent improvement in FEV1 after bronchodilator, the DH- group showed higher ΔIC(bronchodilator-placebo) at rest in relation to the DH+ group (p<0.05). However, this was not found in relation to ΔIC at peak exercise between DH+ and DH- groups (0.19 ± 0.17 L vs. 0.17 ± 0.15 L, p>0.05). In addition, both groups showed similar improvements in Tlim after bronchodilator (median [interquartile range]: 22% [3-60%]vs. 10% [3-53%]; p>0.05).

Question: Can bronchodilators improve exercise tolerance in COPD patients without dynamic hyperinflation?

Improvement in TLim was associated with an increase in IC at rest after bronchodilator in HD- patients with COPD. However, even without that improvement, COPD patients can present with greater exercise tolerance after bronchodilator provided that they develop DH during exercise.

Answer the question based on the following context: Geriatric education is essential to ensure the competency of residents caring for the aging population. This study assesses and correlates resident and faculty perceptions of resident geriatric-related competencies to clinical care. A survey was sent to 40 general surgery residents and 57 faculty members. Five clinical care markers were identified for chart audit. A retrospective chart audit was performed of 22 injured elderly patients. Among the respondents, 30 of 40 (75%) residents and 22 of 57 (39%) faculty completed the survey. Residents rated their competency higher than faculty on all competency-related questions (p = 0.0002). The following 4 questions had a mean faculty rating below acceptable: screening guidelines, delirium management, contraindicated medications, and medication adjustments. On chart review: code status was documented in 7 of 22 (32%) patients and goals of care in 1 of 22 (5%) patients. Pain control included rib block or epidural in 14 of 22 (64%) patients. Contraindicated medications were prescribed in 13 of 22 (59%) patients.

Question: Elderly surgical patients: are there gaps in residency education?

A competency-based needs assessment of geriatric training in a general surgery residency has identified educational "gaps." This needs assessment supports implementation of geriatric education initiatives in our general surgery program.

Answer the question based on the following context: Social deprivation is associated with a greater morbidity and shorter life expectancy. This study evaluates differences in weight loss following bariatric surgery and deprivation, based on UK deprivation measures in a London bariatric centre. All patients undergoing bariatric surgery between 2002 and 2012 were retrospectively identified. Demographic details, type of surgery and percentage excess weight loss data were collected. UK Index of Multiple Deprivation (IMD, 2010) and IMD domain of the Health Deprivation and Disability (HDD) scores were used to assess deprivation (where 1 is the most deprived in rank order and 32,482 is the least deprived). Two-way between-subjects analysis of variance (ANOVA) was performed to examine the effect of IMD score, deprivation, procedure type and gender on percentage excess weight loss. Data were included from 983 patients (178 male, 805 female) involving 3,663 patient episodes. Treatments comprised laparoscopic gastric bands (n=533), gastric bypass (n=362) and gastric balloons (n=88). The average percentage excess weight loss across all procedures was 38 % over a follow-up period (3 months-9 years). There was no correlation between weight loss and IMD/HDD rank scores. Gastric bypass was significantly more effective at achieving weight loss than the other two procedures at 3-, 6- and 9-month and 1-year follow-up.

Question: Is social deprivation associated with weight loss outcomes following bariatric surgery?

Social deprivation does not influence weight loss after bariatric surgery, suggesting that all socioeconomic groups may equally benefit from surgical intervention. Social deprivation should not therefore negatively influence the decision for surgical intervention in these patients.

