Datasets:

llamafactory

/

PubMedQA

like 1

Answer the question based on the following context: Worsening of verbal fluency is reported after subthalamic nucleus deep brain stimulation in Parkinson's disease. It is postulated that these changes could reflect microlesion consecutive to the surgical procedure itself. We evaluated verbal fluency, in 26 patients (mean age, 57.9±8.5 years; mean disease duration, 11.4±3.5 years) both before surgery (baseline) and, after surgery respectively the third day (T3), the tenth day (T10) just after STN implantation before turning on the stimulation and at six months (T180). Number of total words and switches was significantly reduced at T3 and T10, while average cluster size was unchanged. Repeated post-operative neuropsychological testing demonstrated reliable improvement from T3 to T180 on verbal fluency.

Question: Early verbal fluency decline after STN implantation: is it a cognitive microlesion effect?

This study provides evidence of transient verbal fluency decline consecutive to a microlesion effect. Further studies needed to determine a putative relationship between early and long-term verbal fluency impairment.

Answer the question based on the following context: β-blockade (BB) has been shown to prevent bone marrow (BM) dysfunction after trauma and hemorrhagic shock (HS). The impact of the sympathetic system and the role of BB on shock-induced distant organ injury is not known. This study will determine if BB has systemic effects and can diminish gut and lung injury after trauma and HS. Male Sprague-Dawley rats were subjected to lung contusion (LC) followed by 45 minute of HS. Animals (n = 6 per group) were then randomized to either receive propranolol (LCHS + BB) immediately after resuscitation or not (LCHS). Gut permeability was evaluated in by diffusion of Mr 4,000 of fluorescein dextran (FD4) from a segment of small bowel into peripheral blood. Villous injury and lung injury were graded histologically by a blinded reader. Plasma-mediated effects of BB were evaluated in vitro by an assessment of BM progenitor growth. Animals undergoing LCHS had significantly higher plasma levels of FD4 compared with control animals (mean [SEM], 2.8 [0.4]µg/mL vs. 0.8 [0.2] µg/mL). However, animals receiving BB had a significant reduction in plasma FD4 compared with the LCHS group. With the use of BB after LCHS, both ileal and lung injury scores were similar to control. In addition, BM progenitor growth was inhibited by the addition of LCHS plasma, and LCHS + BB plasma showed no inhibition of BM progenitor growth.

Question: Is the sympathetic system involved in shock-induced gut and lung injury?

Propranolol can protect against the detrimental effects of trauma and HS on gut permeability, villous, and lung injury. The effects of BB are likely systemic and appear to be mediated through plasma. BB likely blunts the exaggerated sympathetic response after shock and injury. Propranolol's reduction of both BM dysfunction and distant organ injury further demonstrates the importance of the sympathetic nervous system and its role in potentiating end organ dysfunction after severe trauma.

Answer the question based on the following context: Blunt trauma is a leading cause of morbidity and mortality in children. Despite the potential for malignancy, increased cost, limited small bowel injury detection sensitivity, and the low incidence of injury requiring operative intervention, the use of computed tomographic (CT) scan in pediatric blunt trauma evaluation remains common. Previous studies suggest that a clinical model using examination and laboratory data may help predict intra-abdominal injuries (IAIs) and potentially limit unnecessary CT scans in children. A retrospective chart review of all blunt "trauma alerts" for patients younger than 16 years during an 18-month period was performed at a Level I trauma center. Clinical factors, which might predict blunt IAI (hemodynamics, abdominal examination, serology, and plain radiographs), and potential limitations to performing a reliable abdominal examination (altered mental status, young age) were reviewed. A previously defined clinical prediction model based on six high-risk clinical variables for blunt IAI (hypotension, abnormal abdominal examination, elevated aspartate aminotransferase, elevated amylase, low hematocrit, and heme-positive urinalysis) was applied to each patient. Of the 125 "trauma alert" patients who sustained blunt trauma during the study period, 97 underwent abdominal CT scan, with only 15 identified as IAI. Our prediction rule would have identified 16 of 17 patients with IAI (SE, 94%) as high-risk and missed only 1 patient (grade I spleen laceration, which did not require operation) (negative predictive value, 99%). Of the 83 patients with no risk factors for IAI based on the prediction rule, 54 underwent a negative abdominal CT scan. Of these 54 patients, only 22 had a potential limitation to a reliable abdominal examination. Application of our prediction rule could have prevented unnecessary CT scan in at least 32 patients (33%) during an 18-month period.

Question: Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model?

Use of a prediction model based on high-risk variables for IAI may decrease cost and radiation exposure by reducing the number of abdominal CT scans in children being evaluated for blunt abdominal trauma.

