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Answer the question based on the following context: In acute stroke management, time efficiency in the continuum of patient management is critical. We aimed to determine if implementation of system improvements at our institution translated to reduced picture-to-puncture (P2P) times over a 6-year period. We conducted a single-center retrospective analysis using a prospective acute stroke database of patients treated with intra-arterial therapy from October 2007 to October 2013. Patient demographics, stroke severity, neuroimaging and treatment time points were collected. Annual P2P times, defined as the interval between pretreatment neuroimaging (picture) and commencement of intra-arterial therapy (puncture), were assessed and compared. From 2007 to 2013 a total of 189 patients were identified, of which 181 met the study criteria. At initial presentation, median baseline NIH Stroke Severity score was 17.00 (IQR 11.00-22.00). Annual median P2P times decreased from 171 to 123.5 min, showing a median decrease of 11.5 min per annum (95% CI -23.9 to 0.9) and trending towards statistical significance (p=0.069). Plotted data revealed longer P2P times in instances where stroke onset or CT acquisition times were out-of-hours. Using median regression modeling, the annual decrease in P2P median time reached statistical significance when independently adjusting for CT acquisition time (13.5 min P2P median time reduction, 95% CI -27.0 to -0.1, p=0.048) and for stroke onset time (14.5 min annual P2P median time reduction, 95% CI -26.1 to -2.8, p=0.015).

Question: Picture-to-puncture time in acute stroke endovascular intervention: are we getting faster?

As a consequence of systems improvement at our institution, we were able to demonstrate improved annual median P2P times from 2007 to 2013.

Answer the question based on the following context: Patients frequently turn to the Internet when seeking answers to healthcare related inquiries including questions about the effects of radiation when undergoing radiologic studies. We investigate the readability of online patient education materials concerning radiation safety from multiple Internet resources. Patient education material regarding radiation safety was downloaded from 8 different websites encompassing: (1) the Centers for Disease Control and Prevention, (2) the Environmental Protection Agency, (3) the European Society of Radiology, (4) the Food and Drug Administration, (5) the Mayo Clinic, (6) MedlinePlus, (7) the Nuclear Regulatory Commission, and (8) the Society of Pediatric Radiology. From these 8 resources, a total of 45 articles were analyzed for their level of readability using 10 different readability scales. The 45 articles had a level of readability ranging from 9.4 to the 17.2 grade level. Only 3/45 (6.7%) were written below the 10th grade level. No statistical difference was seen between the readability level of the 8 different websites.

Question: Are we failing to communicate?

All 45 articles from all 8 websites failed to meet the recommendations set forth by the National Institutes of Health and American Medical Association that patient education resources be written between the 3rd and 7th grade level. Rewriting the patient education resources on radiation safety from each of these 8 websites would help many consumers of healthcare information adequately comprehend such material.

Answer the question based on the following context: Curative resection is the treatment of choice for gastric cancer, but it is unclear whether gastrectomy should also include splenectomy. We retrospectively analyzed long-term survival in patients in our hospital who underwent gastrectomy plus splenectomy (G+S) or gastrectomy alone (G-A) for gastric cancer. We identified 214 patients who underwent surgery with curative intent between 1980 and 2003. Of these, 100 underwent G+S, and 114 underwent G-A. The primary endpoint was 5-year overall survival (OS). Median follow-up was 18 months in patients who underwent G+S, and 26.5 months in patients who underwent G-A. The 5-year OS rate was significantly higher in patients who underwent G-A (33.8%; 95% CI 24.2 to 43.4%) than in those who underwent G+S (28.8%; 95% CI 19.6 to 38.0%) (log-rank test, P=0.013).

Question: Is concomitant splenectomy beneficial for the long-term survival of patients with gastric cancer undergoing curative gastrectomy?

Splenectomy does not benefit patients undergoing gastrectomy for gastric cancer. Routine splenectomy should be abandoned in patients undergoing radical resections for gastric cancer.

Answer the question based on the following context: The emergence of multi-drug-resistant gram-negative rods (MDR-GNRs) has become a worldwide problem. To limit the emergence of MDR-GNRs, a tertiary care cancer center in Japan implemented a policy that requires the pre-emptive isolation of patients with organisms that have the potential to be MDR-GNRs. A retrospective analysis was performed. Any gram-negative bacillus isolates categorized as intermediate or resistant to at least 2 classes of antimicrobials were subjected to contact precautions. The incidence of patients with MDR-GNRs was analyzed. There was no difference between the preintervention and intervention time periods in the detection rate of nonfermenting MDR-GNR species (0.15 per 10,000 vs 0.35 per 10,000 patient-days, P = .08). There was an increase in the detection rate of multi-drug-resistant Enterobacteriaceae (0.19 per 10,000 vs 0.56 per 10,000 patient-days, P = .007), which was prominent for extended-spectrum β-lactamase (ESBL)-producing organisms (0.19 per 10,000 vs 0.50 per 10,000 patient-days, P = .02).

Question: Are strict isolation policies based on susceptibility testing actually effective in the prevention of the nosocomial spread of multi-drug-resistant gram-negative rods?

Our intervention kept the emergence of multi-drug-resistant non-glucose-fermenting gram-negative bacilli to a small number, but it failed to prevent an increase in ESBL producers. Policies, such as active detection and isolation, are warranted to decrease the incidence of these bacilli.

Answer the question based on the following context: Recent studies indicate that persistent intestinal inflammation in patients with Crohn's disease (CD) might be caused by abnormal intestinal microbiota. This hypothesis may suggest a beneficial effect of antibiotics in CD therapy. So far, guidelines do not recommend antibiotics except in the treatment of complicated CD, and there are few studies on the effects of rifaximin in these patients. Between December 2011 and December 2012, we performed a blinded randomized trial in 168 patients with a previous history of moderately active CD concerning the efficacy of rifaximin. All the patients had previously achieved remission with standard therapy (prednisone/budesonide). Data from patients receiving 800 mg of rifaximin (83 patients) twice a day for 12 weeks were compared with those from patients who received placebo (83 patients). The primary endpoint was maintaining remission during the follow-up. All the patients (100%; 83/83) on 800 mg of rifaximin were in remission after 12 weeks of treatment in comparison with 84% (70/83) of the placebo group. This significant difference was also persistent at the 24-week follow-up [78% (65/83) vs. 41% (34/83), respectively]. The last evaluation performed at 48 weeks revealed disease activity in 45% (38/83) of the patients of the rifaximin group, i.e. a significant decrease compared with the placebo group [75% (63 of 83)].

Question: Is rifaximin effective in maintaining remission in Crohn's disease?

Remission previously obtained with standard treatment can be sustained in patients with moderately active CD after the administration of 800 mg of rifaximin.

Answer the question based on the following context: Since the introduction of randomized controlled trials (RCT) in clinical research, there has been discussion of whether enrolled patients have worse or better outcomes than comparable non-participants. To investigate whether very preterm infants randomized to a placebo group in an RCT have equivalent neurodevelopmental outcomes to infants who were eligible but not randomized (eligible NR). In the course of an RCT investigating the neuroprotective effect of early high-dose erythropoietin on the neurodevelopment of very preterm infants, the outcome data of 72 infants randomized to placebo were retrospectively compared with those of 108 eligible NR infants. Our primary outcome measures were the mental (MDI) and psychomotor (PDI) developmental indices of the Bayley Scales of Infant Development II at 24 months of corrected age. The outcomes of the two groups were considered equivalent if the confidence intervals (CIs) of their mean differences fitted within our ±5-point margin of equivalence. Except for a higher socioeconomic status of the trial participants, both groups were balanced for most perinatal variables. The mean difference (90% CI) between the eligible NR and the placebo group was -2.1 (-6.1 and 1.9) points for the MDI and -0.8 (-4.2 and 2.5) points for the PDI. After adjusting for the socioeconomic status, maternal age and child age at follow-up, the mean difference for the MDI was -0.5 (-4.3 and 3.4) points.

Question: Randomized controlled trials in very preterm infants: does inclusion in the study result in any long-term benefit?

Our results indicate that the participation of very preterm infants in an RCT is associated with equivalent long-term outcomes compared to non-participating infants.

Answer the question based on the following context: Alzheimer's disease (AD) is one of the main types of dementia affecting about 50-55% of all demented patients. Sleep disturbances in AD patients are associated with the severity of dementia and are often the primary reason for institutionalization. These sleep problems partly resemble the core symptoms of narcolepsy, a sleep disorder caused by a general loss of the neurotransmitter hypocretin. The aim of our study was to investigate whether genetic variants in the hypocretin (HCRT) and in the hypocretin receptors 1 and 2 (HCRTR1, HCRTR2) genes could modify the occurrence and the clinical features of AD and to examine if these possible variants influence the role of the protein in sleep regulation. Using a case-control strategy, we genotyped 388 AD patients and 272 controls for 10 SNPs in the HCRT, HCRTR1 and HCRTR2 genes. In order to evaluate which residues belong to the HCRTR2 binding site, we built a molecular model. The genotypic and allelic frequencies of the rs2653349 polymorphism were different (χ(2) = 5.77, p = 0.016; χ(2) = 6.728, p = 0.035) between AD patients and controls. The carriage of the G allele was associated with an increased AD risk (OR 2.53; 95% CI 1.10-5.80). No significant differences were found in the distribution of either genotypic or allelic frequencies between cases and controls in the HCRTR1 polymorphisms rs2271933, rs10914456 and rs4949449 and in the HCRTR2 polymorphism rs3122156.

Question: Is HCRTR2 a genetic risk factor for Alzheimer's disease?

Our data support the hypothesis that the HCRTR2 gene is likely to be a risk factor for AD. The increased risk inferred is quite small, but in the context of a multi-factorial disease, the presence of this polymorphism may significantly contribute to influencing the susceptibility for AD by interacting with other unknown genetic or environmental factors in sleep regulation.

Answer the question based on the following context: The primary aim of this study was to explore the predictive potential of the preoperative Kushida index score and subsequent outcome following maxillomandibular advancement surgery (MMA). Secondarily we looked at how well the Kushida values of our OSA patients matched the morphometric models diagnostic thresholds. We performed a retrospective analysis of patients who underwent MMA for OSA at our institution. Kushida morphometric scores were calculated using the described formula: P + (Mx - Mn) + 3 × OJ + 3 × [Max (BMI - 25)] × (NC ÷ BMI). Regression analysis was performed to explore the possible association between Kushida index score and outcome variables of postoperative apnoea/hypopnea indices (AHI) and Epworth Sleepiness Scores (ESS). We identified 28 patients with complete data available for analysis. The mean age was 45 years (SD 6) with mean BMI of 28 (SD 3). All, but one patient underwent bi-maxillary procedure with or without genioplasty, with a mean advancement of 8.5 mm (SD 2). The mean Kushida index score in our sample was 79 (SD 14). 89% of patients had postoperative AHI<15 in keeping with surgical success. We found no statistically significant relationship with Kushida morphometric model variables and overall score with either of our outcome variables.

Question: Does the Kushida morphometric model predict outcomes following maxillomandibular advancement surgery for obstructive sleep apnoea?

The mean Kushida index score in our patients was in the range consistent with the morphometric models diagnostic cut-off for OSA. Kushida's morphometric model does not appear to be a good predictor of postoperative success in individuals following MMA. The morphometric model represents a clinical adjunct in the initial diagnostic work-up of OSA patients referred for surgery.

Answer the question based on the following context: Alpha-1-antitrypsin deficiency (AATD), genetic risk factor for premature chronic obstructive pulmonary disease (COPD), often remains undetected. The aim of our study was to analyse the effectiveness of an integrative laboratory algorithm for AATD detection in patients diagnosed with COPD by the age of 45 years, in comparison with the screening approach based on AAT concentration measurement alone. 50 unrelated patients (28 males/22 females, age 52 (24-75 years) diagnosed with COPD before the age of 45 years were enrolled. Immunonephelometric assay for alpha-1-antitrypsin (AAT) and PCR-reverse hybridization for Z and S allele were first-line, and isoelectric focusing and DNA sequencing (ABI Prism BigDye) were reflex tests. AATD associated genotypes were detected in 7 patients (5 ZZ, 1 ZMmalton, 1 ZQ0amersfoort), 10 were heterozygous carriers (8 MZ and 2 MS genotypes) and 33 were without AATD (MM genotype). Carriers and patients without AATD had comparable AAT concentrations (P = 0.125). In majority of participants (48) first line tests were sufficient to analyze AATD presence. In two remaining cases reflex tests identified rare alleles, Mmalton and Q0amersfoort, the later one being reported for the first time in Serbian population. Detection rate did not differ between algorithm and screening both for AATD (P = 0.500) and carriers (P = 0.063).

Question: Is an integrative laboratory algorithm more effective in detecting alpha-1-antitrypsin deficiency in patients with premature chronic obstructive pulmonary disease than AAT concentration based screening approach?

There is a high prevalence of AATD affected subjects and carriers in a group of patients with premature COPD. The use of integrative laboratory algorithm does not improve the effectiveness of AATD detection in comparison with the screening based on AAT concentration alone.

Answer the question based on the following context: To examine reciprocal associations between substance use (cigarette smoking, use of alcohol, marijuana, and other illegal drugs) and suicidal ideation among adolescents and young adults (aged 11-21 at wave 1; aged 24-32 at wave 4). Four waves public-use Add Health data were used in the analysis (N=3342). Respondents were surveyed in 1995, 1996, 2001-2002, and 2008-2009. Current regular smoking, past-year alcohol use, past-year marijuana use, and ever use of other illegal drugs as well as past-year suicidal ideation were measured at the four waves (1995, 1996, 2001-2002, and 2008-2009). Fixed effects models with lagged dependent variables were modeled to test unidirectional associations between substance use and suicidal ideation, and nonrecursive models with feedback loops combining correlated fixed factors were conducted to examine reciprocal relations between each substance use and suicidal ideation, respectively. After adjusting for the latent time-invariant effects and lagged effects of dependent variables, the unidirectional associations from substance use to suicidal ideation were consistently significant, and vice versa. Nonrecursive model results showed that use of cigarette or alcohol increased risk of suicidal ideation, while suicidal ideation was not associated with cigarette or alcohol use. Reversely, drug use (marijuana and other drugs) did not increase risk of suicidal ideation, but suicidal ideation increased risk of illicit drug use.

Question: Suicidal ideation and substance use among adolescents and young adults: a bidirectional relation?

The results suggest that relations between substance use and suicidal ideation are unidirectional, with cigarette or alcohol use increasing risk of suicidal ideation and suicidal ideation increasing risk of illicit drug use.

Answer the question based on the following context: Elevated cobalt and chromium ion concentrations have been associated with the use of metal-on-metal bearings in hip arthroplasty. The use of a differential hardness bearing may reduce metal particle release. The aim of our study was to compare circulating cobalt (Co) and chromium (Cr) ion levels between patients treated with a standard all 'as-cast' heat treated bearing and a differential hardness bearing. One hundred and thirty-two patients implanted with unilateral hip resurfacing arthroplasties and having had blood metal ion studies performed between one and six years after surgery were retrospectively selected. There were 73 patients in the standard all 'as cast' heat treated bearing group (group 1) and 59 in the differential hardness bearing group (group 2). Clinical and quality of life scores were comparable between groups. The median Co in group 1 was 1.01 µg/L and 1.23 µg/L in group 2 (p = 0.0566). The median Cr in group 1 was 1.60 µg/L and 1.34 µg/L in group 2 (p = 0.0505).

Question: Do hardened femoral heads reduce blood metal ion concentrations after hip resurfacing?

Compared with conventional heat-treated CoCr bearings, differential hardness metal-on metal bearings do not confirm in vivo the hopes of a substantial reduction in circulating metal ions concentrations suggested by in vitro wear studies.

Answer the question based on the following context: Electrocardiogram-gated 4D-CTA is a promising technique allowing new insight into aneurysm pathophysiology and possibly improving risk prediction of cerebral aneurysms. Due to the extremely small pulsational excursions (<0.1 mm in diameter), exact segmentation of the aneurysms is of critical importance. In vitro examinations have shown improvement of the accuracy of vessel delineation by iterative reconstruction methods. We hypothesized that this improvement shows a measurable effect on aneurysm pulsations in vivo. Ten patients with cerebral aneurysms underwent 4D-CTA. Images were reconstructed with filtered back-projection and iterative reconstruction. The following parameters were compared between both groups: image noise, absolute aneurysm volumes, pulsatility, and sharpness of aneurysm edges. In iterative reconstruction images, noise was significantly reduced (mean, 9.8 ± 4.0 Hounsfield units versus 8.0 ± 2.5 Hounsfield units; P = .04), but the sharpness of aneurysm edges just missed statistical significance (mean, 3.50 ± 0.49 mm versus 3.42 ± 0.49 mm; P = .06). Absolute volumes (mean, 456.1 ± 775.2 mm(3) versus 461.7 ± 789.9 mm(3); P = .31) and pulsatility (mean, 1.099 ± 0.088 mm(3) versus 1.095 ± 0.082 mm(3); P = .62) did not show a significant difference between iterative reconstruction and filtered back-projection images.

Question: Cerebral aneurysm pulsation: do iterative reconstruction methods improve measurement accuracy in vivo?

CT images reconstructed with iterative reconstruction methods show a tendency toward shorter vessel edges but do not affect absolute aneurysm volumes or pulsatility measurements in vivo.

Answer the question based on the following context: To assess the prevalence of clinically urgent intra-cranial pathology among children who had imaging for a first episode of non-febrile seizure with focal manifestations. We performed a cross sectional study of all children age 1 month to 18 years evaluated for first episode of non-febrile seizure with focal manifestations and having neuroimaging performed within 24h of presentation at a single pediatric ED between 1995 and 2012. We excluded intubated patients, those with known structural brain abnormality and trauma. A single neuro-radiologist reviewed all cranial computed tomography and/or magnetic resonance imaging performed. We defined clinically urgent intracranial pathology as any finding resulting in a change of initial patient management. We performed univariate analysis using χ(2) analysis for categorical data and Mann-Whitney U test for continuous data. We identified 319 patients having a median age of 4.6 years [IQR 1.8-9.4] of which 45% were female. Two hundred sixty-two children had a CT scan, 15 had an MR and 42 had both. Clinically urgent intra-cranial pathology was identified on imaging of 13 patients (4.1%; 95% CI: 2.2, 7.0). Infarction, hemorrhage and thrombosis were most common (9/13). Twelve of 13 were evident on CT scan. Persistent Todd's paresis and age ≤ 18 months were predictors of clinically urgent intracranial pathology. Absence of secondary generalization and multiple seizures on presentation were not predictive.