Answer the question based on the following context: A retrospective study of prospectively collected data. To determine whether comorbid fibromyalgia, identified in patients with chronic disabling occupational musculoskeletal disorders (CDOMDs), resolves with a functional restoration program (FRP). Fibromyalgia involves widespread bodily pain and tenderness to palpation. In recent studies, 23% to 41% of patients with CDOMDs entering an FRP had comorbid fibromyalgia, compared with population averages of 2% to 5%. Few studies have examined whether fibromyalgia diagnoses resolve with any treatment, and none have investigated diagnosis responsiveness to an FRP. A consecutive cohort of patients with CDOMDs (82% with spinal disorders and all reporting chronic spinal pain) and comorbid fibromyalgia (N = 117) completed an FRP, which included quantitatively directed exercise progression and multimodal disability management. Diagnosis responsiveness, evaluated at discharge, created 2 groups: those who retained fibromyalgia and those who did not. These groups were compared with chronic regional lumbar pain only patients (LO group, n = 87), lacking widespread pain and fibromyalgia. Of the patients with comorbid fibromyalgia, 59% (n = 69) retained the fibromyalgia diagnosis (RFM group) and 41% (n = 48) lost the fibromyalgia diagnosis (LFM group) at discharge. Although all 3 groups reported decreased pain intensity, disability, and depressive symptoms from admission to discharge, RFM patients reported higher symptom levels than the LFM and LO groups at discharge. The LFM and LO groups were statistically similar. At 1-year follow-up, LO patients demonstrated higher work retention than both fibromyalgia groups (P<0.03).

Question: Do comorbid fibromyalgia diagnoses change after a functional restoration program in patients with chronic disabling occupational musculoskeletal disorders?

Despite a significant comorbid fibromyalgia prevalence in a cohort of patients with CDOMDs entering an FRP, 41% of patients with an initial fibromyalgia diagnosis no longer met diagnostic criteria for fibromyalgia at discharge and were indistinguishable from LO patients on pain, disability, and depression symptoms. However, both fibromyalgia groups (LFM and RFM) had lower work retention than LO patients 1 year later, suggesting that an FRP may suppress symptoms of fibromyalgia in a subset of patients, but prolonged fibromyalgia-related disability may be more difficult to overcome.

Answer the question based on the following context: Numerical simulations are used for treatment planning in clinical applications of irreversible electroporation (IRE) to determine ablation size and shape. To assess the reliability of simulations for treatment planning, we compared simulation results with empiric outcomes of renal IRE using computed tomography (CT) and histology in an animal model. The ablation size and shape for six different IRE parameter sets (70-90 pulses, 2,000-2,700 V, 70-100 µs) for monopolar and bipolar electrodes was simulated using a numerical model. Employing these treatment parameters, 35 CT-guided IRE ablations were created in both kidneys of six pigs and followed up with CT immediately and after 24 h. Histopathology was analyzed from postablation day 1. Ablation zones on CT measured 81 ± 18 % (day 0, p ≤ 0.05) and 115 ± 18 % (day 1, p ≤ 0.09) of the simulated size for monopolar electrodes, and 190 ± 33 % (day 0, p ≤ 0.001) and 234 ± 12 % (day 1, p ≤ 0.0001) for bipolar electrodes. Histopathology indicated smaller ablation zones than simulated (71 ± 41 %, p ≤ 0.047) and measured on CT (47 ± 16 %, p ≤ 0.005) with complete ablation of kidney parenchyma within the central zone and incomplete ablation in the periphery.

Question: Planning irreversible electroporation in the porcine kidney: are numerical simulations reliable for predicting empiric ablation outcomes?

Both numerical simulations for planning renal IRE and CT measurements may overestimate the size of ablation compared to histology, and ablation effects may be incomplete in the periphery.

Answer the question based on the following context: In view of the fact that mucosal damage associated with HIV-1 infection leads to microbial translocation despite successful antiretroviral treatment, we analysed microbial translocation and expression of the gut-homing β7 receptor on peripheral T cells in HIV-1-infected individuals. Fifteen long-term suppressed HIV-1-infected patients, of whom seven had their treatment intensified with maraviroc and eight with raltegravir, were included in the study. Samples at baseline, at week 48 of intensification, and at weeks 12 and 24 after deintensification were analysed for soluble CD14, lipopolysaccharide (LPS), LPS-binding protein, gut-homing β7 receptor and T-cell subsets. The increases in both microbial translocation and expression of the gut-homing β7 receptor on activated CD8 T cells found during maraviroc intensification were reduced after deintensification. Moreover, the correlations between activated β7(+) T cells and LPS levels found during intensification with maraviroc (P = 0.036 and P = 0.010, respectively) were lost during deintensification. In contrast, microbial translocation was stable during raltegravir intensification, with the exception of decreased LPS levels and activated CD4 β7(+) T cells, which reverted to baseline values after deintensification.