Answer the question based on the following context: Negative-pressure wound therapy (NPWT) has been used for to treat wounds for more than 15 years and, more recently, has been used to secure split-thickness skin grafts. There are some data to support this use of NPWT, but the actual mechanism by which NPWT speeds healing or improves skin graft take is not entirely known. The purpose of this project was to assess whether NPWT improved angiogenesis, wound healing, or graft survival when compared with traditional bolster dressings securing split-thickness skin grafts in a porcine model. We performed two split-thickness skin grafts on each of eight 30 kg Yorkshire pigs. We took graft biopsies on postoperative days 2, 4, 6, 8, and 10 and submitted the samples for immunohistochemical staining, as well as standard hematoxylin and eosin staining. We measured the degree of vascular ingrowth via immunohistochemical staining for von Willenbrand's factor to better identify blood vessel epithelium. We determined the mean cross-sectional area of blood vessels present for each representative specimen, and then compared the bolster and NPWT samples. We also assessed each graft for incorporation and survival at postoperative day 10. Our analysis of the data revealed that there was no statistically significant difference in the degree of vascular ingrowth as measured by mean cross-sectional capillary area (p = 0.23). We did not note any difference in graft survival or apparent incorporation on a macroscopic level, although standard hematoxylin and eosin staining indicated that microscopically, there seemed to be better subjective graft incorporation in the NPWT samples and a nonsignificant trend toward improved graft survival in the NPWT group.

Question: Does treatment of split-thickness skin grafts with negative-pressure wound therapy improve tissue markers of wound healing in a porcine experimental model?

We were unable to demonstrate a significant difference in vessel ingrowth when comparing NPWT and traditional bolster methods for split-thickness skin graft fixation. More studies are needed to elucidate the manner by which NPWT exerts its effects and the true clinical magnitude of these effects.

Answer the question based on the following context: Histiocytic sarcoma (HS) is a rare but highly aggressive disease. The cancer-specific survival of patients with HS is short and only limited response to conventional chemotherapy or radiation therapy is seen. Some data from single case reports have suggested efficacy for high-dose chemotherapy and autologous/allogeneic stem cell transplantation. We report on 4 cases of HS, and demonstrate that different druggable receptors are expressed on HS. Using immunohistochemistry, we detected the expression of platelet-derived growth factor receptor, vascular endothelial growth factor receptor and epidermal growth factor receptor, which are all well-known targets for novel targeted agents. Based on the marker profile, different novel targeted therapies including imatinib, sorafenib and bevacizumab were applied to the patients. We observed a varying clinical course for each patient.

Question: Histiocytic sarcoma - targeted therapy: novel therapeutic options?

In our case series, we demonstrated that different receptors, which represent potential targets for novel drugs, are expressed on HS tumor cells. For a definitive assessment of the efficacy of these agents a prospective case study of a larger number of patients should be performed.

Answer the question based on the following context: The US Military has served in some of the most austere locations in the world. In this ever-changing environment, units are organized into smaller elements operating in very remote areas. This often results in longer evacuation times, which can lead to a delay in pain management if treatment is not initiated in the prehospital setting. Early pain control has become an increasingly crucial military prehospital task and must be controlled from the pain-initiating event. The individual services developed their standardized trauma training based on the recommendations by Frank Butler and the Defense Health Board Committee on Tactical Combat Casualty Care. This training stresses evidence-based treatment modalities, including pain control, derived from casualty injury analysis. Inadequate early pain control may lead to multiple acute and potentially chronic effects. These effects encompass a wide range from changes in blood pressure to delayed wound healing and posttraumatic stress disorder. Therefore, it is essential that pain be addressed in the prehospital environment. Institutional Review Board approval was obtained to conduct a retrospective Joint Theater Trauma Registry comparative study evaluating whether standardized trauma training increased prehospital pain medication administration between 2007 and 2009. These years were selected on the basis of mandatory training initiation dates and available Joint Theater Trauma Registry records. Records were analyzed for all US prehospital trauma cases with documented pain medication administration from Operations Enduring Freedom and Iraqi Freedom for the specified years. Data analysis revealed 232 patients available for review (102 for 2007 and 130 for 2009). A statistically significant prehospital pain treatment increase was noted, from 3.1% in 2007 to 6.7% in 2009 (p<0.0005; 95% confidence interval, 2.39-4.93).

Question: The effects of standardized trauma training on prehospital pain control: have pain medication administration rates increased on the battlefield?

Standardized trauma training has increased the administration of prehospital pain medication and the awareness of the importance of early pain control.