Question: Pediatric first time non-febrile seizure with focal manifestations: is emergent imaging indicated?

Four percent of children imaged with first time, afebrile focal seizures have findings important to initial management. Children younger than ≤ 18 months are at increased risk.

Answer the question based on the following context: Upgrades to electronic health record (EHR) systems scheduled to be introduced in the USA in 2014 will advance document interoperability between care providers. Specifically, the second stage of the federal incentive program for EHR adoption, known as Meaningful Use, requires use of the Consolidated Clinical Document Architecture (C-CDA) for document exchange. In an effort to examine and improve C-CDA based exchange, the SMART (Substitutable Medical Applications and Reusable Technology) C-CDA Collaborative brought together a group of certified EHR and other health information technology vendors. We examined the machine-readable content of collected samples for semantic correctness and consistency. This included parsing with the open-source BlueButton.js tool, testing with a validator used in EHR certification, scoring with an automated open-source tool, and manual inspection. We also conducted group and individual review sessions with participating vendors to understand their interpretation of C-CDA specifications and requirements. We contacted 107 health information technology organizations and collected 91 C-CDA sample documents from 21 distinct technologies. Manual and automated document inspection led to 615 observations of errors and data expression variation across represented technologies. Based upon our analysis and vendor discussions, we identified 11 specific areas that represent relevant barriers to the interoperability of C-CDA documents.

Question: Are Meaningful Use Stage 2 certified EHRs ready for interoperability?

We identified errors and permissible heterogeneity in C-CDA documents that will limit semantic interoperability. Our findings also point to several practical opportunities to improve C-CDA document quality and exchange in the coming years.

Answer the question based on the following context: A health care reform has been taking place to provide cost-effective and coordinated care. One method of achieving these goals is a patient-centered medical home (PCMH) model, which is associated with provision of quality care among children belonging to racial/ethnic minorities. Despite the potential of the PCMH for children of minority backgrounds, little is known about the extent to which minorities with mental disorders have the PCMH. The study examined racial/ethnic disparities among children with mental disorders in accessing care from the PCMH. The 2009-2010 National Survey of Children with Special Health Care Needs (CSHCN) was used for this analysis. Multivariate logistic regressions were applied to capture the racial/ethnic disparities and to analyze a composite outcome of the PCMH. An estimated population size of 4 677 904 CSHCN with mental disorders was included. Among them, 59.94% of children reported to have received medical homes. Compared with white children, the odds of receiving any medical home services decreased among Hispanic children (odds ratio [OR] = 0.69; P<.05) and black children (OR = 0.70; P<.05). The likelihood of having a medical home was lower for Hispanic children than white children, when they had attention deficit hyperactivity disorder (ADHD; OR = 0.57; P<.05) and development delay (OR = 0.73; P<.05). Compared with white children with ADHD or depression having a medical home, the odds of black children with ADHD (OR = 0.63; P<.05) and depression (OR = 0.68; P<.05) having a medical home were lower.

Question: Racial health disparities among special health care needs children with mental disorders: do medical homes cater to their needs?

There were significant racial/ethnic disparities among CSHCN with mental disorders, indicating several sizeable effects of each of the 5 components on Hispanic, black, and other children compared with white children. These differences could be a potential to improve racial/ethnic disparities.

Answer the question based on the following context: Gay men are thought to experience body-image concerns or disorders more frequently than heterosexual men. It is unclear, however, whether these putative concerns are due to unrealistic body ideals (aspiring to a body shape that is difficult or impossible to attain), body-image distortion (misperceiving the actual shape of one's body), or both. We administered a well-established computerized body-image test, the "somatomorphic matrix," to 37 gay men recruited from the community in April 1999 and compared the results with previous data from 49 community-recruited heterosexual comparison men and 24 clinic-recruited heterosexual men with eating disorders. Gay men were indistinguishable from the community-recruited heterosexual comparison men on measures of both body ideals and body-image distortion. By contrast, eating-disordered men were significantly distinguishable from both other groups on body-image distortion. The lack of differences between community gay and heterosexual men on body-image indices seems unlikely to represent a type II error, since the somatomorphic matrix showed ample power to detect abnormalities in the eating-disordered men, despite the smaller sample size of the latter group.

Question: Body-image dissatisfaction in gay versus heterosexual men: is there really a difference?

Contrary to our hypotheses, gay men did not differ significantly from heterosexual men on measures of body image. These unexpected findings cast doubt on the widespread belief that gay men experience greater body-image dissatisfaction than heterosexual men. If our findings are valid, it follows that some previous studies of body image in gay men may possibly have been influenced by selection bias.

Answer the question based on the following context: To evaluate the referral patterns and indications for esophageal pH monitoring in an open-access system and to determine whether these indications conform to practice guidelines of the American Gastroenterological Association (AGA). A total of 851 consecutive patients referred for ambulatory pH monitoring to nine open-access gastrointestinal units over a 12-month period received a structured interview. The indication for the examination was decided by the physician performing the procedure, on the basis of the patient's clinical history and main complaint. Three hundred and twenty-three (38%) examinations were for indications in accordance with the guidelines. The proportion of appropriate requests in each center ranged from 34% to 47%. This figure was not significantly different in larger gastrointestinal units (more than 150 examinations per year) and smaller ones (35% and 40%; p= 0.14). The proportion of appropriate requests was 45% for gastroenterologists, 38% for surgeons, 32% for other specialists, and 24% for primary care physicians (PCPs) (p<0.001). The percentage of appropriateness was significantly different between gastrointestinal specialists and PCPs (p<0.001 vs gastroenterologists, p= 0.015 vs GI surgeons), and between gastroenterologists and other specialists (p= 0.006). The underuse of an empirical trial of acid-suppression therapy in patients with suspected reflux disease and the overuse of this test to confirm a diagnosis in patients with erosive esophagitis and in endoscopy-negative cases with typical symptoms responding completely to antisecretory therapy accounted for most of the referrals, which was not in accordance with the guidelines.

Question: Is esophageal pH monitoring used appropriately in an open-access system?

In an open-access system, a high proportion of esophageal pH studies are done for indications not consistent with published guidelines, particularly among the examinations not requested by gastrointestinal specialists. Further education is still needed on the appropriate use of esophageal pH monitoring and management of gastroesophageal reflux disease (GERD).

Answer the question based on the following context: To test the hypothesis that the presence of national mental health policies, programs and legislation would be associated with lower national suicide rates. Suicide rates from 100 countries were regressed on mental health policy, program and legislation indicators. Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries' suicide rates rose.

Question: Do nations' mental health policies, programs and legislation influence their suicide rates?

It is of concern that most mental health initiatives are associated with an increase in suicide rates. However, there may be acceptable reasons for the observed findings, for example initiatives may have been introduced in areas of increasing need, or a case-finding effect may be operating. Data limitations must also be considered.

Answer the question based on the following context: The role of oxidative stress in the pathogenesis of diseases such as macular degeneration, certain types of cancer, and Alzheimer's disease has received much attention. Thus, there is considerable interest in the potential contribution of antioxidants to the prevention of these diseases. The objective of this study was to determine whether use of supplemental antioxidants (vitamins A, C, or E, plus selenium or zinc) was associated with a reduced risk of development of cognitive impairment or cognitive decline in a representative sample of the community-dwelling elderly. The sample consisted of 2082 nonproxy subjects from the Duke Established Populations for Epidemiologic Studies of the Elderly who were not cognitively impaired at the 1989-1990 interview (baseline for the present analysis). Medication use was determined during in-home interviews. Cognitive function was assessed 3 and 7 years from baseline in terms of incident cognitive impairment, as measured on the Short Portable Mental Status Questionnaire (SPMSQ) using specific cut points (number of errors) based on race and education, and cognitive decline, defined as an increase of>or = 2 errors on the SPMSQ. Multivariate analyses were performed using weighted data adjusted for sampling design and controlled for sociodemographic characteristics, health-related behaviors, and health status. At baseline, 224 (10.8%) subjects were currently taking a supplement containing an antioxidant. During the follow-up period, 24.0% of subjects developed cognitive impairment and 34.5% experienced cognitive decline. Current antioxidant users had a 34.0% lower risk of developing cognitive impairment compared with non-antioxidant users (adjusted relative risk [RR], 0.66; 95% CI, 0.44-1.00) and a 29.0% lower risk of experiencing cognitive decline (adjusted RR, 0.71; 95% CI, 0.49-1.01).

Question: Is antioxidant use protective of cognitive function in the community-dwelling elderly?

The results of this analysis suggest a possible beneficial effect of antioxidant use in terms of reducing cognitive decline among the community-dwelling elderly.

Answer the question based on the following context: Current literature suggests that novices reach a plateau after two to seven trials when training on the MIST VR laparoscopic virtual reality system. We hypothesize that significant benefit may be gained through additional training. Second-year medical students (n = 12) voluntarily enrolled under an IRB-approved protocol for MIST VR training. All subjects completed pre- and posttraining questionnaires and performed 30 repetitions of 12 tasks. Performance data were automatically recorded for each trial. Learning curves for each task were generated by fitting spline curves to the mean overall scores for each repetition. Scores were assessed for plateaus by repeated measures, slope, and best score. On average, subjects completed training in 7.1 h. (range, 5.9-9.2). Two to seven performance plateaus were identified for each of the 12 MIST VR tasks. Initial plateaus were found for all tasks by the 8th repetition; however, ultimate plateaus were not reached until 21-29 repetitions. Overall best score was reached between 20 and 30 repetitions and occurred beyond the ultimate plateau for 9 tasks.

Question: Laparoscopic virtual reality training: are 30 repetitions enough?

These data indicate that a lengthy learning curve exists for novices and may be seen throughout 30 repetitions and possibly beyond. Performance plateaus may not reliably determine training endpoints. We conclude that a significant and variable amount of training may be required to achieve maximal benefit. Neither a predetermined training duration nor an arbitrary number of repetitions may be adequate to ensure laparoscopic proficiency following simulator training. Standards which define performance-based endpoints should be established.

Answer the question based on the following context: Family therapy is sometimes used as adjunctive treatment to pharmacotherapy to help patients recover from mood episodes of bipolar I disorder. However, the efficacy of this practice is not known. Ninety-two patients meeting criteria for a current bipolar I mood episode were randomly assigned to family therapy plus pharmacotherapy, multifamily psychoeducational group therapy plus pharmacotherapy, or pharmacotherapy alone. Time to recovery was analyzed with survival analysis. The proportion of subjects within each treatment group who recovered did not significantly differ, nor did time to recovery. The analyses did not include other outcomes such as psychosocial functioning, prophylaxis against recurrences of mood episodes, or compliance with pharmacotherapy.

Question: Does adjunctive family therapy enhance recovery from bipolar I mood episodes?

Neither adjunctive family therapy nor adjunctive multifamily psychoeducational group therapy significantly improves the rate of recovery from mood episodes of bipolar I disorder, compared to treatment with pharmacotherapy alone.

Answer the question based on the following context: A consistent finding of representative surveys that were conducted in Germany in the early 1990s was that people with depression encountered a substantial amount of stigma and discrimination. The aim of this study was to examine whether public attitudes have improved over the last decade or not. In 2001, a representative survey was carried out among the adult population of the "old" Federal Republic of Germany using the same methodology as in a previous survey in 1990. Regarding emotional reactions of the respondents towards people with depression, our findings are inconsistent. While there has been an increase in the readiness to feel pity and also a slight increase in the tendency to react aggressively, the expression of fear remained unchanged. The public's desire for social distance from people with depression was as strong in 2001 as it had been in 1990.

Question: Public attitudes to people with depression: have there been any changes over the last decade?

The hypothesis of a change for the better regarding public attitudes towards depressed people is not supported by our findings. Further efforts are needed to reach this goal.

Answer the question based on the following context: Data from a sample of suicidal young adults were used to examine the relevance of the kindling and behavioral sensitization models to suicide attempts. Three predictions derived from the kindling and sensitization models were tested: a higher number of suicide attempts would be associated with (a) lower levels of pre-attempt stress; (b) higher suicidal intent; and (c) greater lethality of the current attempt. Measures of life stress and suicidal intent were collected among 123 young adults who attempted suicide just prior to entering treatment. Data on the total number of suicide attempts and the lethality of the current attempt were also collected. Number of suicide attempts was significantly and positively associated with pre-suicidal crisis life stress and suicidal ideation, but was not significantly associated with lethality of the most recent attempt. The young sample drawn from a military medical setting may not accurately represent suicide attempters in the general population. Only total negative life events in the year preceding suicide attempt were examined, not the increase in negative life events immediately prior to suicide attempt.

Question: Kindling and behavioral sensitization: are they relevant to recurrent suicide attempts?

The kindling and sensitization models may not accurately describe the progression of recurrent suicide attempts.

Answer the question based on the following context: Whether plasma N-terminal brain natriuretic peptide (N-BNP) is useful in the diagnosis of heart failure (HF) depends traditionally on whether it is as good as the putative 'gold-standard', left ventricular ejection fraction (LVEF), in indicating cardiac dysfunction. However, since HF is primarily an impairment of function of the cardiac pump, we explored the relationship between N-BNP and direct and indirect indicators of cardiac pump dysfunction. Eighty-six HF patients (mean age 56 years) with a range of LVEF's (mean 36.9+/-15.2%, range 15-66%) and 10 age-matched healthy controls were recruited into the study and had resting N-BNP measured. Cardiopulmonary exercise testing was performed to assess peak oxygen consumption (Vo(2)). A subgroup of 23 subjects underwent further exercise haemodynamic assessment to evaluate peak cardiac power output (CPO). The CHF group had significantly higher N-BNP (median [interquartile range]) levels (299 [705]fmol/ml) than the control group (7 [51] fmol/ml, P<0.005). Significant correlations between N-BNP and peak Vo(2), and N-BNP and peak CPO were observed (R>or =0.5, P<0.005). Although significant correlation was observed between N-BNP and LVEF (R=0.34, P=0.01), the correlations between LVEF and peak Vo(2) or peak CPO (all R<0.3, P>0.3) were not significant. Multivariate analysis identified plasma N-BNP and NYHA class, but not LVEF, as independent predictors of peak Vo(2).

Question: Is plasma N-BNP a good indicator of the functional reserve of failing hearts?

We have found that N-BNP was surprisingly good as a simple indicator of cardiac pump dysfunction. Since heart failure is an inadequacy of function, these results strongly support the notion that N-BNP is a useful blood test in estimating the extent of cardiac pump dysfunction and helpful in establishing positive diagnosis of heart failure.

Answer the question based on the following context: The physicochemical properties of diamorphine (3,6-diacetylmorphine) enhance its bioavailability compared with more lipid-soluble opioids when administered into the epidural space. However, the influence of concentration, volume or mass on the clinical efficacy of diamorphine is not known. In this double-blind, randomized, prospective study, 62 women in active labour and</=5 cm cervical dilatation were recruited to determine whether the mode of action of diamorphine in the epidural space is concentration-dependent. After insertion of a lumbar epidural catheter, patients received epidural diamorphine 3 mg either as a high-volume, low-concentration solution (group A) or a low-volume, high-concentration solution (group B). The concentration of diamorphine was determined by the response of the previous patient in the same group using up-down sequential allocation. Pain corresponding to the previous contraction was assessed using a 100-mm visual analogue score and effective analgesia was defined as</=10 mm within 30 min of epidural injection. There was no significant difference in EC50 for diamorphine between the groups: the difference was 15.0 microg ml(-1) (95% CI -40.3 to 10.3). The EC50 for group A was 237.5 microg ml(-1) (95% CI 221.2 to 253.8) and the EC50 for group B was 252.5 microg ml(-1) (95% CI 232.2 to 272.8). The EC50 ratio was 0.95 (95% CI 0.87 to 1.06). The groups exhibited parallelism (P=0.98). The overall EC50 for all data was 244.2 microg ml(-1) (95% CI 230.8 to 257.2).

Question: Is the clinical efficacy of epidural diamorphine concentration-dependent when used as analgesia for labour?

We conclude that diamorphine provides analgesia in labour by a concentration-dependent effect.

Answer the question based on the following context: To assess the rates of violence in nursery rhymes compared to pre-watershed television viewing. Data regarding television viewing habits, and the amount of violence on British television, were obtained from Ofcom. A compilation of nursery rhymes was examined for episodes of violence by three of the researchers. Each nursery rhyme was analysed by number and type of episode. They were then recited to the fourth researcher whose reactions were scrutinised. There were 1045 violent scenes on pre-watershed television over two weeks, of which 61% showed the act and the result; 51% of programmes contained violence. The 25 nursery rhymes had 20 episodes of violence, with 41% of rhymes being violent in some way; 30% mentioned the act and the result, with 50% only the act. Episodes of law breaking and animal abuse were also identified. Television has 4.8 violent scenes per hour and nursery rhymes have 52.2 violent scenes per hour. Analysis of the reactions of the fourth researcher were inconclusive.

Question: Could nursery rhymes cause violent behaviour?

Although we do not advocate exposure for anyone to violent scenes or stimuli, childhood violence is not a new phenomenon. Whether visual violence and imagined violence have the same effect is likely to depend on the age of the child and the effectiveness of the storyteller. Re-interpretation of the ancient problem of childhood and youth violence through modern eyes is difficult, and laying the blame solely on television viewing is simplistic and may divert attention from vastly more complex societal problems.

Answer the question based on the following context: To evaluate if mental fatigue is a symptom that appears independently from other clinical features in patients with Parkinson disease (PD), and to study if fatigue is persistent over time in these patients. In 1993, 233 patients with PD were included in a community-based study of fatigue and followed prospectively over 8 years. Fatigue was measured by a combination of a seven-point scale and parts of the Nottingham Health Profile (NHP) at baseline and after 4 and 8 years. In addition, the Fatigue Severity Scale (FSS) was used to evaluate fatigue in 2001. Population-averaged logistic regression models for correlated data were performed to study the relationship between fatigue and various demographic and clinical variables. In patients who were followed throughout the 8-year study period, fatigue increased from 35.7% in 1993 to 42.9% in 1997 and 55.7% in 2001. Fatigue was related to disease progression, depression, and excessive daytime sleepiness (EDS). However, the prevalence of fatigue in patients without depression and EDS remained high and increased from 32.1% to 38.9% during the study period. For about 44% of the patients with fatigue the presence of this symptom varied during the study period, as it was persistent in 56% of the patients with fatigue.