Question: Expression of gut-homing β7 receptor on T cells: surrogate marker for microbial translocation in suppressed HIV-1-infected patients?

Microbial translocation is an important factor in gut immune activation and mucosa inflammation, as evidenced by the association between the dynamics of microbial translocation and activated T cells expressing the gut-homing β7 receptor. The recruitment of activated β7(+) T cells to the gut tract when alteration of microbial translocation is maximum may be the major mechanism for recovery of mucosal integrity.

Answer the question based on the following context: To prospectively investigate whether preoperative functional flexion axis in patients with osteoarthritis- and varus-alignment changes after total knee arthroplasty and whether a correlation exists both between preoperative functional flexion axis and native limb deformity. A navigated total knee arthroplasty was performed in 108 patients using a specific software to acquire passive joint kinematics before and after implant positioning. The knee was cycled through three passive range of motions, from 0° to 120°. Functional flexion axis was computed using the mean helical axis algorithm. The angle between the functional flexion axis and the surgical transepicondylar axis was determined on frontal (α (F)) and axial (α (A)) plane. The pre- and postoperative hip-knee-ankle angle, related to femur mechanical axis, was determined. Postoperative functional flexion axis was different from preoperative only on frontal plane, while no differences were found on axial plane. No correlation was found between preoperative α (A) and native limb deformity, while a poor correlation was found in frontal plane, between α (F) and preoperative hip-knee-ankle angle.

Question: Does total knee arthroplasty modify flexion axis of the knee?

Total knee arthroplasty affects functional flexion axis only on frontal plane while has no effect on axial plane. Preoperative functional flexion axis is in a more varus position respect to the transepicondylar axis both in pre- and postoperative conditions. Moreover, the position of the functional axis on frontal plane in preoperative conditions is dependent on native limb alignment, while on axial plane is not dependent on the amount of preoperative varus deformity.