Answer the question based on the following context: The chance of a good response in RA is attenuated in previous anti-TNF users who start new anti-TNF therapy compared to biologic naïve patients. In active RA, those with previous anti-TNF exposure compared to anti-TNF naïve may have different baseline disease activity and patient perceptions when starting a new anti-TNF treatment that could explain the observed response differences.MATERIAL/ The aim of this study was a post hoc analysis of baseline characteristics of patients enrolled in the Optimization of Adalimumab study that was a treat to target vs. routine care study in patients initiating adalimumab. As per the protocol, a maximum of 20% anti-TNF experienced patients were enrolled in the 300 patient trial. Twelve (4.0%) were excluded who previously used other biologics. Baseline characteristics including age, gender, tender and swollen joint counts, disease activity (DAS28), function (HAQ-DI), patient global assessment, patient satisfaction with current treatment, and inflammatory markers (CRP, ESR), were compared between previously anti-TNF experienced [etanercept or infliximab (EXP)], and anti-TNF naïve patients (NAÏVE). The mean (SD) age was 54.8 (13.3) years; 81.0% were female, and 237 (79.0%) were anti-TNF naïve while 51 (17.0%) patients were anti-TNF experienced (29 with etanercept, 16 with infliximab, and 6 for both). The mean (SD) baseline in EXP versus NAÏVE groups respectively was: CRP=21.7(32.9) vs. 17.5(20.7); ESR=28.7(22.5) vs. 29.8(20.4); SJC=10.5(6.0) vs. 10.7(5.6); TJC=12.8(7.1) vs. 12.3(7.3); and DAS28=6.0(1.2) vs. 5.8(1.1). None of the between-group differences were statistically significant, however, the HAQ-DI in EXP was 1.7(0.6) compared to 1.5(0.7) for the NAÏVE (P=0.021). Additionally, EXP patients had a higher patient global score [71.3(26.1) vs. 61.9(26.2), P=0.021].

Question: Do patients with active RA have differences in disease activity and perceptions if anti-TNF naïve versus anti-TNF experienced?

Although anti-TNF naïve and experienced patients who initiated adalimumab were similar, with respect to several baseline characteristics, significant differences in subjective measures were observed, which may indicate more severe patient measures (function and global disease activity) in anti-TNF experienced patients.

Answer the question based on the following context: Reasons for inferior outcome of male compared to female breast cancer are still under debate. Therefore, we retrospectively analyzed male breast cancer cases to figure out possible treatment- and gender-related differences. A total of 40 men (median age 62 years) were curatively treated with mastectomy and postoperative radiotherapy from 1982-2007. They presented predominantly in stages II and IIIb. Postoperative radiotherapy was applied with doses of 1.8-2.5 Gy to a median of 50 Gy including regional lymphatics in 22 patients. Adjuvant systemic treatment consisted of chemotherapy (22.5%) and antihormonal treatment (55%). For reasons of comparison, we estimated outcome of a virtual female matched cohort for no/equal to men/optimal adjuvant treatment with the Adjuvant!Online(®) 8.0 algorithm. After a median follow-up of 47 months, the estimated 5-year local control rate was 97%, disease-free and distant metastasis-free survival rates reached 79% and 82%, respectively. With update of survival data by tumor registry, mean overall survival reached 120 months with 5- and 10-year overall survival rates of 66% and 43%, respectively. Predominant prognostic factor was T-stage for overall survival (T1/2 vs. T4:>80% vs. 30%). The generated virtual matched cohorts of women with equal characteristics reached superior 10-year-overall survival for no/equal to men/optimal adjuvant treatment with 55/59/68%.

Question: Are there biologic differences between male and female breast cancer explaining inferior outcome of men despite equal stage and treatment?

Compared to historical and virtual matched cohorts of women, male breast cancer patients had inferior outcome despite of equal stage and treatment which indicates that biological differences (of tumor or population) may contribute to worse prognosis.

Answer the question based on the following context: Theory of Mind (ToM) refers to the ability to understand the subjectivity of people's intentions, desires, and beliefs. Research shows that ToM in deaf children is delayed, yet the few studies that examined ToM in deaf children with a cochlear implant (CI) report contradictory results. This study examined multiple aspects of ToM in early-implanted children. 3 intention tasks were administered to 72 children with CI and 69 normal-hearing children (age, 12-60 months). Furthermore, 3 desire and belief tasks were administered to a subsample of children aged 30 months or over. Children with CI showed intention-understanding skills equal to normal-hearing children, but lagged behind on desire and belief understanding, even after excluding children with language delays.

Question: Does hearing lead to understanding?

Children with CI appear to master the initial stages of ToM development, but fall behind on more advanced ToM abilities. Yet, both groups showed similar patterns of development.

Answer the question based on the following context: An inverse relationship between major depressive disorder (MDD) and bone mineral density (BMD) has been suggested, but prospective evaluation in premenopausal women is lacking. Participants of this prospective study were 21 to 45 year-old premenopausal women with MDD (n = 92) and healthy controls (n = 44). We measured BMD at the anteroposterior lumbar spine, femoral neck, total hip, mid-distal radius, trochanter, and Ward's triangle, as well as serum intact parathyroid hormone (iPTH), ionized calcium, plasma adrenocorticotropic hormone (ACTH), serum cortisol, and 24-hour urinary-free cortisol levels at 0, 6, 12, 24, and 36 months. 25-hydroxyvitamin D was measured at baseline. At baseline, BMD tended to be lower in women with MDD compared to controls and BMD remained stable over time in both groups. At baseline, 6, 12, and 24 months intact PTH levels were significantly higher in women with MDD vs. controls. At baseline, ionized calcium and 25-hydroxyvitamin D levels were significantly lower in women with MDD compared to controls. At baseline and 12 months, bone-specific alkaline phosphatase, a marker of bone formation, was significantly higher in women with MDD vs. controls. Plasma ACTH was also higher in women with MDD at baseline and 6 months. Serum osteocalcin, urinary N-telopeptide, serum cortisol, and urinary free cortisol levels were not different between the two groups throughout the study.