Question: Is fatigue an independent and persistent symptom in patients with Parkinson disease?

The authors confirmed the high prevalence of mental fatigue in patients with Parkinson disease (PD). Fatigue is related to other non-motor features such as depression and excessive daytime sleepiness, but cannot be explained by this comorbidity alone. In more than half of the patients mental fatigue is persistent and seems to be an independent symptom that develops parallel to the progressive neurodegenerative disorder of PD.

Answer the question based on the following context: The importance of glucose control is recognized both by patients with diabetes and their physicians. However, other preventative interventions, such as using medications to manage lipid and blood pressure levels, are underused for diabetic patients. To determine whether patients with diligent glucose management are more likely to use medications that treat lipids and blood pressure. Administrative data records were evaluated for all diabetic patients aged 65 or older residing in Ontario in 1999 without pre-existing coronary artery disease (n=161,553). Measures of diligent glucose management were insulin use and frequent capillary glucose testing ((3) 2 per day). Outcomes were prescription of a lipid-lowering drug or antihypertensive drug. Using multivariate modeling, odds ratios for each diligence measure were determined for each outcome, adjusting for age, sex, comorbidities, and other covariates. Patients using insulin did not have a clinically important difference in lipid-lowering drug use (adjusted odds ratio 0.9, 99% confidence interval 0.9 - 1.0, P=0.002) or antihypertensive drug use (adjusted odds ratio 1.1, 99% confidence interval 1.0 - 1.1, P<0.001) versus non-users. Adjusted odds ratios for frequent glucose testing were not significantly different from unity for either lipid-lowering or antihypertensive drug use.

Question: Risk modification for diabetic patients. Are other risk factors treated as diligently as glycemia?

Patients who required and were capable of diligent glucose management, which is invasive, expensive and time-consuming, were no more likely to use medications to control lipids or blood pressure. Preventative care for patients with diabetes may be too focused on glycemic control, and may be neglecting the management of other cardiovascular risk factors.

Answer the question based on the following context: While decision analysis and treatment algorithms have repeatedly been shown to improve quality of care in many areas of medicine, no such algorithm has emerged for the invasive management of lower extremity peripheral arterial disease. Using the best available evidence-based outcomes data, our group designed a standardization tool, the Lower Extremity Grading System (LEGS) score, which consistently directs limbs to a specific treatment on the basis of presentation. The purpose of this study was to examine whether use of such a tool improves outcomes by directing treatment of lower extremity peripheral arterial disease. Over 18 months (July 2001-December 2002) our group intervened in 673 limbs (angioplasty, open surgery, primary limb amputation) with lower extremity peripheral arterial disease. During this time we developed the LEGS score, and implemented its prospective use for the final 362 limbs. For the purpose of this study, all 673 limbs were retrospectively scored with the LEGS score to determine the LEGS recommended best treatment. Of the 673 limbs, 551 (81.9%) received the same treatment as recommended with LEGS and 122 (18.1%) received treatment contrary to LEGS. Limbs treated contrary to LEGS (cases) were then compared with matched control limbs (treated according to LEGS), with similar angiographic findings, clinical presentation, preoperative functional status, comorbid conditions and operative technical factors. Outcomes measured at 6 months included arterial reconstruction patency, limb salvage, survival, and maintenance of ambulatory status and independent living status. Kaplan-Meier curves were used to assess patency, limb salvage, and survival; associated survival curves were compared with the log-rank test. Functional outcomes were compared with the Fisher exact test. After matching case limbs with control limbs, 9 limbs had no control match. Thus 113 limbs in 100 patients treated contrary to LEGS were compared with 113 limbs in 100 patients treated according to LEGS. Limbs treated contrary to LEGS resulted in significantly inferior outcomes at 6 months for measures of primary patency (57.5% vs 84.3%; P<.001), secondary patency (73.2% vs 96.2%; P<.001), limb salvage (89.7% vs 97.2%; P = .04), and maintenance of ambulatory status (78% vs 92%; P = .02). As an additional finding, 29.6% (92 of 311) of interventions performed before implementation of the algorithm were treated contrary to LEGS, and thus contrary to objectively determined best therapy, compared with 8.3% (30 of 362) after LEGS implementation (P<.001).

Question: Does a standardization tool to direct invasive therapy for symptomatic lower extremity peripheral arterial disease improve outcomes?

Limbs treated according to our standardization tool resulted in better outcomes compared with limbs treated contrary to the algorithm. These data suggest that routine use of an appropriately validated treatment standardization algorithm is capable of improving overall results for invasive treatment of lower extremity peripheral arterial disease.

Answer the question based on the following context: Upper endoscopy is an invasive procedure. However, the benefits of routinely administered sedative medication or topical pharyngeal anesthesic are controversial. The aim of this study was to clarify their effects on patient tolerance and difficulty of upper endoscopy. A total of 252 patients scheduled for diagnostic upper endoscopy were randomly assigned to 4 groups: (1) sedation with midazolam and placebo pharyngeal spray (midazolam group), (2) placebo sedation and lidocaine pharyngeal spray (lidocaine group), (3) placebo sedation and placebo pharyngeal spray (placebo group), and (4) no intravenous cannula/pharyngeal spray (control group). The endoscopist and the patient assessed the procedure immediately after the examination. Another questionnaire was sent to the patients 2 weeks later. Patients in the midazolam group rated the examination easier and less uncomfortable compared with those in the other groups. The differences were especially evident in the questionnaires completed 2 weeks after the examination ( p<0.001). Lidocaine did not significantly improve patient tolerance. However, endoscopists found the procedure easier in patients in the lidocaine group compared with the midazolam ( p<0.01) and control groups ( p<0.01) but not the placebo group.

Question: Is routine sedation or topical pharyngeal anesthesia beneficial during upper endoscopy?

Routine administration of midazolam for sedation increased patient tolerance for upper endoscopy. However, endoscopists found intubation to be more difficult in sedated vs. non-sedated patients. Topical pharyngeal anesthesia did not enhance patient tolerance, but it did make upper endoscopy technically easier compared with endoscopy in patients sedated with midazolam without topical pharyngeal anesthesia, and in patients who had no sedation or pharyngeal anesthesia, but not in patients who received placebo sedation and placebo pharyngeal anesthesia.

Answer the question based on the following context: The International Society of Nephrologists and Renal Pathology Society (ISN/RPS) classification of lupus nephritis proposes a controversial subclassification of class IV lupus nephritis into IV-segmental (IV-S) and IV-global (IV-G). A retrospective analysis of a biopsy-proven cohort of patients with lupus nephritis using the ISN/RPS classification was performed. The prevalence of class IV was 47% in the cohort of 70 patients with lupus nephritis. Of 33 patients with class IV lupus nephritis, 11 patients had class IV-S and 22 patients had class IV-G. There were no significant differences in age, sex, and ethnicity in the 2 groups. Greater serological activity (lower C4 level) was observed in the IV-S group, whereas serum creatinine levels and diastolic blood pressures were significantly greater in the IV-G group. Hematocrit levels, significant proteinuria (urine protein>or =3 + ), duration of systemic lupus erythematosus, and the Systemic Lupus Erythematosus Disease Activity Index were similar in the 2 groups. Histologically, combined lesions with segmental endocapillary proliferation and fibrinoid necrosis were significantly more frequent in the IV-S group. The percentage of glomeruli with cellular crescents also was greater in the IV-S group, but the difference was not significant. Wire loops were more common in the IV-G group. Transformation to IV-G was observed in 2 of 3 specimens from repeated biopsies available in the IV-S group; greater than 50% of the IV-G group had both segmental and global glomerular involvement. No significant difference was detected in outcomes in the 2 groups after average follow-ups of 38 and 55 months in the IV-S and IV-G groups, respectively.

Question: New subcategories of class IV lupus nephritis: are there clinical, histologic, and outcome differences?

A clinical and prognostic distinction between IV-S and IV-G remains to be proven.

Answer the question based on the following context: Despite evidence supporting anticoagulant use in atrial fibrillation, this modality is not fully utilized. Retrospective chart review of 297 patients with nonvalvular atrial fibrillation between 1997 to 2000. 124 patients received warfarin and 166 did not; 91 patients suffered stroke. Age (P = 0.232) and gender (P = 0.745) were not determinant factors for starting anticoagulation prophylaxis. Whites were more likely to receive anticoagulation therapy than blacks (P = 0.043). Cardiologists were 4.5 times more likely to prescribe warfarin than neurologists and internists (P = 0.035). Neurologists (P = 0.305) and internists (P = 0.770) had similar warfarin prescription patterns and often with patients experiencing the highest rates of stroke.

Question: Clinical correlation between effective anticoagulants and risk of stroke: are we using evidence-based strategies?

Lack of a uniform pattern in anticoagulant administration, despite multiple guidelines, is disturbing. Continuous physician education and community awareness by local and federal medical agencies is essential and cost-effective.

Answer the question based on the following context: What has become of lifestyle differences in a united Europe, where member states become more and more similar on aspects such as welfare systems and population dynamics? In this paper, we try to answer the question whether the gap in lifestyle-related risk factors in Europe has narrowed over the past 30-40 years. Smoking, alcohol consumption, physical activity, obesity and food consumption all have an impact on cancer, cardiovascular disease and other non-communicable diseases. Databases of Eurostat, OECD (Organisation for Economic Co-operation and Development) and the World Health Organisation were screened for data on lifestyle-related risk factors in the European Union, and a literature search was performed for studies that collected international comparable data about the selected factors. The gap in European lifestyle has narrowed over the past 30-40 years for smoking (women), alcohol consumption and total fat intake. For fruit and vegetable consumption, convergence is not occurring. For some risk factors, such as smoking and obesity, intranational differences surpass the international differences.

Question: Lifestyle-related risks: are trends in Europe converging?

The results support the notion of convergent lifestyles among Europeans over time. We also found that there is a serious lack of reliable data on lifestyle-related risk factors that are suitable for international comparison. It is essential to invest in reliable and internationally comparable data, obtained according to best evidence, to get more insight into real differences regarding risk factors in Europe. The European Public Health programme may be an opportunity to realize these goals.

Answer the question based on the following context: Patients with acute hepatic failure (AHF) were always given first priority on the transplant waiting list. We investigated whether AHF patients will deprive other patients on the waiting list of the chance of liver transplantation (LTx). From January 1999 to March 2003, a total of 423 patients were on the transplant waiting list at the National Taiwan University Hospital. Sixty-five of the patients had AHF caused by hepatitis-B-related disease (HBV, n = 52, 80%), Wilson disease (n = 3, 4.6%), drug-induced AHF (n = 3, 4.6%), and other causes (n = 7, 10.8%).Thirty-three patients died and 16 survived by medical treatment. Two received LTx abroad and 14 underwent LTx at our hospital (7 living-related; 7 cadaver). A total of 140 patients died while waiting for a transplant during the period studied. Of them, 107 were among 358 non-AHF patients (30%), and time-to-death interval was 133 +/- 175 days (median: 62); 33 were among 65 AHF patients (51%); time to death was 19 +/- 28 days (median: 8). There were 35 cadaver donor livers available during the period; 28 of 358 non-AHF patients (7.8%), and 7 of 65 AHF patients (10.7%) received cadaveric LTx. Their waiting time totaled 342 +/- 316 and 12 +/- 9 days, respectively (P<.0001).

Question: Do patients with acute liver failure have a better chance to receive liver grafting?

Most AHF patients died unless they received liver grafts. Even with a higher priority assigned to them, AHF patients still have little chance to get a cadaver donor liver in Taiwan, and non-AHF patients have an even slimmer chance. Therefore, we need to encourage liver donation from living-related donors.

Answer the question based on the following context: The Milan criteria, namely, tumors 5 cm or less in diameter in patients with single hepatocellular carcinoma (HCC), no more than 3 tumor nodules, and each 3 cm or less in diameter in patients with multiple tumors, are accepted for cadaveric liver allocation. However, in living donor liver transplantation (LDLT), graft donation may only depend on the donor's intention. The aim of this study was to elucidate the feasibility of Milan criteria in LDLT. From January 2001 to December 2002, 46 cases of liver transplantation (LT) for HCC included 5 hospital mortalities and 3 cadaveric transplantations, all of which were excluded. We classified the patients into Group I cases that met the Milan criteria and Group II cases that did not meet the Milan criteria. The analyses examined tumor-related risk factors affecting recurrence and survival, such as tumor size, number of tumor nodules, and presence of microvascular and macrovascular invasion. Twenty-one cases belonged to Group I and 17 to Group II. There was no significant difference in the recurrence or survival rates between Groups I and II. The risk factors affecting recurrence were macrovascular invasion and tumor size (5 cm). The number of tumor nodules and microvascular invasion did not appear to affect recurrence. The risk factor affecting survival was macrovascular invasion.

Question: Can we expand the Milan criteria for hepatocellular carcinoma in living donor liver transplantation?

We suggest that in selected cases the Milan criteria could be extended to increase the number of tumor nodules as long as the HCC were small and did not macrovascular invasion.

Answer the question based on the following context: Genetic modification of donor dendritic cells (DC) is a potential therapy for allograft rejection. We hypothesized that in vitro interleukin-10 (IL)-10-transfected DC (DC-IL-10) may induce allogeneic T-cell apoptosis, resulting in prolonged allograft survival rat small intestine. Myeloid DC from Wistar-Furth rats (RT-1u) were propagated with rrGM-CSFand rrIL-4,then genetically modified to express the hIL-10 gene. Secretion of IL-10 was quantitated by enzyme-linked immunosorbent assay (ELISA). Allogeneic T cells from Lewis (LEW; RT-1(l)) at proliferative responses were determined by MTT assay in primary mixed leukocyte reactions. We then used a combination of DNA agarose gel electrophoresis, acridine orange staining, and Annexin V/propridium iodide assays to examine apoptosis of allogeneic T cells exposed to DC-IL-10. Then 5 x 10(6) donor-derived DC-IL-10 or untransduced DC were injected intravenously 7 days before small intestine transplantation (WF-->LEW). DC-IL-10 showed pronounced impairment of T-cell allostimulatory activity. Apoptotic T cells were detected in the DC-IL-10 group. Flow cytometry counting at 72 hours showed 45.1% apoptotic T cells in response to DC-IL-10, whereas the untransduced group did not undergo significant apoptosis (P<.01). DC-IL-10 pretreated recipients showed moderate prolongation of allograft survival compared with controls (20.7 +/- 6.0 days vs 7.5 +/- 2.2 days, P<.01).

Question: Allogeneic T-cell apoptosis induced by interleukin-10-modified dendritic cells: a mechanism of prolongation of intestine allograft survival?

DC-IL-10 induced allogeneic T-cell hyporesponsiveness in vitro, possibly due to apoptosis. DC-IL-10 pretreated recipients displayed prolonged intestinal allograft survival rates.

Answer the question based on the following context: The results of studies evaluating the effect of hormone replacement therapy (HRT) on the cardiovascular risk raise many controversies. This may be related to both the type of treatment used and the disregard of additional risk factors. The objective of the study was to evaluate the effect of natural estrogens taken transdermally and synthetic estrogens taken orally on the concentrations of lipoprotein (a) [Lp(a)], homocysteine, and C-reactive protein (CRP) in healthy women in the early postmenopausal period. Material The study was conducted on 61 healthy women with average age of 52.3 +/- 4.1 years, in the postmenopausal period, who were randomly assigned to 3 groups depending on the type and route of administration of the products. Group I (n = 24) was administered transdermal estrogens (micronized 17beta-estradiol; Systen, Janssen-Cilag, Switzerland) and progesterone in the second phase of the cycle. Group II (n = 21) was administered oral hormones (Cyclo-Menorette). Group III (n = 16), serving as a control, included women taking placebo in the form of patches. In each group, therapeutic cycles took 22 days and were followed by a treatment-free interval of 7 to 10 days for a 3-month period. After 3 months of treatment, Lp(a) and homocysteine levels were not significantly different from the baseline, irrespective of the route of administration of estrogens or placebo. Both forms of HRT used indicate significant difference in changes of CRP concentration during 3 months of administration (analysis of variance P = .0356). CRP concentration values increased in the group of women using oral HRT from 1.22 to 2.68 mg/L. In the group of women using oral therapy, significantly more cases (61%) of increase in CRP concentration compared with 39% in the transdermal HRT group (chi(2) P = .015) were observed.

Question: Does the type of hormone replacement therapy affect lipoprotein (a), homocysteine, and C-reactive protein levels in postmenopausal women?

On the basis of our observations, it appears that in women in the early postmenopausal stage with normal initial concentrations of Lp(a) and homocystein, the form of therapy used has no influence on values of these parameters. The 2 forms of HRT therapy differ in effect, which is expressed as a change in CRP concentration. A tendency to increase CRP values when using oral HRT is observed, while such an effect is not observed in case of transdermal therapy after 3 months.

Answer the question based on the following context: To determine the membrane lipid peroxidation of human spermatozoon in a cohort of smokers in comparison of never-smokers. Malondialdehyde (MDA), a stable product of the membrane lipid peroxidation, was assessed in 25 smokers and in 17 never-smokers. In parallel, an evaluation of sperm characteristics was realized for all the studied patients. For the first time, between smokers and never-smokers, a significative increase of MDA concentrations was found by the U-Mann and Whitney test (0.118 +/- 0.176 vs 0.0392 +/- 0.0117 nmol/10(6) spermatozoa), a decrease of the forward motility (grade A), (18 +/- 8 vs 25 +/- 8%) and total sperm count (265.56 +/- 186.96 x 10(6) vs 399.30 +/- 322.23 x10(6)), and also an increase of tapering heads (6 +/- 4 vs 2 +/- 2%) or morphological stress pattern cells (39 +/- 6 vs 24 +/- 5%). In the smokers group, negative significative correlations were found by the non-parametric Spearman test between the MDA concentrations and the sperm count per mL (r=-0.767, p<0.001), the total sperm count (r=-0.656, p<0.001) and the percentage of normal morphology (r=-0.644, p<0.001).

Question: Tobacco: a potential inductor of lipid peroxidation of the human spermatozoon membrane?

Given of deleterious effects of tobacco in a large panel of human cells and specially on the male gametes, the increase of spermatozoon membrane MDA concentrations and the sperm abnormalities found in the group of smokers may be linked to cigarette smoking.