Answer the question based on the following context: The initiation and progression of knee and hip arthritis have been related to limb loading during ambulation. Although altered gait mechanics with unilateral lower limb loss often result in larger and more prolonged forces through the intact limb, how these forces differ with traumatic limb loss and duration of ambulation have not been well described.QUESTIONS/ The purpose of this study was to determine whether biomechanical variables of joint and limb loading (external adduction moments, vertical ground reaction force loading rates, and impulses) are larger in the intact limb of servicemembers with versus without unilateral lower limb loss and whether intact limb loading differs between shorter (≤ 6 months) versus longer (≥ 2 years) durations of ambulation with a prosthesis. A retrospective review was conducted of all clinical and research gait evaluations performed in the biomechanics laboratory at Walter Reed Army Medical Center and Walter Reed National Military Medical Center between January 2008 and December 2012. Biomechanical data meeting all inclusion and exclusion criteria were obtained for 32 individuals with unilateral transtibial limb loss, 49 with unilateral transfemoral limb loss, and 28 without limb loss. Individuals with unilateral lower limb loss were separated by their experience ambulating with a prosthesis at the time of the gait collection, ≤ 6 months or ≥ 2 years, to determine the effect of duration of ambulation with a prosthesis. Intact limb mean and peak vertical ground reaction force loading rates (median [range; 95% confidence interval]) were larger for transtibial subjects with ≤6 months of experience ambulating with a prosthesis versus control subjects (mean: 12.13 body weight [BW]/s [4.45-16.79; 10.18-12.81]versus 9.03 BW/s [4.64-14.47; 8.26-9.74]; effect size [ES]= 0.40; p = 0.003; and peak: 17.23 BW/s [6.58-25.25; 15.46-19.01] versus 13.60 BW/s [9.82-19.51; 12.98-15.05]; ES = 0.43; p = 0.001), respectively. Intact limb mean and peak vertical ground reaction force loading rates were also larger in subjects with transfemoral limb loss with ≤ 6 months and ≥ 2 years of experience ambulating with a prosthesis versus control subjects (mean: 12.67 BW/s [5.88-18.15; 11.06-14.47] and 12.59 BW/s [8.08-17.39; 11.83-13.68]versus 9.03 BW/s [4.64-14.47; 8.26-9.74]; ES ≥ 0.53; p<0.001; peak: 19.82 BW/s [11.93-29.43; 18.35-23.05] and 21.33 BW/s [16.68-36.69; 20.66-24.26]versus 13.60 BW/s [9.82-19.51; 12.98-15.05]; ES ≥ 0.68; p<0.001, respectively). Similarly, intact limb vertical ground reaction force impulses (0.63 BW·s [0.53-0.81; 0.67-0.69] and 0.62 BW·s [0.55-0.74; 0.60-0.63]versus 0.57 BW·s [0.50-0.66; 0.55-0.58]; ES ≥ 0.53, p<0.001) were also larger among both groups of transfemoral subjects versus control subjects, respectively. Limb loading variables were not statistically different between times ambulating with a prosthesis within groups with transtibial or transfemoral limb loss.

Question: Does intact limb loading differ in servicemembers with traumatic lower limb loss?

Larger intact limb loading in individuals with traumatic transtibial loss were only noted early in the rehabilitation process, but these variables were present early and late in the rehabilitation process for those with transfemoral limb loss. Such evidence suggests an increased risk for early onset and progression of arthritis in the intact limb, especially in those with transfemoral limb loss.

Answer the question based on the following context: Biofilm-related periprosthetic infections are catastrophic to patients and clinicians. Data suggest the addition of vitamin E to UHMWPE may have the ability to reduce biofilm formation on the surface of UHMWPE; however, previous studies were performed using stagnant broth solutions that may not have simulated a physiologic environment. In addition, the observed differences in levels of bacterial attachment, though statistically significant, may not be clinically significant.QUESTIONS/ We blended vitamin E with UHMWPE material and tested it for the ability to resist biofilm formation using a clinical isolate of methicillin-resistant Staphylococcus aureus (MRSA). Three additional materials were tested for comparison: highly crosslinked UHMWPE, compression-molded UHMWPE, and polyetheretherketone. We also determined whether the surface roughness of these materials facilitated biofilm formation. Using a flow cell system, samples of each material type were placed into separate chambers. A 10% solution of brain-heart infusion broth containing 10(5) colony-forming units (CFUs)/mL was flowed through the flow cell over 48 hours. The number of bacteria that adhered to the surface was quantified and biofilm formation was observed qualitatively using scanning electron microscopy. Optical profilometry was used to determine the surface roughness of each material type. Vitamin E-blended UHMWPE did not reduce biofilm formation of a clinically relevant strain of MRSA compared to materials that did not have vitamin E. More specifically, vitamin E-blended materials had similar amounts of biofilm formation (~ 8 log10 CFUs/cm(2)) compared to materials not containing vitamin E (~ 8.1 log10 CFUs/cm(2)) (p>0.4). The roughness of vitamin E-blended material surfaces (mean ± SD: 1.85 ± 0.46 µm) compared to that of materials without vitamin E (2.06 ± 1.24 µm) did not appear to influence biofilm formation.

Question: Does vitamin E-blended UHMWPE prevent biofilm formation?

Under physiologically relevant conditions, vitamin E-blended UHMWPE did not have the ability to reduce the formation of biofilms by MRSA.