Question: Do premenopausal women with major depression have low bone mineral density?

Women with MDD tended to have lower BMD than controls over time. Larger and longer studies are necessary to extend these observations with the possibility of prophylactic therapy for osteoporosis.

Answer the question based on the following context: Our previous research and other studies with radiotracers showed evidence of a centripetal drainage pathway, separate from blood or lymphatic vessels, that can be visualized when a small amount of low molecular weight tracer is injected subcutaneously into a given region on skin of humans. In order to further characterize this interesting biological phenomenon, animal experiments are designed to elucidate histological and physiologic characteristics of these visualized pathways. Multiple tracers are injected subcutaneously into an acupuncture point of KI3 to visualize centripetal pathways by magnetic resonance imaging or fluorescein photography in 85 healthy rabbits. The pathways are compared with venography and indirect lymphangiography. Fluid flow through the pathways is observed by methods of altering their hydrated state, hydrolyzing by different collagenases, and histology is elucidated by optical, fluorescein and electron microscopy. Histological and magnetic imaging examinations of these visualized pathways show they consist of perivenous loose connective tissues. As evidenced by examinations of tracers' uptake, they appear to function as a draining pathway for free interstitial fluid. Fluorescein sodium from KI3 is found in the pathways of hind limbs and segments of the small intestines, partial pulmonary veins and results in pericardial effusion, suggesting systematical involvement of this perivenous pathway. The hydraulic conductivity of these pathways can be compromised by the collapse of their fiber-rich beds hydrolyzed by either of collagenase type I, III, IV or V.

Question: Fluid flow along venous adventitia in rabbits: is it a potential drainage system complementary to vascular circulations?

The identification of pathways comprising perivenous loose connective tissues with a high hydraulic conductivity draining interstitial fluid in hind limbs of a mammal suggests a potential drainage system complementary to vascular circulations. These findings may provide new insights into a systematically distributed collagenous connective tissue with a circulatory function and their potential relevance to the nature of acupuncture meridians.

Answer the question based on the following context: Perinatal research on anxiety and depression has primarily focused on mothers. We have limited knowledge of fathers' anxiety during the perinatal period yet there is evidence that the parenting capacity of a person can be compromised by anxiety and depression. The purpose of this paper is to identify the impact of a father inclusive intervention on perinatal anxiety and depression. The prime focus of the intervention was to provide education and support to fathers of breastfeeding partners with the aim of increasing both initiation and duration of breastfeeding. A repeated measures cohort study was conducted during a RCT that was implemented across eight public maternity hospitals in Perth, Western Australia between May 2008 and June 2009. A baseline questionnaire which included the Hospital Anxiety and Depression Scale (HADS) was administered to all participants on the first night of their hospital based antenatal education program and was repeated at six weeks postnatal. SPSS version 17 was used for reporting descriptive results. The mean anxiety levels at baseline for the fathers in the intervention group (n=289) and control group (n=244) were 4.58 and 4.22 respectively. At 6 weeks postnatal (only matched pairs), intervention and control group were 3.93 and 3.79. More intervention group fathers self-rated less anxiety compared to the fathers in the control group from baseline to post test (p=0.048). Depression scores for intervention fathers at baseline (mean=1.09) and at six weeks (mean=1.09) were very similar to fathers in the control group at baseline (mean=1.11) and at six weeks (mean=1.07) with no significant changes.

Question: Can father inclusive practice reduce paternal postnatal anxiety?

Both intervention and control group fathers experienced some anxiety prior to the birth of their baby, but this was rapidly reduced at six weeks. Paternal anxiety is common to new fathers and providing them with information and strategies for problem-solving can increase their knowledge and potentially lower the risk of postnatal anxiety.