Answer the question based on the following context: To quantify the clinical consistency of expert panelists' ratings of appropriateness of pre-operative and post-operative chemotherapy plus radiation for rectal cancer. A panel of nine physicians (two surgeons, four medical oncologists, three radiation oncologists) rated the appropriateness of providing pre-operative and post-operative treatments for rectal cancer, utilizing a modified-Delphi (RAND/UCLA) approach. Clinical scenarios were paired so that each component of a pair differed by only one clinical feature (e.g. tumor stage). A pair of appropriateness ratings was defined as inconsistent when the clinical scenario that should have had the higher (or at least equal) appropriateness rating was given a lower rating. The rate of inconsistency was analyzed for panelists' ratings of pre- and post-operative chemotherapy plus radiation. The final panel rating was inconsistent for 1.19% of pre-operative scenario pairs, and 0.77% of post-operative scenario pairs. Using the conventional RAND/UCLA definition of appropriateness, the magnitude of the inconsistency would produce inconsistent appropriateness ratings in 0.43% of pre-operative and 0.11% of post-operative scenario pairs. There was significant variation in the rate of inconsistency among individual panelists' final ratings of both pre-operative (range: 0.43-5.17%, P<0.001) and post-operative (range: 0.51-2.34%, P<0.001) scenarios. Panelists' overall average rate of inconsistency improved significantly after the panel meeting and discussion (from 5.62 to 2.25% for pre-operative scenarios, and from 1.47 to 1.24% for post-operative scenarios, both P<0.05). There was no clear difference between specialty groups. Inconsistency was related to the structure of the rating manual: in the second round there were no inconsistent ratings when scenario pairs occurred on the same page of the manual.

Question: The consistency of panelists' appropriateness ratings: do experts produce clinically logical scores for rectal cancer treatment?

The RAND/UCLA appropriateness method can produce ratings for cancer treatment that are highly clinically consistent. Modifications to the structure of rating manuals to facilitate direct assessment of consistency at the time of rating may reduce inconsistency further.

Answer the question based on the following context: To assess the effectiveness of a primary care referral scheme on increasing physical activity at 1 year from referral. Design Two-group randomized controlled trial recruiting primary care referrals to a borough-based exercise scheme. Setting A local authority borough in the north-west of England. Participants 545 patients defined as sedentary by a primary care practitioner. Intervention Referral to a local-authority exercise referral scheme and written information compared with written information only. Main outcome measures Meeting physical activity target at 12 months following referral, with a secondary outcome measured at 6 months from referral. At 12 months, a non-significant increase of 5 per cent was observed in the intervention compared with control group, for participation in at least 90 minutes of moderate/vigorous activity per week (25.8 versus 20.4 per cent, OR 1.45, 0.84 to 2.50, p = 0.18). At 6 months, a 10 per cent treatment effect was observed which was significant (22.6 versus 13.6 per cent, OR 1.67, 1.08 to 2.60, p = 0.05). The intervention increased satisfaction with information but this did not influence adherence with physical activity.

Question: Does primary care referral to an exercise programme increase physical activity one year later?

Community-based physical activity referral schemes have some impact on reducing sedentary behaviour in the short-term, but which is unlikely to be sustained and lead to benefits in terms of health.

Answer the question based on the following context: Cross sectional survey of households from private dwellings, conducted by the Australian Bureau of Statistics (ABS), using a stratified multistage area sample design. Australia, 1998-99. Nationally representative sample of households (n = 6892). Expenditure on meals at restaurants, alcohol, alcoholic beverages at licensed premises, gambling, and insurance. The odds of reporting expenditure on restaurant food and health insurance were 20% and 40% smaller for smoking than non-smoking households, respectively. The odds of reporting expenditure on alcohol (not including expenditure at licensed premises), drinking at licensed premises, and gambling were 100%, 50%, and 40% greater for smoking than for non-smoking households, respectively.

Question: Is household smoking status associated with expenditure on food at restaurants, alcohol, gambling and insurance?

The study suggests that smokers are more likely to engage in risky behaviour. Implementing smoking bans in licensed premises and gambling venues can provide an opportunity to reduce smoking prevalence. Quitting or cutting down smoking can provide opportunities for expenditure on other products or services, and enhance standards of living.

Answer the question based on the following context: Although analysis of the transmitral inflow (TMF) pattern is widely used for evaluating left ventricular diastolic function and provides valuable information for the management of heart failure (HF) in sinus rhythm, its utility in patients with atrial fibrillation (AF) has not been established. The aim of this study was to investigate the relationship between the ratio of transmitral peak E-wave velocity to flow propagation velocity (E/Vp) obtained by a newly developed dual Doppler system and the plasma B-type natriuretic peptide (BNP) concentration or pulmonary capillary wedge pressure (PCWP) for evaluating the severity of heart failure with AF. In 68 patients with AF, the E/Vp was compared with plasma BNP concentration and PCWP. A cutoff value of>or =1.7 for E/Vp predicted a plasma BNP concentrationl of>or =200 pg/ml, with 80% sensitivity and 84% specificity. Only E/Vp was found to be independently significant by stepwise multilinear regression analysis (r=0.40, p=0.01). PCWP values had good correlation with E/Vp (r=0.63, p<0.01) and were significantly higher in the group with E/Vp>/=1.7 (16+/-6 mmHg vs 11+/-4 mmHg, p<0.05).

Question: Is the ratio of transmitral peak E-wave velocity to color flow propagation velocity useful for evaluating the severity of heart failure in atrial fibrillation?

The Doppler-derived index of E/Vp correlated well with the neurohormonal and hemodynamic parameters, and was useful for evaluating the severity of heart failure with AF.

Answer the question based on the following context: Eosinophils are important components of allergic inflammation. The immunoglobulin A (IgA) Fc receptor (FcalphaRI), encoded by the FCAR gene, is a possible candidate for eosinophil activation at mucosal surfaces, where IgA is abundant. Both elevated cell surface expression of FcalphaRI and increased avidity for IgA were described on eosinophils from allergic subjects. The aim of our study was to examine the possible association of FCAR gene polymorphisms with allergic asthma. We screened three regions of the FCAR gene: (1) the promoter region, (2) exon 3, encoding the first extracellular domain (EC1), and (3) exon 5, coding for the transmembrane and cytoplasmic domain, for new and published polymorphisms using a sensitive temperature gradient gel electrophoresis technique and compared their frequencies in 112 patients diagnosed with allergic asthma and 100 healthy controls. Six polymorphisms, including two novel ones, were detected. No differences between patients and controls were found in the distribution of any of these polymorphisms.

Question: Are single nucleotide polymorphisms of the immunoglobulin A Fc receptor gene associated with allergic asthma?

FcalphaRI polymorphism does not seem to be a risk factor in allergic asthma. Nevertheless, this is the first report on the distribution of 6 single nucleotide polymorphisms of the FCAR gene in a human population and the first study on FCAR polymorphism in allergic asthma.

Answer the question based on the following context: Small bowel diverticulum is a rare disease that can be found incidentally during a surgical operation. Since reported complication rate is low, uncomplicated small bowel diverticula are generally recommended to be untreated. The aim of this study was to elucidate clinical features of this disease and to determine whether incidental small bowel diverticula should be removed for cure. We reviewed the medical records of 80 patients with small bowel diverticular disease who underwent operation at Asan Medical Center between July 1989 and March 2003, retrospectively. Male to female ratio was 61:19, and the mean age was 44 (0-91) years. The most common diverticulum of small bowel is Meckel's diverticulum (63.8%), followed by duodenal diverticulum (15%), jejunal diverticulum (12.5%), and ileal diverticulum (8.7%). Of the 80 cases, 43 (53.7%) were symptomatic, and 37 (46.3%) were incidental. In the symptomatic patients, the most frequent symptom was abdominal pain (58.1%), followed by bleeding (44.2%). As for the treatments, segmental resection (53.7%) was performed more commonly than diverticulectomy (43.8%) in the symptomatic patients. Postoperative complications occurred more commonly in the symptomatic patients (25.6%) than the incidental patients (8.1%). Duodenal diverticula had a high morbidity and mortality rate.

Question: Should small bowel diverticula be removed?

We should consider the diverticular disease of small bowel in patients with unexplained abdominal pain or gastrointestinal bleeding. As most small bowel diverticula, except for duodenal diverticula, are found incidentally and easily removed without postoperative morbidity or mortality, surgical resection appears to be recommended for the purpose of accurate diagnosis and treatment.

Answer the question based on the following context: Multicentered randomized controlled trial. To determine if previously validated low back pain (LBP) subgroups respond differently to contrasting exercise prescriptions. The role of "patient-specific" exercises in managing LBP is controversial. A total of 312 acute, subacute, and chronic patients, including LBP-only and sciatica, underwent a standardized mechanical assessment classifying them by their pain response, specifically eliciting either a "directional preference" (DP) (i.e., an immediate, lasting improvement in pain from performing either repeated lumbar flexion, extension, or sideglide/rotation tests), or no DP. Only DP subjects were randomized to: 1) directional exercises "matching" their preferred direction (DP), 2) exercises directionally "opposite" their DP, or 3) "nondirectional" exercises. Outcome measures included pain intensity, location, disability, medication use, degree of recovery, depression, and work interference. A DP was elicited in 74% (230) of subjects. One third of both the opposite and non-directionally treated subjects withdrew within 2 weeks because of no improvement or worsening (no matched subject withdrew). Significantly greater improvements occurred in matched subjects compared with both other treatment groups in every outcome (P values<0.001), including a threefold decrease in medication use.

Question: Does it matter which exercise?

Consistent with prior evidence, a standardized mechanical assessment identified a large subgroup of LBP patients with a DP. Regardless of subjects' direction of preference, the response to contrasting exercise prescriptions was significantly different: exercises matching subjects' DP significantly and rapidly decreased pain and medication use and improved in all other outcomes. If repeatable, such subgroup validation has important implications for LBP management.

Answer the question based on the following context: Office blood pressure (OBP) and home blood pressure (HBP) enable the identification of patients with masked hypertension. Masked hypertension is defined by normal OBP and high HBP and is known as a pejorative cardiovascular risk factor. The objective was to evaluate in the SHEAF study the influence of the number of office or home blood pressure measurements on the classification of patients as masked hypertensives. Patients with OBP<140/90 mmHg (mean of six values: three measurements at two separate visits, V1 and V2) and HBP>135/85 mmHg (mean of all valid measurements performed over a 4-day period) were the masked hypertensive reference group. The consistency of the classification was evaluated by using five definitions of HBP values (mean of the 3, 6, 9, 12 and 15 first measurements) and two definitions of OBP values (mean of three measurements at V1 and mean of three measurements at V2). Among the 4939 treated hypertensives included in the SHEAF study, 463 (9.4%) were classified as masked hypertensives (reference group). By decreasing the number of office or home measurements, the prevalence of masked hypertension ranged from 8.9-12.1%. The sensitivity of the classification ranged from 94-69% therefore 6-31% of the masked hypertensives were not detected. The specificity ranged from 98-94% therefore 1-6% of patients were wrongly classified as masked hypertensives.

Question: Detection of masked hypertension by home blood pressure measurement: is the number of measurements an important issue?

A limited number of home and office BP measurements allowed the detection of masked hypertension with a high specificity and a low sensitivity. A sufficient number of measurements (three measurements at two visits for OBP and three measurements in the morning and in the evening over 2 days for HBP) are required to diagnose masked hypertension.

Answer the question based on the following context: There is a striking need for additional therapies of bone marrow oedema (BME) and aseptic osteonecrosis (AON) in paediatric oncology patients. Hyperbaric oxygenation (HBO) therapy used in the treatment of osteoradionecrosis is demonstrated effectiveness. Aim of this retrospective analysis was to investigate whether HBO-therapy might lead to subjective as well as objective effects in the treatment of BME and/or AON in paediatric oncology patients with acute lymphoblastic leukaemia (ALL) or Non-Hodgkin lymphoma (NHL). Between 11/1988 and 01/2001 27/291 (9.3 %) patients with ALL or NHL were diagnosed with a BME and/or AON in the Clinic for Paediatric Oncology, Haematology, and Immunology at University of Dusseldorf. 19/27 patients were submitted to HBO-therapy. Patients received average 45 HBO-treatments per patient (min. 13, max. 80 treatments). The affected regions were re-evaluated with MRI for radiological extent of lesions every 3 months. Pain in its intensity and localisation was serially recorded during HBO-therapy as key symptom in 11 of 19 patients. 27 patients (15 females, 12 males; mean age at diagnosis of malignancy 8.2 +/- 4.7 (SD) years, range 7 months to 16 years) presented with 138 lesions. 133/138 lesions were localised in the lower extremities. At diagnosis of BME and/or AON, 78/133 lesions were shown in females and 55/133 lesions in male. Girls<10 years predominantly presented BME (33 BME vs. 6 AON), girls aged>10 years predominantly offered AON (28 AON vs. 11 BME). BME was more often exhibited in boys<10 years (34 BME vs. 10 AON) and rarely in boys>10 years (4 BME vs. 6 AON). 11 patients treated with HBO-therapy were serially evaluated for pain intensity throughout their HBO-therapy courses by visual analogue scale (VAS) assessment. During the first 15 treatment courses the HBO-therapy a clear-cut reduction of pain was observed. The mean pain score before the first HBO-treatment unit was 2.4 +/- 2.7 (X +/- SD), decreased before the fifth to 1.6 +/- 1.7 and prior to the 35 (th) and 40 (th) HBO treatment to 0. Girls<10 years treated with HBO showed an increase of BME (31 -->46) and declining AON numbers (6 -->2). Girls>10 years with and without HBO-therapy showed decrease of BME lesions (7 -->4 vs. 4 -->0), whereas AON increased in the HBO-treated group (28 -->29) as well as the non-treated group (0 -->4). Males<10 years showed an increase in BME lesion numbers despite HBO intervention (24 -->26). The AON lesion numbers dropped in parallel (6 -->3). Male patients not treated with HBO showed constant numbers of BME (11-->11) and a decreased numbers of AON (4 -->2). All differences are statistically not significant.

Question: Bone marrow oedema and aseptic osteonecrosis in children and adolescents with acute lymphoblastic leukaemia or non-Hodgkin-lymphoma treated with hyperbaric-oxygen-therapy (HBO): an approach to cure?

Children and adolescents diagnosed with ALL or NHL have a risk for accruement of BME and/or AON irrespective of the age, with an almost exclusive involvement of the lower extremities. Lesions of pedal bones and ankle joints predominantly affect children<10 years. Lesions of knee and hip joints predominantly affect children>10 years. In children<10 years of age we demonstrate declining AON numbers and conversion of AON to BME thereby implicating possible beneficial effect of HBO in such patients. HBO failed to show beneficial effect on BME whether by preventing new lesions or by improving existent lesions in children>10 years.

Answer the question based on the following context: Early and late results of surgical palliation for unresectable periampullary neoplasms were evaluated in 24 patients older than 70 years and compared with the same results obtained from 33 younger patients. The two groups of patients were comparable, except for age. Biliary bypass associated to gastric bypass was the most common performed procedure. No significant differences in the results (morbidity, mortality, and outcome) were found in the two groups of patients. In addition, the results of palliative surgery in the elderly were compared with those obtained from a comparable group of 35 patients palliated with endoscopic stent insertion: surgical palliation resulted in better long-term results.

Question: Is the chronologic age a contra-indication for surgical palliation of unresectable periampullary neoplasms?

This study provides evidence that the chronologic age is not a contra-indication for surgical palliation of periampullary neoplasms and that surgery provides a better quality of residual life.

Answer the question based on the following context: In order to treat children with Attention-deficit/Hyperactivity Disorder (ADHD) with a once-a-day stimulant several galenic approaches have been tried. The long acting methylphenidate (MPH, Medikinet-Retard) is a preparation with a two-step dynamic to release MPH (step one: acute; step two: prolonged). The efficacy of Medikinet-Retard, a new long-acting methylphenidate preparation, is analyzed based on the assessment of parents in the afternoon. In a multicenter drug treatment study (placebo controlled, randomized, double-blind) 85 children (normal intelligence, age 6 to 16 years, diagnosis of ADHD according to DSM-IV) were investigated over 4 weeks with weekly visits. Forty-three children received Medikinet-Retard and forty-two children placebo. The weekly dose titration depending on body weight and symptomatology allowed a final maximum of 60 mg. The effects on ADHD as perveived by the parents were assessed weekly with a German symptom checklist for ADHD according to DSM-IV and ICD-10 (FBB-HKS). The differences between baseline and last week of treatment were compared statistically between groups. There was a large and statistically significant positive drug effect on ADHD symptomatology. The effect size of these differences was d = 1.2 (total score). Effects were found on inattention, hyperactivity and impulsity on the respective subscales. The efficacy of Medikinet-Retard was evaluated by the parents on an average as good. The rate of responders was four-times higher in the verum-group. The correlations of the changed scores in the parent ratings with the respective change scores in the teacher ratings were in the medium range.

Question: Does a morning dose of Methylphenidate Retard reduce hyperkinetic symptoms in the afternoon?

This is the first study with a German long-acting methylphenidate preparation (Medikinet-Retard). According to data based on parents' assessments, the drug showed very good clinical efficacy and safety in children with ADHD. Its two step galenic release of methylphenidate seems to be appropriate for a once-a-day (morning) stimulant in schoolchildren.

Answer the question based on the following context: To analyze specialist doctors' opinions, attitudes and habits with respect to e-health, and the repercussions of these factors on doctor/patient relations. Use of a survey to analyse attitudes, Internet use, habits and opinions about the advantages and disadvantages of the Internet among 302 doctors in eight Spanish hospitals. Of the doctors surveyed, 80% have access to and use the Internet. Almost 40% use the Internet for less than one hour a day; doctors in smaller hospitals spend more time on the Internet and men spend more time than women. The most frequently visited websites are PubMed (11%) and Google (22%); when choosing a website, periodical updating and prestige are important to 78% and 69%, respectively; 37% have taken a course through the Internet; 35% consult electronic journals systematically; 16% regularly collaborate with, or write materials for healthcare websites; 12% receive electronic mail from their patients. Three clusters of information were generated in this study to classify the participating hospital doctors: the different types of information the doctors consulted, the way the Internet enhances doctor/patient relations and the aspects that the doctors consider relevant when connecting to the Internet.