Answer the question based on the following context: Crohn's disease (CD), Ulcerative Colitis (UC) and Indeterminate Colitis (IC), commonly known as Inflammatory Bowel Disease (IBD) represent a heterogeneous group of chronic diseases of unknown origin and varying course, diagnosed in pediatric age at 25 to 30% of cases. Epidemiological international studies studies show IBD incidence has increased exponentially in industrialized nations over the last 50 years. Characterization of the pediatric population diagnosed with IBD, followed at medical consultation in Gastroenterology at Hospital de Dona Estefânia (HDE). Descriptive and retrospective study by consulting the medical files of patients diagnosed with IBD followed between 1987 and 2009 (23 years). Clinical, radiological and histological criteria were used to define IBD. The following variables were studied: sex, family history, race, characterization of IBD, age at diagnosis, time from onset of symptoms to diagnosis and clinical presentation. Four different periods of time were compared: 1987-1992, 1993-1998, 1999-2004 and 2005-2009. 100 children were included (51 female), of which 59% are CD, 38% UC and 3% IC. Family history of IBD was present in 7 cases, with no sex difference between UC and CD. During the period of time between 2005-2009, it was registered the highest number of new cases (55 total, mean: 11 cases / year) and between 1987-1992 the lowest (9, 1.5 cases / year). Time from onset of symptoms to diagnosis was highly variable, ranging from 9 months (1987-1992) to 4 months (2005-2009). Children's age at the time of diagnosis varied from 14 months to 17 years, with a mean of 10.5 years. The most common symptoms at time of presentation were abdominal pain, diarrhea, and hematochezia.

Question: Pediatric inflammatory bowel disease: is it still increasing?

IBD are a heterogeneous group of diseases, not always easy to diagnose and difficult to classify as diagnostic criteria are not always uniform. The results show the number of IBD new cases has been rising during the last two decades, mainly CD, with no difference between gender. Time from onset of symptoms to diagnosis has been decreasing although age at time of diagnosis and clinical presentation has showed no difference in the last 20 years.

Answer the question based on the following context: Multimorbidity is known for its negative effects on health related functioning. It remains unclear if these effects are stable over time. The aim was to investigate if the relation between single morbidity/multimorbidity and health related functioning is temporary or persistent. Data were collected as part of the Maastricht Aging Study (MAAS), a prospective study into the determinants of cognitive aging. Participants (n=1184), 24-81 years old, were recruited from a patient database in primary care (Registration Network Family Practices). Morbidity status (i.e. healthy, single morbidity or multimorbidity) and the Short Form Health Survey (SF-36) were both assessed at baseline, at 3- and 6-year follow-up. At baseline but not at 3- and 6-year follow-up, participants with single morbidity reported poorer physical functioning than their healthy counterparts. Multimorbidity was associated with poorer physical functioning at all measurements. Participants with multimorbidity showed a steep decrease in physical functioning between 3- and 6-year follow-up. Multimorbidity appeared to be unrelated to mental functioning. At baseline and at 3-year follow-up, participants who had a change in morbidity status reported poorer physical functioning than their healthy counterparts.

Question: The effect of multimorbidity on health related functioning: temporary or persistent?

Poorer physical functioning that accompanies multimorbidity is persistent and may even increase over time. People, who acquire one or more diseases during the 3-year follow-up, already showed poorer physical functioning at baseline compared to people who remained healthy during these years. Post-hoc analyses, using the SCL-90 as an outcome measure, did show that multimorbidity was related to depressive and anxiety complaints. However, these complaints seem to decline over time.

Answer the question based on the following context: To determine the effect of a six-week exercise intervention on gross motor function for non-ambulant children with cerebral palsy. A parallel arm randomized controlled trial. Four special schools. Thirty-five children aged 8-17 with bilateral cerebral palsy; Gross Motor Function Classification System levels IV-V. Participants were randomly allocated to a static bike group, a treadmill group or control group. Participants in the bike and treadmill groups received exercise training sessions, three times weekly for six weeks. The control group received their usual care. Blinded assessments were performed at baseline and six weeks and followed up at 12 and 18 weeks. Gross Motor Function Measures GMFM-66, GMFM-88D and GMFM-88E. At six weeks significant differences were found in GMFM-88D scores between the bike group and the control group, and the treadmill group and the control group (P<0.05). The mean change (SD) in GMFM-88D score was 5.9 (6.8) for the bike group; 3.7 (4.4) for the treadmill group and 0.5 (1.9) for the control group. No significant differences were found for GMFM-66 or GMFM-88E scores between the bike group and control group, or the treadmill group and control group, although trends of improvement were observed for both exercise groups. The improvements observed declined during the follow-up period.

Question: Can a six-week exercise intervention improve gross motor function for non-ambulant children with cerebral palsy?

This study provides preliminary evidence that exercising on a bike or treadmill may provide short-term improvements in gross motor function for non-ambulant children with cerebral palsy. This needs to be tested in a large-scale randomized trial.

Answer the question based on the following context: Cosmetic breast implants may impair the ability to detect breast cancers. The aims of this study were to examine whether implants and implant characteristics are associated with more advanced breast tumors at diagnosis and poorer survival. Study population includes all invasive breast cancer cases diagnosed during follow-up of the large Canadian Breast Implant Cohort. A total of 409 women with cosmetic breast implants and 444 women with other cosmetic surgery were diagnosed with breast cancer. These women were compared for stage at diagnosis using multinomial logistic regression models. Cox proportional hazards regression models were used for breast cancer-specific mortality analyses. Comparisons were also conducted according to implant characteristics. Compared with women with other cosmetic surgery, those with cosmetic breast implants had at later stage breast cancer diagnosis (OR of having stage III/IV vs. stage I at diagnosis: 3.04, 95% confidence interval (CI): 1.81-5.10; P<0.001). A nonstatistically significant increase in breast cancer-specific mortality rate for women with breast implants relative to surgical controls was observed (HR = 1.32, 95% CI: 0.94-1.83, P = 0.11). No statistically significant differences in stage and breast cancer mortality were observed according to implant characteristics.

Question: Do breast implants adversely affect prognosis among those subsequently diagnosed with breast cancer?

At diagnosis, breast cancers tended to be at more advanced stages among women with cosmetic breast implants. Breast cancer-specific survival was lower in these women although the reduction did not reach statistical significance.

Answer the question based on the following context: The incidence of ureteropelvic junction obstruction (UPJO) and concomitant vesicoureteral reflux (VUR) ranges from 14 to 18 %. Therefore, different guidelines recommend a voiding cystourethrogram (VCUG) to identify cases of VUR early in the diagnostic process. Aim of this multicenter study was to reassess the incidence of concomitant VUR and the need for additional VCUG in a large cohort of patients with UPJO. Furthermore, we asked for clinical objectives that defined the need for VCUG with the intention of minimizing radiation exposure and the need for invasive diagnostic procedures. Medical records for 266 patients (69 girls, 197 boys) with UPJO were analyzed retrospectively. Data were obtained on gender, clinical symptoms, results of pre- and postnatal ultrasound, VCUG and 99(m)Technetium-MAG3 (MAG3) scan. They were correlated with the incidence of concomitant VUR. One hundred and seventy-eight patients (67 %) underwent VCUG. Concomitant VUR was detected in 13 patients. Dilating VUR (dVUR) was observed in 11 patients. In our study, the overall incidence of a concomitant VUR was 7.3 %. In cases of proven VUR, we observed a positive predictive value for female gender, ureteral dilatation, renal insufficiency, and recurrent urinary tract infections (UTI). But there was no correlation between concomitant VUR and the severity of hydronephrosis.

Question: Children and adolescents with ureteropelvic junction obstruction: is an additional voiding cystourethrogram necessary?

Our data suggest that the low incidence of concomitant VUR in cases of UPJO does not justify the routine use of VCUG as a routine diagnostic tool. Especially, ureteral dilatation and recurrent UTI have a positive predictive value for concomitant VUR.

Answer the question based on the following context: Blood hemoglobin (Hb) can be continuously monitored utilizing noninvasive spectrophotometric finger sensors (Masimo SpHb). SpHb is not a consistently accurate guide to transfusion decisions when compared with laboratory Co-Oximetry (tHb). We evaluated whether a finger digital nerve block (DNB) would increase perfusion and, thereby, improve the accuracy of SpHb. Twenty adult patients undergoing spinal surgery received a DNB with lidocaine to the finger used for the monitoring of SpHb. SpHb-tHb differences were determined immediately following the DNB and approximately every hour thereafter. These differences were compared with those in our previously reported patients (N = 20) with no DNB. The SpHb-tHb difference was defined as "very accurate" if <0.5 g/dL and "inaccurate" if >2.0 g/dL. Perfusion index (PI) values at the time of each SpHb-tHb measurement were compared. There were 57 and 78 data points in this and our previous study, respectively. The presence of a DNB resulted in 37 % of measurements having SpHb values in the "very accurate group" versus 12 % in patients without a DNB. When the PI value was >2.0, only 1 of 57 DNB values was in the "inaccurate" group. The PI values were both higher and less variable in the patients who received a DNB.

Question: Does a digital regional nerve block improve the accuracy of noninvasive hemoglobin monitoring?

A DNB significantly increased the number of "very accurate" SpHb values and decreased the number of "inaccurate" values. We conclude that a DNB may facilitate the use of SpHb as a guide to transfusion decisions, particularly when the PI is >2.0.

Answer the question based on the following context: Despite lack of evidence-based support, chest X-ray (CXR) prior to thyroid surgery is often used to identify tracheal deviation that may predict difficulty with intubation. The aim of this study is to establish the utility of preoperative CXR to assess tracheal deviation in this group of patients. We analyzed a prospective database of 1,000 consecutive patients who underwent thyroid surgery. Patients' charts were reviewed for demographic data, CXR readings, other imaging findings, anesthesia records, and pathology findings. Patients with tracheal deviation (TD) on CXR were compared to patients without (no TD). Six hundred eighty-nine (69 %) patients had a CXR performed prior to surgery. TD was identified in 252 (37 %) patients while 437 (63 %) did not have TD. The two groups did not significantly differ in mean age, BMI, or gender. Patients with TD on CXR had larger thyroid glands (51 ± 4 vs. 28 ± 2 g, p<0.001) and reported a higher rate of tracheal compressive symptoms (19 vs. 12 %, p = 0.005). However, this did not translate into more difficult intubations as reported by the anesthesiologist (5 vs. 7 %, p = 0.31) or more intubation attempts (1.2 ± 0 vs. 1.1 ± 0, p = 0.1). Lung findings on CXR that resulted in further workup were identified in 32 (5 %) patients, with additional pathology found in only 6 (1 %) patients.