Question: Are Spanish physicians ready to take advantage of the Internet?

Spanish doctors consider the Internet to be a tool that enhances doctor/patient relations. New technologies are accelerating the substitution of a paternalistic model by ones where the patient has access to more information and resources. There appears to be a favourable attitude towards seeking a second opinion through the Internet, although not towards patients' 'chats'.

Answer the question based on the following context: Patient-centered care requires clinicians to recognize and act on patients' expectations. However, relatively little is known about the specific expectations patients bring to the primary care visit. To describe the nature and prevalence of patients' specific expectations for tests, referrals, and new medications, and to examine the relationship between fulfillment of these expectations and patient satisfaction. Prospective cohort study. VA general medicine clinic.PATIENTS/ Two hundred fifty-three adult male outpatients seeing their primary care provider for a scheduled visit. Fifty-six percent of patients reported at least 1 expectation for a test, referral, or new medication. Thirty-one percent had 1 expectation, while 25% had 2 or more expectations. Expectations were evenly distributed among tests, referrals, and new medications (37%, 30%, and 33%, respectively). Half of the patients who expressed an expectation did not receive one or more of the desired tests, referrals, or new medications. Nevertheless, satisfaction was very high (median of 1.5 for visit-specific satisfaction on a 1 to 5 scale, with 1 representing "excellent"). Satisfaction was not related to whether expectations were met or unmet, except that patients who did not receive desired medications reported lower satisfaction.

Question: Do unmet expectations for specific tests, referrals, and new medications reduce patients' satisfaction?

Patients' expectations are varied and often vague. Clinicians trying to implement the values of patient-centered care must be prepared to elicit, identify, and address many expectations.

Answer the question based on the following context: To investigate patient preferences for a patient-centered or a biomedical communication style. Randomized study. Urgent care and ambulatory medicine clinics in an academic medical center. We recruited 250 English-speaking adult patients, excluding patients whose medical illnesses prevented evaluation of the study intervention. Participants watched one of three videotaped scenarios of simulated patient-physician discussions of complementary and alternative medicine (CAM). Each participant watched two versions of the scenario (biomedical vs. patient-centered communication style) and completed written and oral questionnaires to assess outcome measurements. Main outcome measures were 1) preferences for a patient-centered versus a biomedical communication style; and 2) predictors of communication style preference. Participants who preferred the patient-centered style (69%; 95% confidence interval [CI], 63 to 75) tended to be younger (82% [51/62]for age<30; 68% [100/148] for ages 30-59; 55% [21/38]for age>59; P<.03), more educated (76% [54/71] for postcollege education; 73% [94/128]for some college; 49% [23/47] for high school only; P= .003), use CAM (75% [140/188]vs. 55% [33/60] for nonusers; P= .006), and have a patient-centered physician (88% [74/84]vs. 30% [16/54] for those with a biomedical physician; P<.0001). On multivariate analysis, factors independently associated with preferring the patient-centered style included younger age, use of herbal CAM, having a patient-centered physician, and rating a "doctor's interest in you as a person" as "very important."

Question: Patient-centered communication: do patients really prefer it?

Given that a significant proportion of patients prefer a biomedical communication style, practicing physicians and medical educators should strive for flexible approaches to physician-patient communication.

Answer the question based on the following context: Compared to whites, African Americans have been found to have greater morbidity and mortality from HIV, partly due to their lower use of effective antiretroviral therapy. Why racial disparities in antiretroviral use exist is not completely understood. We examined whether racial concordance (patients and providers having the same race) affects the time of receipt of protease inhibitors. We analyzed data from a prospective, cohort study of a national probability sample of 1,241 adults receiving HIV care with linked data from 287 providers. We examined the association between patient-provider racial concordance and time from when the Food and Drug Administration approved the first protease inhibitor to the time when patients first received a protease inhibitor. In our unadjusted model, white patients received protease inhibitors much earlier than African-American patients (median 277 days compared to 439 days; P<.0001). Adjusting for patient characteristics only, African-American patients with white providers received protease inhibitors significantly later than African-American patients with African-American providers (median 461 days vs. 342 days respectively; P<.001) and white patients with white providers (median 461 vs. 353 days respectively; P= .002). In this model, no difference was found between African-American patients with African-American providers and white patients with white providers (342 vs. 353 days respectively; P>.20). Adjusting for patients' trust in providers, as well as other patient and provider characteristics in subsequent models, did not account for these differences.

Question: Does racial concordance between HIV-positive patients and their physicians affect the time to receipt of protease inhibitors?

Patient-provider racial concordance was associated with time to receipt of protease inhibitor therapy for persons with HIV. Racial concordance should be addressed in programs, policies, and future racial and ethnic health disparity research.

Answer the question based on the following context: CD146 is a novel cell adhesion molecule localized at the endothelial junction. Its increased plasma levels in chronic renal failure are linked to endothelial dysfunction. Endothelial dysfunction and hemostatic disturbances, a common feature of nephrotic syndrome (NS), mimics a state of protein loosing by peritoneal membrane in patients on chronic ambulatory peritoneal dialyses (CAPD). The aim of the study was to assess CD146 in relation to other markers of endothelial cell injury in patients with NS in comparison to patients on CAPD. We studied 45 CAPD patients, 43 patients with nephrotic syndrome and 25 healthy volunteers. Markers of endothelial cell injury: TFPI total, full length, truncated, von Willebrand factor, trombomodulin, P-selectin, E-selectin, ICAM, VCAM and CD146 were assessed using commercially available kits. All these markers studied except selectins were significantly elevated in patients with NS and CAPD when compared to the healthy volunteers. In CAPD, VCAM, thrombomodulin and CD146 were significantly elevated over NS patients. CD146 correlated significantly with ICAM as well as total and truncated TFPI in CAPD patients. Moreover, total TFPI was positively related to VCAM. CD146 correlated with ICAM in NS, whereas in healthy volunteers CD146 correlated only with TFPI concentration.

Question: Is there a link between CD146, a novel adhesion molecule and other markers of endothelial dysfunction in nephrotic syndrome and continuous ambulatory peritoneal dialysis?

Our studies indicate that in nephrotic patients, as well as in CAPD, there is an evidence of endothelial cell injury. Correlations between CD146 and adhesion molecules and TFPI might further support its use as a endothelial cell function marker.

Answer the question based on the following context: The superior patency of ITA grafts to saphenous veins is conclusive. The aim of the study was to collate mid-term benefit between patients receiving bilateral ITA (BITA) or single ITA (SITA). Outcome of 1378 pts with isolated CABG operated between 1/97-8/99 was analyzed retrospectively. Follow-up was 4.0 to 6.6 years (average 5.3). A total of 716 pts received BITA, 662 SITA and additional saphenous veins. We evaluated mortality rate, freedom from reoperation, intervention (PTCA/stent), and incidence of cardiac events and quality of life with respect to pts risk factors. Demographic data: Male gender was more frequent in both groups (BITA females: n=115; males: n=601; SITA females: n=150; males: n=512; p<0.01). Mean age was comparable in both groups with 69.2 years (42.7 to 88.6 years) in the BITA group and 71.0 years (47.3 to 91.6 years) (n. s.) in the SITA group. Incidence of diabetes mellitus (26.0 vs 25.9%) as well as the mean BMI (27.4 vs 27.0%) did not differ statistically in both groups. Clinical characteristics like NYHA/ CCS classifications showed a significant difference towards superior results only for stadium I in the BITA group. Mortality/cardiac events after 5.3 years average: Total mortality revealed 5.2% (n=37) in the BITA vs 9.1% (n=60) in the SITA group (p</=0.005). The cardiac-related mortality was 0.7% (n=5) in the BITA and 2.0% (n=13) in the SITA group (p<0.05). The non-cardiac-related mortality did not differ significantly (2.7 vs 2.9%). The incidence of redo-operations was 0.1% (BITA) vs 0.6% (SITA) (n. s). Cardiac interventions like PTCA or stent were performed in 3.1% (BITA) vs 4.7% (SITA) or 3.7% (BITA) vs 4.2% (SITA) (n. s.) respectively. Infarction-rate was 2.0% in the BITA and 3.0% in the SITA group (n. s.).

Question: Double thoracic artery--halved mid-term mortality?

Mid- to long-term benefit of patients receiving bilateral ITA is superior to those with single ITA. Cardiac-related mortality and incidence of reoperation was reduced to less than half after BITA grafting. Freedom from cardiac interventions (PTCA/stent), NYHA/CCS classifications and quality of life were rarely influenced by BITA frequency.

Answer the question based on the following context: Conflicting results on the association of pityriasis rosea and human herpesvirus 7 infection have been reported by different investigators.AIM: To review the level of evidence for such an association. Medline was searched with unlimited data entry and 13 reports were retrieved. The data were analyzed for a causative association according to the criteria of Fredericks and Relman, which take into consideration latent infection and the reactivation of viruses characteristic of herpesviruses, and the roles of sequence-based detection methods. None of the criteria was substantiated by the findings of most investigators. Factors leading to the discrepancies of the results were discussed.

Question: Is human herpesvirus 7 the causative agent of pityriasis rosea?

There is currently insufficient evidence that human herpesvirus 7 infection is causally related to pityriasis rosea.

Answer the question based on the following context: The accuracy of physicians' assessment of the severity of gastro-oesophageal reflux disease is unclear.AIM: To correlate physician and patient assessment of gastro-oesophageal reflux disease severity and its response to treatment. Adult uninvestigated gastro-oesophageal reflux disease patients (n = 217) completed symptom and health-related quality of life questionnaires at baseline and after treatment with esomeprazole 40 mg p.o. daily. Pearson coefficients quantified correlations between physician assessments and patient responses. At baseline, the strongest correlations were heartburn severity (0.31), overall symptom severity (0.44) and a domain of the quality of life in reflux and dyspepsia questionnaire (0.31) (P<0.001). Correlations of change with treatment were greater than baseline correlations: heartburn (0.39), overall symptoms (0.50) and global rate of change -- stomach problems (0.72, all P<0.001). The mean difference between the physicians' assessment of change and the patients' global rating of change was 0.20 (95% confidence intervals: 0.10-0.29) with physicians overestimating benefit.

Question: Do physicians correctly assess patient symptom severity in gastro-oesophageal reflux disease?

Correlations were often significant, although weak to moderate and better with symptom severity than with health-related quality of life instruments as well as with change after therapy than at baseline. Increasing attention to health-related quality of life may help physicians better understand patients' experience. In clinical trials, treatment success should be assessed by the patient as well as the physician.

Answer the question based on the following context: Many terminally ill patients enroll in a hospice late in their illness, and recent data indicate decreasing lengths of hospice enrollment, yet we know little about the impact of hospice enrollment length on surviving caregivers. This is the first study the authors know of that examines the association between hospice enrollment length and subsequent major depressive disorder among surviving caregivers. The authors conducted a prospective cohort study with 174 primary family caregivers of consecutively enrolled hospice patients with cancer between October 1999 and September 2001. Using data from in-person interviews at the time of enrollment and 6-8 months after the patient's death, they estimated with logistic regression the adjusted risk of major depressive disorder with the Structured Clinical Interview for the DSM-IV axis I modules based on the number of days of hospice care before death. Caregivers of patients enrolled with hospice for 3 or fewer days were significantly more likely to have major depressive disorder at the follow-up interview than caregivers of those with longer hospice enrollment (24.1% versus 9.0%, respectively), adjusted for baseline major depressive disorder and other potential confounders.

Question: Depression among surviving caregivers: does length of hospice enrollment matter?

The findings identify a target group for whom bereavement services might be most needed. The authors also suggest that earlier hospice enrollment may help reduce the risk of major depressive disorder during the first 6-8 months of bereavement, which raises concerns about recent trends toward decreasing lengths of hospice enrollment before death.

Answer the question based on the following context: An extensive literature has demonstrated a relationship between hospital volume and outcomes for surgical care and other medical procedures. The authors examined whether an analogous association exists between the volume of mental health delivery and the quality of mental health care. The study used data for the 384 health maintenance organizations participating in the Health Employer Data and Information Set (HEDIS), covering 73 million enrollees nationwide. Analyses examined the association between three measures of mental health volume (total annual ambulatory visits, inpatient discharges, and inpatient days) and the five HEDIS measures of mental health performance (two measures of follow-up after psychiatric hospitalization and three measures of outpatient antidepressant management), with adjustment for plan and enrollee characteristics. Plans in the lowest quartile of outpatient and inpatient mental health volume had an 8.45 (95% CI [confidence interval]=4.97-14.37) to 21.09 (95% CI=11.32-39.28) times increase in odds of poor 7- and 30-day follow-up after discharge from inpatient psychiatric hospitalization. Low-volume plans had a 3.49 (95% CI=2.15-5.67) to 5.42 (95% CI=3.21-9.15) times increase in odds of poor performance on the acute, continuation, and provider measures of antidepressant treatment.

Question: The volume-quality relationship of mental health care: does practice make perfect?

The large and consistent association between mental health volume and performance suggests parallels with the medical and surgical literature. As with that previous literature, further work is needed to better understand the mechanisms underlying this association and the potential implications for using volume as a criterion in plan choice.

Answer the question based on the following context: We examined whether racial differences exist in cholesterol monitoring, use of lipid-lowering agents, and achievement of guideline-recommended low-density lipoprotein (LDL) levels for secondary prevention of coronary heart disease. We reviewed charts for 1045 African American and White patients with coronary heart disease at 5 Veterans Affairs (VA) hospitals. Lipid levels were obtained in 67.0% of patients. Whites and African Americans had similar screening rates and mean lipid levels. Among the 544 ideal candidates for therapy, rates of treatment and achievement of target LDL levels were similar.

Question: Is lipid-lowering therapy underused by African Americans at high risk of coronary heart disease within the VA health care system?

We found no disparities in cholesterol management. This absence of disparities may be the result of VA quality improvement initiatives or prescription coverage through the VA health care system.

Answer the question based on the following context: The aim of this study was to investigate whether the tumor parameters of spinal intramedullary ependymomas are significant predictors of clinical presentation and postsurgical outcome. The study involved 21 cases of intramedullary ependymoma that were operated on between 1988 and 2001. The patients were 13 males (62%) and 8 females (38%), with an age range of 9-70 years (median 38 years). In most cases (13; 62%), preoperative neurologic examination revealed a sensorimotor deficit in at least one limb. Complete tumor removal was achieved in all cases. The patients with wider tumors had poorer preoperative neurologic condition and poorer neurologic outcome. Tumor length (equivalent to myelotomy length) was not correlated with preoperative neurologic status, but longer length was significantly associated with development of dysesthesia post surgery. In contrast to tumor length, tumor/cord ratio (ratio of the tumor width to the largest cord width at the tumor site) was identified as a significant predictor of preoperative neurologic status and outcome. Ratio values of>0.80 were correlated with poorer preoperative clinical status and poorer neurologic outcome. Neither extent of edema (determined from length [in millimeters] of hyperintensity on T2-weighted images) nor presence of a cyst in the tumor was significant relative to postoperative neurologic recovery in these cases.

Question: Surgical treatment of intramedullary spinal cord ependymomas: can outcome be predicted by tumor parameters?

This study demonstrated that the width of the tumor relative to the cord is the main predictor of neurologic presentation and postoperative status. The length of the tumor affects the postoperative dysesthesia development.

Answer the question based on the following context: Although exercise training is established as an integrated part of treatment regimes in both patients with transmural myocardial infarction (MI) and chronic congestive heart failure (CHF), there is no consensus yet on the appropriateness of water exercises and swimming. One reason is the lack of information concerning both central hemodynamic volume and pressure responses during immersion in these patients. This paper presents explorative studies on changes in cardiac dimensions and central hemodynamics during graded immersion and swimming in patients with moderate and/or severe MI and in patients with moderate and/or compensated severe CHF. For comparison purposes, healthy subjects were assessed. Measurements were performed by using Swan-Ganz right heart catheterization, subxiphoidal echocardiography, and Doppler-echocardiography. The major findings were: 1) Indicators of an increase in preload were seen in patients with moderate and severe MI. In both patient groups, upright immersion to the neck and supine body position at rest in the water resulted in abnormal mean pulmonary artery pressure (PAm) and mean pulmonary capillary pressures (PCPm), respectively. During low-speed swimming (20-25 m.min(-1)), the PAm and/or PCPm were higher than during supine cycle ergometry at a load of 100 W. 2) Left ventricular overload and decrease and/or no change in stroke volume occurred in patients with severe CHF who were immersed up to the neck. 3) Patient's well-being was maintained despite hemodynamic deterioration.

Question: Exercise in heart failure: should aqua therapy and swimming be allowed?

The acute responses during immersion and swimming suggest the need for additional studies on long-term changes in cardiac dimensions and central hemodynamic in both patients with severe MI and severe CHF who undergo a swimming program, compared with nonswimming patients with MI and CHF of similar etiology and severity of disease.

Answer the question based on the following context: To compare the diagnostic value of contrast-enhanced CT (ceCT) and 2-[18-F]-fluoro-2-deoxyglucose-PET/CT in patients with metastatic colorectal cancer to the liver. Despite preoperative evaluation with ceCT, the tumor load in patients with metastatic colorectal cancer to the liver is often underestimated. Positron emission tomography (PET) has been used in combination with the ceCT to improve identification of intra- and extrahepatic tumors in these patients. We compared ceCT and a novel fused PET/CT technique in patients evaluated for liver resection for metastatic colorectal cancer. Patients evaluated for resection of liver metastases from colorectal cancer were entered into a prospective database. Each patient received a ceCT and a PET/CT, and both examinations were evaluated independently by a radiologist/nuclear medicine physician without the knowledge of the results of other diagnostic techniques. The sensitivity and the specificity of both tests regarding the detection of intrahepatic tumor load, extra/hepatic metastases, and local recurrence at the colorectal site were determined. The main end point of the study was to assess the impact of the PET/CT findings on the therapeutic strategy. Seventy-six patients with a median age of 63 years were included in the study. ceCT and PET/CT provided comparable findings for the detection of intrahepatic metastases with a sensitivity of 95% and 91%, respectively. However, PET/CT was superior in establishing the diagnosis of intrahepatic recurrences in patients with prior hepatectomy (specificity 50% vs. 100%, P = 0.04). Local recurrences at the primary colo-rectal resection site were detected by ceCT and PET/CT with a sensitivity of 53% and 93%, respectively (P = 0.03). Extrahepatic disease was missed in the ceCT in one third of the cases (sensitivity 64%), whereas PET/CT failed to detect extrahepatic lesions in only 11% of the cases (sensitivity 89%) (P = 0.02). New findings in the PET/CT resulted in a change in the therapeutic strategy in 21% of the patients.

Question: Does the novel PET/CT imaging modality impact on the treatment of patients with metastatic colorectal cancer of the liver?

PET/CT and ceCT provide similar information regarding hepatic metastases of colorectal cancer, whereas PET/CT is superior to ceCT for the detection of recurrent intrahepatic tumors after hepatectomy, extrahepatic metastases, and local recurrence at the site of the initial colorectal surgery. We now routinely perform PET/CT on all patients being evaluated for liver resection for metastatic colorectal cancer.

Answer the question based on the following context: To evaluate the influence of the response to preoperative chemotherapy, especially tumor progression, on the outcome following resection of multiple colorectal liver metastases (CRM). Hepatic resection is the only treatment that currently offers a chance of long-term survival, although it is associated with a poor outcome in patients with multinodular CRM. Because of its better efficacy, chemotherapy is increasingly proposed as neoadjuvant treatment in such patients to allow or to facilitate the radicality of resection. However, little is known of the efficacy of such a strategy and the influence of the response to chemotherapy on the outcome of hepatic resection. We retrospectively analyzed the course of 131 consecutive patients who underwent liver resection for multiple (>or =4) CRM after systemic chemotherapy between 1993 and 2000, representing 30% of all liver resections performed for CRM in our institution during that period. Chemotherapy included mainly 5-fluorouracil, leucovorin, and either oxaliplatin or irinotecan for a mean of 9.8 courses (median, 9 courses). Patients were divided into 3 groups according to the type of response obtained to preoperative chemotherapy. All liver resections were performed with curative intent. We analyzed patient outcome in relation to response to preoperative chemotherapy. There were 58 patients (44%) who underwent hepatectomy after an objective tumor response (group 1), 39 (30%) after tumor stabilization (group 2), and 34 (26%) after tumor progression (group 3). At the time of diagnosis, mean tumor size and number of metastases were similar in the 3 groups. No differences were observed regarding patient demographics, characteristics of the primary tumor, type of liver resection, and postoperative course. First line treatments were different between groups with a higher proportion of oxaliplatin- and/or irinotecan-based treatments in group 1 (P<0.01). A higher number of lines of chemotherapy were used in group 2 (P = 0.002). Overall survival was 86%, 41%, and 28% at 1, 3, and 5 years, respectively. Five-year survival was much lower in group 3 compared with groups 1 and 2 (8% vs. 37% and 30%, respectively at 5 years, P<0.0001). Disease-free survival was 3% compared with 21% and 20%, respectively (P = 0.02). In a multivariate analysis, tumor progression on chemotherapy (P<0.0001), elevated preoperative serum CA 19-9 (P<0.0001), number of resected metastases (P<0.001), and the number of lines of chemotherapy (P<0.04), but not the type of first line treatment, were independently associated with decreased survival.

Question: Tumor progression while on chemotherapy: a contraindication to liver resection for multiple colorectal metastases?

Liver resection is able to offer long-term survival to patients with multiple colorectal metastases provided that the metastatic disease is controlled by chemotherapy prior to surgery. Tumor progression before surgery is associated with a poor outcome, even after potentially curative hepatectomy. Tumor control before surgery is crucial to offer a chance of prolonged remission in patients with multiple metastases.

Answer the question based on the following context: Nearly 50 % of subjects with continuing symptoms of attention-deficit hyperactivity disorder (ADHD) in adulthood show a comorbid substance use disorder. Both, ADHD and alcohol dependence have a high genetic load and might even share overlapping sources of genetic liability. We investigated phenotype and 5-HTT/5-HT2c allelic characteristics in 314 alcoholics of German descent. 21 % of the alcoholics fulfilled DSM-IV-criteria of ADHD with ongoing symptoms in adulthood. There was no significant difference in 5-HTT- or 5-HT2c-allele distribution between alcoholics and matched controls or between alcoholics with or without ADHD.

Question: ADHD and alcohol dependence: a common genetic predisposition?

In our sample the functional relevant 5-HTT-promoter and the 5-HT2c-receptor Cys23Ser polymorphism do not contribute to the supposed common genetic predisposition of ADHD and alcohol dependence.

Answer the question based on the following context: To identify a possible relationship between the non-surgical treatment regimen and outcome. In a sample of 170 patients with sciatica due to a herniated disk the intensity of a conservative multimodal inpatient treatment in a neurological department was extracted. The outcome was examined using two prospective cohorts (183 patients). These results were compared with published data from orthopaedic inpatient rehabilitation in Germany. The neurological inpatient treatment regimen was more intense than the orthopaedic inpatient rehabilitation, especially with regard to physiotherapy. In contrast, physical therapy was applied more often in orthopaedic rehabilitation. A better short-term outcome with regard to pain intensity was found after multimodal conservative treatment.

Question: Radicular low back pain: is there a relationship between the treatment regimen and outcome?

Further studies are needed to compare different treatment regimens in patients with sciatica.

Answer the question based on the following context: To examine the benefit of specialist rheumatology consultation and followup for the first 238 patients referred to a tertiary care fibromyalgia (FM) clinic with emphasis on final diagnosis and outcome. A retrospective chart review was performed for the first 238 patients attending a rheumatology subspecialty FM clinic. The main variables of interest were management received at the clinic, final diagnosis, and outcome. The final diagnosis was FM in 68%, and some other condition in the remaining 32%. Specialist contact was identified as useful in 73% of the total patient group, 96 with FM and 74 with non-FM. In the patients with FM who received followup in the clinic, outcome was judged favorable in 54%, whereas 46% showed no change or decline in health status.

Question: Is there benefit in referring patients with fibromyalgia to a specialist clinic?

An important value of specialist rheumatology contact for patients with a symptom suggestive of diffuse musculoskeletal pain is to ensure that some other potentially treatable condition is not overlooked, rather than the provision of ongoing care for those with FM. Continued followup in a specialist clinic for patients with a primary diagnosis of FM is of questionable benefit.

Answer the question based on the following context: The Internet is a popular, but ungoverned, source of medical information. This study tracked the change in performance of commonly available search engines and the quality of medical data therein over a four-year period. We compared the accuracy of information on a commonly performed surgical procedure (vasectomy) using six standard search engines in a four-year period and with two recently developed search engines. The top 25 ranked sites cited by each search engine were scored for description of the procedure, post-operative instructions, complications and unproven associations. There was no improvement in quality of individual sites over the study period. Additionally, the hit rate of search engines remained poor with 27 sites cited (40%) in 2002 either irrelevant or unavailable. Few useful sites with accurate information on surgical procedures are available on the Internet and simple search strategies fail to identify site quality or relevancy.

Question: Surgical informatics on the Internet: any improvement?

At present, the Internet cannot be recommended as a reliable resource for many aspects of health information for patients. The onus is on health-care providers to provide high quality sites and direct patients to these sources of reliable information

Answer the question based on the following context: To determine whether specific regions of cerebral cortex are activated at the onset and during the propagation of absence seizures. Twenty-five absence seizures were recorded in five subjects (all women; age 19-58 years) with primary generalized epilepsy. To improve spatial resolution, all studies were performed with dense-array, 256-channel scalp EEG. Source analysis was conducted with equivalent dipole (BESA) and smoothed linear inverse (LORETA) methods. Analyses were applied to the spike components of each spike-wave burst in each seizure, with sources visualized with standard brain models. For each patient, the major findings were apparent on inspection of the scalp EEG maps and waveforms, and the two methods of source analysis gave generally convergent results. The onset of seizures was typically associated with activation of discrete, often unilateral areas of dorsolateral frontal or orbital frontal lobe. Consistently across all seizures, the negative slow wave was maximal over frontal cortex, and the spike that appeared to follow the slow wave was highly localized over frontopolar regions of orbital frontal lobe. In addition, sources in dorsomedial frontal cortex were engaged for each spike-wave cycle. Although each patient showed unique features, the absence seizures of all patients showed rapid, stereotyped evolution to engage both mesial frontal and orbital frontal cortex sources during the repeating cycles of spike-wave activity.

Question: Are "generalized" seizures truly generalized?

These data suggest that absence seizures are not truly "generalized," with immediate global cortical involvement, but rather involve selective cortical networks, including orbital frontal and mesial frontal regions, in the propagation of ictal discharges.

Answer the question based on the following context: To measure the prevalence of anticholinergic use cross-sectionally in patients receiving cholinesterase inhibitors and to describe change in use of anticholinergics upon inception of cholinesterase inhibitor treatment. Cross-sectional and inception cohort studies. State of Iowa. Iowa Medicaid beneficiaries aged 50 and older with a pharmacy claim for a cholinesterase inhibitor during January 1997 through February 2000. Anticholinergic use was determined for all patients with a cholinesterase inhibitor pharmacy claim during January and February of 2000. A frequency distribution of all anticholinergics was compiled, with emphasis placed on those considered inappropriate in the elderly. In a separate analysis, anticholinergic use was determined at two points: 90 days before and after cholinesterase inhibitor inception. Of 557 patients receiving a cholinesterase inhibitor, 197 (35.4%) received an anticholinergic concurrently. Of all anticholinergics, 74.5% (178/239) had been identified as inappropriate for use in the elderly, 22.2% (53/239) under any circumstances. At the time of cholinesterase inhibitor inception, 30.2% (143/474) and 33.5% (159/474) of patients received an anticholinergic 90 days before and 90 days after inception, respectively. Increases in anticholinergic prescribing upon cholinesterase inhibitor inception exceeded decreases (Wilcoxon signed-rank test, S=529, P=.020).

Question: The concurrent use of anticholinergics and cholinesterase inhibitors: rare event or common practice?

The concurrent use of anticholinergics and cholinesterase inhibitors is common although rarely appropriate. Patients with Alzheimer's disease deserve to receive the optimum benefit from cholinesterase inhibitor treatment, which can only be achieved through diligent and appropriate use of concurrent pharmacotherapy.

Answer the question based on the following context: IIeoscopy is not routinely attempted because of its perceived technical difficulty, time constraints, and the expectation of a low diagnostic yield. To investigate the value of routine ileoscopy as an integral part of colonoscopy in terms of additional diagnostic information, extra time spent, and the relationship between ileoscopy rate and accumulation of colonoscopic experience. We examined colonoscopy data from September 1995 to April 2004 of a gastroenterological firm. Crude and adjusted total colonoscopy rates (CTCR, ATCR) and ileoscopy rate (IR) were calculated. For calculation of ATCR and IR, 108 procedures in patients with previous colonic resection and 91 with unavoidable reasons for failure to reach cecum were excluded. Time trend in ileoscopy rate was analyzed with IR as a function of cumulative colonoscopy experience. Data on procedure times were collected for 1,222 consecutive colonoscopies between November 2000 and April 2004. Sixty-three procedures in patients with previous colonic resection, and 47 unavoidable and 14 avoidable failures to reach cecum were excluded from analysis of procedure times. Of 2,537 colonoscopies, 1,902 were performed by a single consultant and 635 by eight trainees with or without assistance from the consultant. The CTCR, ATCR, and IR were 94%, 97.5%, and 71.5% respectively. IR and ATCR rose progressively to plateau at 85% and 99% after 600 and 750 procedures respectively. The diagnostic yield from ileoscopy and ileal histology was 16.7% and 19% in patients with colonic inflammatory bowel disease, and 2.69% and 7.4% in other patients. Twenty six ileoscopies in 24 patients showed Crohn's ileitis with normal colon. The other diagnoses were NSAID related or nonspecific ileitis, ileal lipoma, ileal villous atrophy, and amyloidosis. The median anus to cecum and cecum to ileum times were 8.5 and 2 minutes (interquartile ranges=5.5 to 14 and 1 to 4 minutes) respectively. Procedure times for colonoscopies involving trainees were significantly longer compared with those by the consultant alone (median anus to cecum and cecum to ileum times=16.5 v 7 and 2.5 v 1.5 minutes; p<0.0001 and 95% CI for difference=7.5 to 9 and 0.5 to 1 minutes respectively). The median length of ileum examined was 15 cms (IR=10-20 cms).

Question: Is routine ileoscopy useful?

IIeoscopy is the gold standard in the documentation of completeness of colonoscopy. With practice, it can be achieved routinely in at least 85% of colonoscopies. In skilled hands, it adds only 3 minutes to the procedure time, and contributes significantly to quality assurance and diagnostic yield.

Answer the question based on the following context: Presence of intestinal metaplasia in the gastric cardia (cardia intestinal metaplasia, CIM) has been reported in 5-34% of patients undergoing upper endoscopy and is a topic of interest given the rising incidence of cancer in this location. The aim of this article is to determine the prevalence of CIM in biopsies obtained from two separate locations within the gastric cardia. Patients presenting to the endoscopy unit for upper endoscopy for any symptoms were invited to participate in the study. The biopsy protocol included: eight biopsies from the gastric cardia, four from upper cardia (forceps across the squamocolumnar junction), four from lower cardia (within 1 cm of upper cardia), and four each from the gastric body and antrum. All cardia biopsies were stained with hematoxylin and eosin (H&E) and alcian blue at pH 2.5 for the presence of goblet cells and the body/antrum biopsies were stained with Steiner silver stain for Helicobacter pylori detection. In patients testing negative for H. pylori by histology, a serology test was performed. Sixty-five patients have been evaluated by this protocol; median age 54 yr (range: 34-81 yr), 63 males, 53 Caucasians, and 12 African Americans. The detection of CIM was as follows: upper cardia only, 7, both upper and lower cardia, 5, and lower cardia only, 7. Thus, CIM was detected in 12 patients (18%) in the upper cardia biopsies, in 12 patients (18%) in the lower cardia; overall prevalence of CIM was 29% (19 patients). Fifty-eight percent of CIM patients tested positive for H. pylori by either histology or serology. The addition of serology allowed for the detection of eight additional H. pylori-positive CIM patients.

Question: Detection of cardia intestinal metaplasia: do the biopsy number and location matter?

The prevalence of CIM in this study was similar (18%, four biopsies) at each location; however, if both locations were considered (eight biopsies), the prevalence increased to 29%. Thus, CIM prevalence may vary depending on the number of biopsies obtained as well as on the location of biopsies. Use of additional testing detects more patients who are H. pylori positive and should be performed if association of CIM with H. pylori is contemplated. Future endoscopic studies of the gastric cardia should specify the location of biopsies, the number of biopsies obtained, and the tests used to diagnose H. pylori.

Answer the question based on the following context: To investigate the relationship between urinary incontinence and women's levels and hours of participation in 31 activities. A subset of panel members from the Health and Retirement Study completed the self-administered Consumption and Activities Mail Survey questionnaire in 2001. These data were linked with Health and Retirement Study 2000 data. Analyses were limited to 2,190 female Consumption and Activities Mail Survey self-respondents born in 1947 or earlier. Logistic regression was used to predict activity participation. Linear regression was used to predict the number of hours of participation. The hypothesis that urinary incontinence affects women's time use and activity patterns was supported. Compared with the continent women, the incontinent women were less likely to have house cleaned, shopped, physically shown affection, or attended religious services in the recent past; and were more likely to have watched television or made music by singing or playing an instrument. Compared with continent activity participants, incontinent participants reported significantly fewer hours spent walking, communicating with friends and family by telephone or e-mail, working for pay, using a computer, and engaging in personal grooming and hygiene.

Question: Does urinary incontinence affect middle-aged and older women's time use and activity patterns?

These findings substantiate prior work on the relationship between urinary incontinence and quality of life, and suggest a useful route for educating patients about the impact of urinary incontinence. Clinicians must be alert to opportunities for encouraging incontinent women to be active. It is also important to consider the implications for time use and activity patterns when advising patients about treatment and management options.

Answer the question based on the following context: A young people's clinic has been running at the Archway Sexual Health Clinic since 1997. This offers a weekly walk-in service to both young men and women under 20 years old. To review the audit data of over 7 years' experience from the dedicated young people's clinic at the Archway Sexual Health Clinic, the "Arch." These data were collected by retrospective notes review of a consecutive series of all male attendees over a 7 year period from 1997 to the end of 2003 with collection of data in Microsoft Excel database. These figures show an overall increase in attendee numbers, but also a relative rise in the numbers of young men using the service. A high number of bacterial sexually transmitted infections were detected. In 2001 and 2003 respectively, 14.5% and 17.8% of the young men using the service were diagnosed with Chlamydia trachomatis. A user survey aimed to identify factors that may be encouraging the young men to access the service.

Question: Are we getting the message across?

Responding to the views of young men using the service has played a part in service development. Initiatives at the "Arch" such as the condom policy and choice of gender of staff may be factors encouraging increasing attendances. Continuing to work with other agencies to develop ways to engage young men are recommended. Word of mouth recommendation cannot be underestimated in publicising the service.

Answer the question based on the following context: To review and summarise various types of Peruvian evidence on sexual behaviour, HIV/STI exposure and risk, and discuss how to increase its usefulness for HIV/STI risk trend monitoring in Peru. Review HIV sentinel surveillance conducted by the Ministry of Health; data from the Demographic and Health Surveys (DHS); and academic publications on sexual behaviour in combination with biological markers. Changes over time, quality of data, size of studies, and intended audience are discussed. Data from HIV sentinel surveillance showed very high (8-23%) HIV seroprevalence among men having sex with men, but stable, relatively low figures among female sex workers (1%) and antenatal clinic patients (under 0.5%). DHS data suggest that single women increased their sexual activity throughout the 1990s but did not raise their contraceptive use accordingly, resulting in increased early conceptions. The contribution of condoms to overall contraceptive protection increased threefold in 1992-2000. According to the 1996 survey, men become sexually active 2.5 years earlier than women, but marry or cohabit four years later than women; women marry or cohabit 1.5-2.5 years after first sex, whereas men take eight years to do so. Finally, published studies confirmed dramatic differences in HIV prevalence between men who have sex with men and other populations, and also suggested patterns of bridging from men to women.

Question: Monitoring trends in sexual behaviour and HIV/STIs in Peru: are available data sufficient?

Data available from the three sources are numerous, although limitations of each approach reduce their monitoring utility: Ministry of Health studies should select better sentinel populations and timely process behavioural data. Future demographic surveys should incorporate an AIDS risk perspective and include men.