Question: Routine chest X-ray prior to thyroid surgery: is it always necessary?

There is no correlation between a finding of tracheal deviation on preoperative CXR and difficult intubation in thyroid patients. Therefore, CXR for the sole purpose of identifying tracheal deviation in thyroid surgery candidates is not warranted.

Answer the question based on the following context: Metachronous autotransplantation of cryopreserved parathyroid tissue is a technique for treating postoperative hypoparathyroidism after parathyroid surgery for renal hyperparathyroidism (rHPT). The aim of the present study was to evaluate our institution's experience with metachronous autotransplantation to analyze the role of cryopreservation in the treatment of rHPT and to determine for whom and when cryopreservation of parathyroid tissue should be deemed necessary. A prospective database of patients with rHPT who underwent surgery between 1976 and 2011 was screened for patients with hypoparathyroidism who received a metachronous autotransplantation. Data were analyzed regarding clinical data, histopathological findings of the cryopreserved parathyroid tissues, and patient outcome after metachronous replantation of parathyroid tissue. Fifteen of 883 patients with rHPT underwent a metachronous autotransplantation under local anesthesia at a mean time of 23 months following the last cervical surgery. Histopathology of the parathyroid tissue chosen for transplantation revealed a necrosis rate of 0 % in 14 and 70 % in one patient. Mean preoperative serum calcium and parathyroid hormone (PTH) levels were 2.0 mmol/l and 3.7 pg/ml, respectively. Autotransplantation raised mean serum calcium and PTH levels to 2.2 mmol/l and 97.5 pg/ml, respectively, after a mean follow-up of 78 months.

Question: Cryopreservation of parathyroid tissue after parathyroid surgery for renal hyperparathyroidism: does it really make sense?

Metachronous autotransplantation following parathyroid surgery in patients with rHPT effectively normalizes PTH and calcium levels. The success rate is high if an adequate cryopreservation procedure is applied. However, it is rarely necessary, and therefore the cryopreservation of parathyroid tissue in all patients has to be questioned, at least from an economic point of view.

Answer the question based on the following context: Self-reported prescription medication use data is often used to measure differences across ethnic groups, but its accuracy may differ across ethnic groups. We compared ethnic groups' self-reported medication use to their administrative records for respondents with diabetes, hypertension, and asthma. We linked the Canadian Community Health Survey to administrative prescription drug records for 17,191 respondents in British Columbia, Canada. We evaluated the concordance between self-reported medication use and prescription drug records using positive predictive value, negative predictive value, sensitivity, specificity, and kappa statistic for self-identified Whites, Chinese, South Asians, and Southeast Asians/Filipinos. The concordance was calculated using prescription drug records as the reference standard. We also estimated the odds of disagreement (either a false positive or negative) in medication use with logistic regressions for each ethnic group, and compared them using the Blinder-Oaxaca method. We found that Chinese had the worst positive predictive value for asthma medication use at 0.41, while South Asians had the worst sensitivity for hypertension medication use at 0.60. The difference in reporting an error between ethnic groups was likely explained by differences in respondent characteristics. Particularly, if White respondents had the same characteristics as South Asians, then White respondents would have had 1.031 (95% CI: 1.020-1.041) higher odds of disagreement for hypertension medication use than with their own characteristics.

Question: Does concordance between survey responses and administrative records differ by ethnicity for prescription medication?

Self-reported medication use may be a valid measure of ethnic groups' medication use if ethnic differences in characteristics, like household income are held constant. However, an important determinant of validity for all ethnic groups is whether medications are used routinely, or for a specific episode.