Answer the question based on the following context: In patients presenting to the emergency department (ED) with an initial diagnostic impression of noncardiac chest pain, we determine the 30-day incidence of adverse cardiac events and characteristics associated with those events. The multicenter, prospectively collected Internet Tracking Registry for Acute Coronary Syndromes (i*tr ACS ) registry of patients with chest pain enrolled from June 1, 1999, to August 1, 2001, was reviewed. We included patients if the physician's initial diagnostic impression was noncardiac chest pain after the medical history, physical examination, and initial 12-lead ECG. ED records, inpatient records, and follow-up results were reviewed for evidence of an adverse cardiac event defined as ST-segment or non-ST-segment elevation myocardial infarction, unstable angina, revascularization, or cardiac death within 30 days. Of 17,737 patients enrolled in i*tr ACS , 2,992 had an initial emergency physician impression of noncardiac chest pain. Of these, 85 (2.8%) patients had definite evidence for an adverse cardiac event. The adverse cardiac event group was older (61.2 versus 47.9 years), more likely to be men (58.6% versus 38.7%), and had a higher Acute Cardiac Ischemia-Time Insensitive Predictive Instrument score (26.1 versus 15.6). Factors associated with adverse cardiac events included hypercholesterolemia, diabetes, history of coronary artery disease, and history of congestive heart failure.

Question: Is the initial diagnostic impression of "noncardiac chest pain" adequate to exclude cardiac disease?

When the initial impression is noncardiac chest pain, high-risk features such as traditional cardiovascular risk factors or a history of coronary artery disease are associated with adverse cardiac events. In the absence of well-defined criteria, treating physicians should consider further evaluation before diagnosing patients with noncardiac chest pain if these features are present.

Answer the question based on the following context: The main purpose of this study is to assess the achievements and barriers to advancement for Saudi women in a medical academic setup. We studied the career progression of female medical graduates, who were appointed an academic position in King Faisal University, Dammam, Kingdom of Saudi Arabia (KSA) between 1982 and 2003 and compared it to the male counterpart. The information was collected from the Dean's ship of admission and registration, employees and faculty affairs administration office, self completed and telephone surveys. The percentage of medical graduates who were appointed on an academic post in the University was 4.4% for females and 4% for males. The females specialized in various fields and progressed equitably with the males in their postgraduate studies. Academic promotion to higher ranks was slower for females in comparison to males. This was related to various reasons related to family responsibilities, social strains, lack of family friendly policies in the institutions, lack of mentoring relationship, and bias against females.

Question: Saudi women in academic medicine. Are they succeeding?

Saudi women in academic medicine have succeeded at the junior level. They specialized in various fields and excelled. Their further academic progression needs the support of senior academic staff, the chairs and the institution administration.

Answer the question based on the following context: The magnetization transfer ratio (MTR) is a MR-based neuroimaging procedure aiming at the quantification of the structural integrity of brain tissue. Its contribution to the differential diagnosis of dementias was examined and discussed in relation to the pathogenesis of age-related dementias. Sixty-one patients from a memory clinic were diagnosed by general physical and neuropsychiatric examination, and underwent neuropsychologic testing and neuroimaging using MRI. Their clinical diagnoses were based on standard operational research criteria. Additionally, the MTR in 10 defined regions of interest (ROI) was determined. This investigation was performed using a T1-weighted SE sequence. Average MTR values were determined in the individual ROI and their combinations and correlated with the age, gender, cognitive impairment and clinical diagnosis. Sensitivity, specificity, positive and negative predictive value were determined, as well as the rate of correct classifications. For cognitive healthy subjects, the MRT values correlate only mildly, though significantly, with age in the hippocampus and with gender in the dorsal corpus callosum. In contrast, the MTR in the frontal white matter correlates strongly and highly significantly with cognitive impairment in patients with dementia. The differential diagnostic assignment of Alzheimer's disease versus vascular dementia by MTR provides a correct classification of approximately 50 % to 70 %. PPV for no dementia vs. vascular dementia or the NPV for vascular vs. Alzheimer's disease are considerably higher exceeding 80 %. For no dementia vs. Alzheimer's disease, the NPV was over 90 %.

Question: Does magnetization transfer ratio (MTR) contribute to the diagnosis and differential diagnosis of the dementias?

MTR values indicate functional changes in the brain tissue between cognitive healthy and demented patients, and correlate with the cognitive loss, but not with age and gender. In principle, the MTR is suitable for the diagnosis of age-related dementias, but does not contribute substantially to the differential diagnosis of vascular dementia vs. Alzheimer's disease. The present results support the assumption of a synergy between vascular and degenerative components of age-related dementias.

Answer the question based on the following context: To compare the histomorphology of pelvic floor specimens of 94 female cadavers, ten male cadavers, and 24 female symptomatic patients who underwent pelvic floor surgery, and to evaluate the association of age, parity, and sex to myogenic and/or neurogenic changes to the levator ani muscle (LAM). The pelvic floor was biopsied at the pubococcygeus, the iliococcygeus and the coccygeus muscle. After staining, signs for myogenic/neurogenic changes to the muscle were evaluated (fibrosis, variation in fiber diameter, centralization of nuclei, small angulated fibers, and type grouping). To identify the intact neuromuscular junction stainings with NCAM (neuronal cell adhesion molecule) and acetylcholinesterase (ACE) were used. A significant influence of age and parity on the histomorphological criteria of myogenic cell-damage was shown in this study. Although these criteria were found even in young nulliparous women, there was a significant increase in older or parous women with at least one vaginal delivery. We failed to demonstrate significant changes between the nulliparous LAM, the male LAM, and the LAM from women with prolapse and incontinence. None of the specimen showed any obvious evidence of neuropathy.

Question: Is the histomorphological concept of the female pelvic floor and its changes due to age and vaginal delivery correct?

We have evaluated histological criteria adapted from the examination of limb muscles in the LAM of nulliparous young women. "Myogenic changes" seem to be a normal finding in the LAM. The increase of these changes with aging and parity points to mechanical stress to the LAM as the most plausible causative factor. We propose that further studies using histomorphological techniques of the pelvic floor muscle in nulliparous and parous women should clarify the potential role of our histological findings.

Answer the question based on the following context: The purpose of the present paper was to investigate whether screening for abdominal aortic aneurysm (AAA) causes health-related quality of life to change in men or their partners. A cross-sectional case-control comparison was undertaken of men aged 65-83 years living in Perth, Western Australia, using questionnaires incorporating three validated instruments (Medical Outcomes Study Short Form-36, EuroQol EQ-5D and Hospital Anxiety and Depression Scale) as well as several independent questions about quality of life. The 2009 men who attended for ultrasound scans of the abdominal aorta completed a short prescreening questionnaire about their perception of their general health. Four hundred and ninety-eight men (157 with an AAA and 341 with a normal aorta) were sent two questionnaires for completion 12 months after screening, one for themselves and one for their partner, each being about the quality of life of the respondent. Men with an AAA were more limited in performing physical activities than those with a normal aorta (t-test of means P = 0.04). After screening, men with an AAA were significantly less likely to have current pain or discomfort than those with a normal aorta (multivariate odds ratio: 0.5; 95% confidence interval (CI): 0.3-0.9) and reported fewer visits to their doctor. The mean level of self-perceived general health increased for all men from before to after screening (from 63.4 to 65.4).

Question: Is screening for abdominal aortic aneurysm bad for your health and well-being?

Apart from physical functioning, screening was not associated with decreases in health and well-being. A high proportion of men rated their health over the year after screening as being either the same or improved, regardless of whether or not they were found to have an AAA.

Answer the question based on the following context: As part of the SENTRY Antimicrobial Surveillance Programme, 383 non-replicative randomly collected Pseudomonas aeruginosa isolates were collected during 1999-2002. These strains originated from three geographically distinct hospitals within Italy: Genoa (Northern Italy); Rome and Catania (Sicily), and were further studied to identify the prevalence of metallo-beta-lactamase (MbetaL) alleles across Italy and to determine their genetic details. Multidrug-resistant (MDR) strains were identified by MIC analysis followed by genotyping and PCR-based strategies. Initial MIC analysis identified 31 MDR isolates that displayed an Etest MbetaL-positive phenotype. Of these, 25 produced either the MbetaL VIM-1 or IMP-13 as detected by PCR and sequencing. VIM-1-producing isolates were found at all sites, whereas IMP-13-producing isolates were only found in Rome. MbetaL-producing isolates were found at all Italian SENTRY sites and together amounted to 6.5% of all P. aeruginosa isolates. Genetic analysis indicated that many strains contained multiple integrons and identified two novel MbetaL integrons, one from the site in Genoa and one from Sicily. Integrons identical in structure and sequence to In70, the first identified and characterized bla(VIM)-containing integron from Verona, were found in isolates with distinct ribotypes at the Roman and Sicilian sites indicating that this integron has recently disseminated across Italy. All 25 MbetaL-producing isolates were genetically linked in that all isolates contained Tn5051 sequences and all harboured the insertion sequence IsPa7 which may be involved in the mobilization of these resistance alleles.

Question: Italian metallo-beta-lactamases: a national problem?

Taken together, these results indicate that Italy has a nationwide problem of MDR P. aeruginosa produced by mobile MbetaL genes.

Answer the question based on the following context: To assess if three-monthly reassessment of ABPI is necessary and to determine the possibility of identifying which patients may benefit from more frequent reassessment. The sample comprised 88 consecutive patients with 175 limbs attending community leg ulcer clinics for reassessment after leg ulcer healing had been achieved with compression therapy. Outcome measures were: a fall in ABPI to below 0.8, months between reassessments and arterial disease history. ABPI fell from above 0.8 to below 0.8 in seven limbs in six patients over time periods of between six and 24 months. Of these seven limbs, six had an ABPI between 0.8 and 1.0 at the initial assessment, indicating they had some arterial impairment. ABPI fell below 0.7 (0.58) in only one patient, and this was detected at a six-month reassessment. None of the patients with no or just one arterial symptom experienced a reduction in ABPI to below 0.8. Those whose ABPIs fell below this level had two or more arterial symptoms.

Question: Should ABPI be measured in patients with healed venous leg ulcers every three months?

Three-monthly reassessment of healed limbs is not recommended as most patients who initially have an ABPI above 1.0 are unlikely to change during this time. However, patients with two or more arterial risk factors, diabetes and an initial ABPI of below 1.0 are likely to need closer monitoring. More in-depth research is needed to examine this problem.

Answer the question based on the following context: To develop a preliminary characterization of the urological personality. Thirty-four urology residents (29 male) from all eleven Canadian training programs anonymously completed the Revised NEO personality inventory (NEO-PI-R(c)), a commercially available validated personality assessment tool in which participants agree or disagree with a compilation of 240 statements. A score is generated in each of five character traits according to the five factor theory of personality: extraversion (E), openness (O), conscientiousness (C), agreeableness (A) and neuroticism (N). The group mean on each scale was compared to the normative mean for the general adult population using one-sample, two-tailed t tests. Urology residents scored significantly higher than the general population on three of the five personality factors: extraversion (E) (p<.001), openness (O) (p<.02) and conscientiousness (C) (p<.05). There was no significant difference from norms in agreeableness (A) or neuroticism (N).

Question: The urological personality: is it unique?

The high scores in 'extraversion' reflect the social, warm, active and talkative nature of urology residents. As well, urology residents tend to be willing to entertain new ideas and are purposeful and determined based on their high scores on 'openness' and 'conscientiousness' respectively. Canadian urology residents possess a distinct personality in comparison to the general population. These provocative findings should be interpreted with caution. If confirmed on a wider basis, the data may be helpful in career counseling and resident selection. Future studies examining differences between the urological personality and other surgical subspecialties may further refine applications of the data.

Answer the question based on the following context: To evaluate the impact of an emergency department (ED)-based nurse discharge plan coordinator (NDPC) on unscheduled return visits within 14 days of discharge, satisfaction with discharge recommendations, adherence with discharge instructions, and perception of well-being of elder patients discharged from the ED. Patients aged 75 years and older discharged from the ED of the Sir Mortimer B. Davis-Jewish General Hospital were recruited in a pre/post study. During the pre (control) phase, study patients (n = 905) received standard discharge care. Patients in the post (intervention) phase (n = 819) received the intervention of an ED-based NDPC. The intervention included patient education, coordination of appointments, patient education, telephone follow-up, and access to the NDPC for up to seven days following discharge. Patients in the two groups were similar with respect to gender and age. However, the patients managed by the ED NDPC appeared to be, at baseline, less autonomous, frailer, and sicker. The unadjusted relative risk for unscheduled return visits within 14 days of discharge was 0.79 (95% confidence interval [95% CI] = 0.62 to 1.02). A relative risk reduction of 27% (95% CI = 0% to 44%) for unscheduled return visits was observed for up to eight days postdischarge, and a relative risk reduction of 19% (95% CI = -2% to 36%) for unscheduled return visits was observed for up to 14 days postdischarge. Significant increases in satisfaction with the clarity of discharge information and perceived well-being were also noted.

Question: An emergency department-based nurse discharge coordinator for elder patients: does it make a difference?

An ED-based NDPC, dedicated specifically to the discharge planning care of elder patients, reduces the proportion of unscheduled ED return visits and facilitates the transition from ED back home and into the community health care network.

Answer the question based on the following context: Our objective was to describe patients who telephone frequently after hours to physicians (frequent callers) and categorize their medical problems and resource utilization. Charts of frequent callers were reviewed and compared with those of a systematically selected group from the same family medicine residency practice (control group). Data collected included demographic and clinical information, as well as information on utilization of office, emergency department, and hospital services. In addition, 4 family physicians reviewed the patient information and identified the primary diagnosis for frequent callers. Frequent callers were predominately female; had 3 times as many office visits, diagnoses, and medications; and had 8 times as many hospital admissions as the control group. The most common primary diagnostic categories were psychiatric disorders (36%), pain (21%), chronic illnesses (16%), pregnancy (13%), and common problems of childhood (9%).

Question: Are frequent callers to family physicians high utilizers?

Frequent callers represent a unique group of patients with high utilization of health care services. Better targeted patient education and referral to other support services may decrease the number of calls and utilization of health services. Alternatively, among high utilizers, frequent telephone calls may be a substitute for other forms of care.

Answer the question based on the following context: Consent has been placed at the centre of doctor-patient relationships. Attempts to improve the consent process in medicine have drawn on bioethical and legal traditions. Current approaches to consent emphasise the provision of information and have, in the UK, resulted in a single standardised format and process for both elective and emergency situations. Investigation of patients' perceptions and priorities are important in understanding the quality of the consent process. In this qualitative study, semi-structured interviews were conducted with 25 women. Eleven had elective and 14 had emergency operations in obstetrics and gynaecology. All interviews were recorded and transcribed verbatim. Data analysis was based on the constant comparative method. Participants' perceptions of surgery strongly influenced the meanings they gave to consent. Some, particularly those undergoing elective operations, wanted surgery. Others were uncertain of their desire for surgery or felt that it was imposed on them. Consenting was interpreted as a ritualistic legal procedure. There was an overwhelming tendency to view consent as not primarily serving patients' needs, although some advantages of the consent process were identified. Accounts made no reference to ethics.

Question: Women's accounts of consenting to surgery: is consent a quality problem?

Countering paternalism will remain difficult to achieve if issues surrounding consent continue to be debated between professionals without due effort to reflect patients' own views and values and to appreciate the circumstances under which consent is sought.

Answer the question based on the following context: The objective of this study was to define the epidemiology of thyroid cancer in our regional population and compare results with Surveillance, Epidemiology, and End RESULTS (SEER) Program cancer registry trends. Thyroid cancer cases diagnosed between 1990 and 2000 were identified in the Florida Cancer Data System (FCDS). Overall, gender-specific, age-specific, and stage-specific incidence rates were calculated. All rates are per 100,000 and age-adjusted to the 2000 U.S. standard population. Estimated Annual Percent Change (EAPC) was calculated with a linear least-squares model. Patients with thyroid cancer (n = 8603) were identified in the FCDS registry. Age-adjusted incidence rates increased from 4.2 per 100,000 to 7 per 100,000 in 2000. The EAPC for this period was 5.5% (P<.001). The SEER incidence rates increased from 7.9 to 10.2 per 100,000, and the EAPC was 3.7% (P<.05). Analysis of gender-specific incidence rates showed increases from 6 and 2.2 per 100,000 in 1990 to 10.1 and 3.8 per 100,000 in 2000 among females and males, respectively, with EAPCs of 5.9% (females) and 4.5% (males) (P<.001). With stratification by age group, the highest incidence rates were 9 per 100,000 in the group aged 65 to 84 years and 8.4 per 100,000 in the group aged 45 to 64 years.

Question: Thyroid cancer: is the incidence still increasing?

Thyroid cancer incidence rates in Florida almost doubled over the 1990-2000 period and are concordant with SEER trends. Etiologic studies addressing temporal changes in reproductive factors, more intensive diagnostic activities, and changes in histological criteria are warranted.

Answer the question based on the following context: The purpose of this study was to assess (patient) characteristics that might influence the prevalence of physiological uptake of [18F]fluorodeoxyglucose (FDG) in the neck and upper chest region (FDG NUC) in positron emission tomography (PET) imaging. Retrospective study of static FDG PET scans in patients with malignant lymphoma, head and neck, lung or thyroid malignancy. The investigated determinants were gender, age, body mass index (BMI), tumour type, referring centre (community or university hospital), first or later PET scan, and use of benzodiazepines. Eighty (31%) of 260 scans showed FDG NUC. We found a strong inverse relation between age and FDG NUC (P<0.001). After adjusting for age, older head and neck tumour patients were more at risk for developing FDG NUC compared with other tumours (P=0.011). Gender, use of benzodiazepines, referring specialist, first or later PET scan or low BMI (<20 kg.m(-2)) did not influence the prevalence of FDG NUC.

Question: Physiological uptake of [18F]fluorodeoxyglucose in the neck and upper chest region: are there predictive characteristics?

Multivariate logistic regression showed a strong inverse association between age and FDG NUC. No association between low BMI and FNUC could be established. In our hospital no protective effect of benzodiazepines could be determined. These data suggest that a trial designed to evaluate the efficiency of interventions to diminish FDG NUC should focus on younger patients.

Answer the question based on the following context: Chronic replication of cytomegalovirus and EBV in early life may affect the immune system and play a role in the development of allergy in children. To assess the relation between cytomegalovirus infection and allergic disorders in children, including a possible interaction with EBV infection. From a prospective birth cohort study in Stockholm, on factors of importance for development of allergy, 2581 four-year-old children were enrolled. The classification of allergic diseases was based on questionnaire answers and determination of IgE antibodies to common airborne and food allergens. IgG to cytomegalovirus was determined by a commercial ELISA and to EBV by indirect immunofluorescence. A total of 1191 (46%) children were cytomegalovirus-seropositive. There were no significant associations between seropositivity to cytomegalovirus and allergic manifestations, such as bronchial asthma, suspected allergic rhinitis, or atopic dermatitis. Seropositivity to cytomegalovirus alone, ie, without seropositivity to EBV, was related to IgE antibodies to airborne and food allergens (adjusted odds ratio, 1.8; 95% CI, 1.2-2.9). An antagonism between cytomegalovirus and EBV in relation to sensitization to airborne and food allergens was suggested ( P = .05).

Question: Cytomegalovirus infection and development of allergic diseases in early childhood: interaction with EBV infection?

The study does not support the hypothesis that previous cytomegalovirus infection plays an important role in the pathogenesis of bronchial asthma, suspected allergic rhinitis, or atopic dermatitis in children. However, in the absence of EBV infection, cytomegalovirus infection may be related to sensitization to airborne and food allergens.

Answer the question based on the following context: To survey Canadian dermatologists for specialty-specific physician resource information including demographics, workload and future career plans. In 2001, the Canadian Dermatology Association (CDA) surveyed 555 dermatologists in Canada to gain specialty-specific physician resource information. Three hundred and seventy-one dermatologists (69%) provided information about themselves, their workloads and their future career goals. The average Canadian dermatologist is 52 years old and 35% of practicing dermatologists are over the age of 55. Eighty-nine percent of dermatologists practice in an urban setting, 19% include practice in a rural setting while less than 0.5% practice in remote areas. Canadian dermatologists spend 61% of their clinical time providing services in Medical Dermatology. Within 5 years, 50% of dermatologists reported that they plan to reduce their practices or retire.

Question: The Canadian Dermatology Workforce Survey: implications for the future of Canadian dermatology--who will be your skin expert?

The Canadian Dermatology Workforce Survey provides a snapshot of the current practice of dermatology in Canada. It also serves to highlight the critical shortage of dermatologists, which will continue to worsen without immediate, innovative planning for the future.

Answer the question based on the following context: Loosening of the prosthetic cup is the limiting factor in the service life of total hip prostheses (THPs). Despite effective culture methods, the detection of low-grade infection in patients with loose implants still presents a challenge. It is crucial to distinguish between "aseptic" loosening and loosening due to periprosthetic infection, so that appropriate treatment can be administered. We investigated whether aseptic loosening of the acetabular components of THPs is due to unrecognized infection. From October through December 2002, a total of 24 patients with acetabular cup loosening were investigated. Only patients without clinical signs of infection and with negative results of bacteriologic culture of synovial fluid (obtained by preoperative aspiration) were included in the study. Intraoperative biopsy samples obtained from the neocapsule and synovia (e.g., the interface membrane) were examined by means of routine culture methods and by polymerase chain reaction (PCR) for detection of 16S ribosomal RNA (rRNA). Control subjects included 9 patients undergoing primary hip arthroplasty. C-reactive protein levels and erythrocyte sedimentation rates were slightly elevated in the group with loosening, compared with the control group, but the difference was not statistically significant. PCR and routine culture showed no microorganisms in either group, with the exception of 1 patient in the loosening group.

Question: Is "aseptic" loosening of the prosthetic cup after total hip replacement due to nonculturable bacterial pathogens in patients with low-grade infection?

PCR for detection of 16S rRNA in tissue specimens obtained from hip joints is not superior to routine bacteriologic culture techniques for detection of low-grade infections. However, these results demonstrate that the loosening of cups in THPs do not usually result from nonculturable periprosthetic infection, if the microbiological processing is adequate.

Answer the question based on the following context: Screening rates for colorectal cancer remain low compared with screening rates for other cancers. The size of the unscreened population and the capacity to provide widespread screening are unknown. We estimated the number of average-risk persons aged 50 years or older not screened for colorectal cancer, the number of procedures required for this population, and the endoscopic capacity to satisfy this unmet need. Using data from the US Census Bureau and the Centers for Disease Control and Prevention's National Health Interview Survey, we designed a forecasting model to estimate the number of persons in the United States currently not screened for colorectal cancer and the number of examinations needed to screen these persons. Test need was compared with available capacity, based on results from the national Survey of Endoscopic Capacity, assuming different proportions of available capacity were used for colorectal cancer screening. Approximately 41.8 million average-risk people aged 50 years or older have not been screened for colorectal cancer according to national guidelines. Sufficient capacity exists to screen the unscreened population within 1 year using fecal occult blood testing followed by diagnostic colonoscopy for positive tests. Depending on the proportion of available capacity used for colorectal cancer screening, it could take up to 10 years to screen the unscreened population using flexible sigmoidoscopy or colonoscopy.

Question: Is there endoscopic capacity to provide colorectal cancer screening to the unscreened population in the United States?

The capacity exists for widespread screening with fecal occult blood testing. The capacity for screening with flexible sigmoidoscopy or colonoscopy depends on the proportion of available capacity used for colorectal cancer screening.

Answer the question based on the following context: The number of elderly offenders in England and Wales is increasing. There is, therefore, a concern that their needs may not be met by existing forensic services. However, there is a paucity of information on elderly patients referred to existing forensic psychiatric units. Data on patients over the age of 65 years referred to a large medium secure forensic psychiatric unit in London were collected for a 13-year period using a retrospective design. The sample was divided into those who had first offended before the age of 65 and those who had offended after the age of 65. Data was also collected on victims of the offences. 5477 referrals were made during the study period. Those aged over 65 years accounted for 78 (1.4%) of all referrals. These 78 referrals were for 55 patients. Forty-five of these had offended. Case notes of 42 patients from this group were screened. Sexual and violent offences accounted respectively for 20 (47%) and 15 (36%) of offences. 31% had no psychiatric disorder but organic disorders accounted for 21% of cases. Only eight (19%) required admission to the medium secure unit. Fourteen (33%) had first offended after the age of 65 while others were known to either the forensic services or criminal justice system before the age of 65. The two groups did not differ from each other.

Question: Is there a case for a specialist forensic psychiatry service for the elderly?

The elderly accounted for very few referrals to the medium secure forensic service, yet there is a high prevalence of psychiatric morbidity in both remand and sentenced elderly prisoners. Therefore, elderly offenders with psychiatric morbidity may benefit from specialist old age psychiatric forensic services, perhaps at a supraregional level.

Answer the question based on the following context: To evaluate the risk of performing inappropriate (131)I ablative therapies for thyroid carcinoma in patients lacking thyroid remnants or metastases, using a strategy of treatment without a preliminary iodine-131 diagnostic whole-body scan (DxWBS). Retrospective evaluation of post-therapy whole-body scans to assess the prevalence of thyroid remnants or metastases after total thyroidectomy. Comparison of (131)I uptake test and thyroglobulin (Tg) off levothyroxine (L-T4) performed before therapy with post-therapy scans, in order to evaluate the ability to predict inappropriate treatments. A group of 875 consecutive patients with previous total or near-total thyroidectomy for differentiated thyroid carcinoma underwent (131)I ablative therapy without a preliminary (131)I-DxWBS. All patients were clinically free of distant metastases and macroscopic residual tumour. Whole-body scans were performed 2-5 days after the treatment as gold standard for thyroid remnants and metastases; 24-h (131)I quantitative neck uptake test and Tg off L-T4 were performed before (131)I therapy. The majority of patients (94%) were found to have thyroid remnants or metastases at post-therapy scans, in most cases (91.2%) with detectable Tg off L-T4 and positive 24-h neck uptake. 14 patients (1.6%) with tiny lymph-node metastases positive at post-therapy scans showed undetectable Tg off L-T4. In 30 patients (3.6%) faint positive post-therapy images for thyroid remnants have been classified as false-positive results on the basis of both negative 24-h neck uptake and undetectable Tg off L-T4.

Question: Are there disadvantages in administering 131I ablation therapy in patients with differentiated thyroid carcinoma without a preablative diagnostic 131I whole-body scan?

This study confirms that most patients have residual thyroid tissue after total thyroidectomy and that it seems reasonable to omit routine diagnostic whole-body scans before (131)I treatment with clinical, managerial and economic advantages.

Answer the question based on the following context: Lung cancer remains to be the leading cause of cancer death worldwide. Patients with similar lung cancer may experience quite different clinical outcomes. Reliable molecular prognostic markers are needed to characterize the disparity. In order to identify the genes responsible for the aggressiveness of squamous cell carcinoma of the lung, we applied DNA microarray technology to a case control study. Fifteen patients with surgically treated stage I squamous cell lung cancer were selected. Ten were one-to-one matched on tumour size and grade, age, gender, and smoking status; five died of lung cancer recurrence within 24 months (high-aggressive group), and five survived more than 54 months after surgery (low-aggressive group). Five additional tissues were included as test samples. Unsupervised and supervised approaches were used to explore the relationship among samples and identify differentially expressed genes. We also evaluated the gene markers' accuracy in segregating samples to their respective group. Functional gene networks for the significant genes were retrieved, and their association with survival was tested. Unsupervised clustering did not group tumours based on survival experience. At p<0.05, 294 and 246 differentially expressed genes for matched and unmatched analysis respectively were identified between the low and high aggressive groups. Linear discriminant analysis was performed on all samples using the 27 top unique genes, and the results showed an overall accuracy rate of 80%. Tests on the association of 24 gene networks with study outcome showed that 7 were highly correlated with the survival time of the lung cancer patients.

Question: Can gene expression profiling predict survival for patients with squamous cell carcinoma of the lung?

The overall gene expression pattern between the high and low aggressive squamous cell carcinomas of the lung did not differ significantly with the control of confounding factors. A small subset of genes or genes in specific pathways may be responsible for the aggressive nature of a tumour and could potentially serve as panels of prognostic markers for stage I squamous cell lung cancer.

Answer the question based on the following context: Computed tomography (CT) of the head is the current standard for diagnosing intracranial pathology following blunt head trauma. It is common practice to repeat the head CT to evaluate any progression of injury. Recent retrospective reviews have challenged the need for serial head CT after traumatic brain injury (TBI). This study intends to prospectively examine the value of routine serial head CT after TBI. Consecutive adult blunt trauma patients with an abnormal head CT admitted to an urban, Level I trauma center from January 2003 to September 2003 were prospectively studied. Variables collected included: initial head CT results, indication for repeat head CT (routine versus neurologic change), number and results of repeat head CT scans, and clinical interventions following repeat head CT. Over the 9-month period, there were 128 patients admitted with an abnormal head CT after sustaining blunt trauma. The 16 patients who died within 24 hours and the 12 patients who went directly to craniotomy were excluded. The remaining 100 patients make up the study population. Abnormal head CT findings were subarachnoid hemorrhage (47%), intraparenchymal hemorrhage (37%), subdural hematoma (28%), contusion (14%), epidural hematoma (11%), intraventricular hemorrhage (3%), and diffuse axonal injury (2%). Overall, 32 patients (32%) had only the admission head CT, while 68 patients (68%) underwent 90 repeat CT scans. Of the repeat head CT scans, 81 (90%) were performed on a routine basis without neurologic change. The remaining 9 (10%) were performed for a change in Glasgow Coma Scale (n = 5), change in intracranial pressure (n = 1), change in Glasgow Coma Scale and intracranial pressure (n = 1), change in pupil size (n = 1), or sudden appearance of a headache (n = 1). Three patients had their care altered after repeat head CT: two underwent craniotomy and one was started on barbiturate therapy. All three patients had their repeat head CT after neurologic change (decrease in Glasgow Coma Scale in 2 and increase in intracranial pressure in 1).

Question: Does routine serial computed tomography of the head influence management of traumatic brain injury?

Serial head CT is common after TBI. Most repeat head CT scans are performed on a routine basis without neurologic change. Few patients with TBI have their management altered after repeat head CT, and these patients have neurologic deterioration before the repeat head CT. The use of routine serial head CT in patients without neurologic deterioration is not supported by the findings of this study.

Answer the question based on the following context: Helmet laws remain controversial. Opponents believe negative findings are a result of biased statistical analyses that fail to account for the impact of alcohol and drugs. In this study, we evaluated the effect that helmet use had upon injury severity, outcome controlling for alcohol or drug use, resource utilization, and financial burden using the National Trauma Data Bank (NTDB). Two groups of patients, helmeted and non-helmeted motorcyclists, were identified using the NTDB over an 8-year period. Group differences were compared using nonparametric Wilcoxon tests for continuous variables and Fisher's exact test for dichotomous outcomes. To evaluate the effect that alcohol or drug use had on mortality, logistic regression models were created. A total of 9,769 patients were identified by the NTDB of which 6756 (69.2%) were helmeted and 3013 (30.8%) were non-helmeted. Helmet use was associated with lower injury severity, mortality, and resource utilization. Non-helmeted motorcyclists accrued greater hospital charges and were significantly less likely to have health insurance. When controlling for alcohol or drug use, mortality continued to be significantly associated with non-helmet use.

Question: Non-helmeted motorcyclists: a burden to society?

Non-helmeted motorcyclists have worse outcomes than their helmeted counterparts independent of the use of alcohol or drugs. Furthermore, they monopolize more hospital resources, incur higher hospital charges, and as non-helmeted motorcyclists frequently do not have insurance, reimbursement in this group of patients is poor. Thus, the burden of caring for these patients is transmitted to society as a whole.

Answer the question based on the following context: The purpose of this study was to determine whether admission non-computed tomography (CT) criteria can exclude intra-abdominal injury in stable patients sustaining blunt abdominal trauma. Seven hundred fourteen hemodynamically stable patients with suspicion of blunt abdominal trauma were included in the study. Admission data for clinical examination, sonography, routine laboratory studies, chest/pelvic radiographic findings, and Glasgow Coma Scale (GCS) score were recorded. Each patient underwent helical abdominal CT. Injuries were considered major if they required surgery or angiographic intervention. At the authors' institution, angiography is routinely performed if there is a splenic injury of American Association for the Surgery of Trauma grade II or higher or a liver injury of American Association for the Surgery of Trauma grade III or higher. Statistical analysis was performed to determine the value of isolated and combined clinical, radiologic, and laboratory parameters in depicting an intra-abdominal injury with regard to CT results and clinical follow-up. The best combination of criteria to identify a major abdominal injury was obtained when sonography, chest radiography, and three laboratory parameters (serum glutamic oxaloacetic transaminase, white blood cell count, and hematocrit) were normal: 22% (129 of 589) of patients without major injuries fulfilled these criteria. The only combination of criteria that completely excluded intra-abdominal injury was obtained when clinical criteria combined with a Glasgow Coma Scale score>13, bedside radiologic studies, and laboratory data were all normal, but only 12% (68 of 578) of patients without abdominal injury fulfilled these criteria.

Question: Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography?

After blunt abdominal trauma, admission non-CT criteria can at best identify 12% of patients without intra-abdominal injuries and 22% of patients without major injuries.

Answer the question based on the following context: Methods available to predict cardiovascular disease (CVD) and coronary heart disease (CHD) risk include the Joint British Societies Risk Chart (JBSRC), the CardioRisk Manager (CRM) calculator, the PROCAM calculation and specific to diabetes, the UKPDS risk engine. Our aim was to examine their efficacy in a clinic-based population of diabetic patients. Patients were identified who attended clinic at baseline (1990-1991) and categorised by the presence/absence of CHD/CVD at follow-up (2000-2001). Ten-year risk was calculated using JBSRC, CRM, PROCAM and the UKPDS risk engine. A total of 798 patients were identified under follow-up (2000-2001), with sufficient data for risk prediction. Risk prediction methods were assessed by: (1) the Hosmer-Lemeshow test (calibration test); (2) the C-index, derived from the ROC curve [a discriminatory measure ranging from 0.5 (no discrimination) to 1.0 (perfect discrimination)]; and (3) Spearman correlation of the observed and predicted risk. All tests (except PROCAM) demonstrated acceptable discrimination with respect to CHD/CVD, however, all underestimated the risk of future events. With respect to CVD, the JBSRC had a C-index of 0.80, CRM: 0.76 0.74 and 0.67. With respect to CHD the C-indexes were 0.77, 0.73, 0.65 and 0.76 respectively. Risk prediction by CRM had a stronger relationship with observed events than UKPDS and PROCAM (r=0.97, 0.86, 0.81 respectively).

Question: Cardiovascular risk and diabetes. Are the methods of risk prediction satisfactory?

All scores have reasonable discrimination, but underestimate future events. The CRM showed the strongest correlation between observed and predicted risk with the least amount of scatter from the line of best fit. The CRM, when adjusted by the calibration factor, provides the most accurate method of risk prediction.

Answer the question based on the following context: The underlying mechanisms of panic attacks (PA's) are still unclear. Theories focusing on these mechanisms differ in their description of the relationship between panic and fear. The main controversy concerns whether a PA resembles the classical flight response, or whether it is qualitatively different from fear. According to the first theory, a PA would result in hypothalamic-pituitary-adrenal axis (HPA-axis) activation, whereas according to the second, it would not. So far, inconclusive results have been reported in studies measuring HPA-axis activity after laboratory evoked PA's. The present study was designed to assess cortisol levels following a 35% CO2 challenge in Panic Disorder (PD) patients compared to healthy volunteers as a measurement of HPA-axis activity. Twenty-three PD patients and 20 healthy volunteers participated in the study. Cortisol was determined in saliva at regular intervals before and after the challenge. Furthermore, attention was paid to possible gender effects. Although the 35% CO2 inhalation induced a significant increase in anxiety, no cortisol increase was found. Moreover, there was no difference between patient and control cortisol values following the 35% CO2 challenge, whereas the delta anxiety scores were far more pronounced in the patient group. Interestingly, male PD patients showed higher cortisol values.

Question: Salivary cortisol in panic: are males more vulnerable?

This study may be in accordance with the view that PA's are not accompanied by an important HPA-axis activation. There are some indications for aberrant cortisol secretion in male PD patients. Further research needs to confirm whether male and female PD patients differ in their underlying mechanisms related to HPA-axis activity.