Answer the question based on the following context: To investigate the prognostic value of autonomic variables in patients with symptomatic chronic heart failure (HF) treated according to current recommendations. We analysed 24 h time-domain [standard deviation of all normal-to-normal RR intervals (SDNN)], frequency-domain [very low frequency and low frequency power (VFLP and LFP)], and non-linear [detrended fluctuation analysis (DFA)] heart rate variability, deceleration capacity (DC), and heart rate turbulence (HRT) in 388 sinus rhythm HF patients enrolled in the GISSI-HF Holter substudy [82% males, age 65 ±10 years, New York Heart Association (NYHA) functional class III-IV 20%, left ventricular ejection fraction (LVEF) 33 ±8%]. Cardiovascular (CV) mortality and combined sudden death + implantable cardioverter defibrillator (ICD) discharge were assessed as a function of continuous variables in the entire population and in patients with LVEF>30% in univariate and multivariable Cox proportional hazards models. After a median of 47 months, 57 patients died of CV causes and 47 experienced the arrhythmic endpoint. For CV mortality, VLFP, LFP, and turbulence slope (TS) improved predictive discrimination (c-index) and risk classification [integrated discrimination improvement (IDI)] when added to clinical variables [age ≥70 years, LVEF, non-sustained ventricular tachycardia (NSVT), serum creatinine], while for arrhythmic mortality although the c-index increased in all three autonomic markers, the results of the IDI were statistically significant only for TS when added to NSVT, serum creatinine, and ischaemic aetiology. In 194 patients with LVEF>30% (20 arrhythmic events), the hazard ratio of an impaired TS (<2.5 msper RR interval) was 3.81 (95% confidence interval 1.35-10.7,P = 0.012) after adjustment for serum creatinine.

Question: Autonomic markers and cardiovascular and arrhythmic events in heart failure patients: still a place in prognostication?

Autonomic indexes still have independent predictive value on long-term outcome in HF patients. HRT may help in identifying patients with LVEF>30% at increased arrhythmic risk. Trial registration NCT00336336.

Answer the question based on the following context: To estimate the prevalence of sleep problems and the effect of potential correlates in low-income settings from Africa and Asia, where the evidence is lacking. Cross-sectional. Community-wide samples from 8 countries across Africa and Asia participating in the INDEPTH WHO-SAGE multicenter collaboration during 2006-2007. The participating sites included rural populations in Ghana, Tanzania, South Africa, India, Bangladesh, Vietnam, and Indonesia, and an urban area in Kenya. There were 24,434 women and 19,501 men age 50 yr and older. N/A. Two measures of sleep quality, over the past 30 days, were assessed alongside a number of sociodemographic variables, measures of quality of life, and comorbidities. Overall, 16.6% of participants reported severe/extreme nocturnal sleep problems, with a striking variation across the 8 populations, ranging from 3.9% (Purworejo, Indonesia and Nairobi, Kenya) to more than 40.0% (Matlab, Bangladesh). There was a consistent pattern of higher prevalence of sleep problems in women and older age groups. In bivariate analyses, lower education, not living in partnership, and poorer self-rated quality of life were consistently associated with higher prevalence of sleep problems (P<0.001). In multivariate logistic regression analyses, limited physical functionality or greater disability and feelings of depression and anxiety were consistently strong, independent correlates of sleep problems, in both women and men, across the 8 sites (P<0.001).

Question: Sleep problems: an emerging global epidemic?

A large number of older adults in low-income settings are currently experiencing sleep problems, which emphasizes the global dimension of this emerging public health issue. This study corroborates the multifaceted nature of sleep problems, which are strongly linked to poorer general well-being and quality of life, and psychiatric comorbidities.

Answer the question based on the following context: Growing evidence points to a causative relationship between altered activity of peroxisome proliferator-activated receptor γ (PPARγ) and psoriasis on the one hand, and its relationship with metabolic syndrome (MS) on the other. Could altered PPARγ levels be one of the culprits responsible for translating the metabolic state among psoriatic patients? This investigational cross-sectional study included 60 psoriatics and 60 controls. Subjects were subgrouped according to the presence or absence of MS. Biopsies were taken from all subjects for immunohistochemical staining for PPARγ and western blot technique was carried out. PPARγ immunostaining in psoriatics was significantly lower than in controls with the lowest levels documented in patients with MS (P<0.001). PPARγ immunostaining level was significantly lower in diabetics, hypertensive and insulin resistance patients (P<0.05). It also showed a significant positive correlation with high density lipoprotein (HDL) levels and significant negative correlation with age, psoriasis area and severity index (PASI), body mass index, and blood glucose levels. Similar results were obtained by western blot technique.

Question: Psoriasis and metabolic syndrome: is peroxisome proliferator-activated receptor-γ part of the missing link?

Reduced PPARγ could be added to the factors responsible for translating the metabolic state among psoriatic patients. PPARγ agonists can present an adjuvant therapeutic tool in treatment of psoriatics with MS.

Answer the question based on the following context: To present the feasibility and safety of fluoro-less endoscopic treatment of ureteral stones to diminish radiation exposure of the patient and operating team, and to determine circumstances where a fluoroscopic imaging is mandatory. Between 2010 and 2011, 93 patients with ureteral calculi who underwent ureteroscopic treatment by experienced urologists were retrospectively evaluated. Manipulations, such as guidewire, ureteral stent insertion, and balloon dilatation were performed with visual and tactile cues. Patient demographics, need for fluoroscopic imaging, operation and fluoroscopy time, and complication and success rates were investigated. The mean age of patients was 34.03 ± 12.09 years (range, 9-63 years). The mean stone size was 10.64 ± 3.16 mm (range, 6-17 mm). The stones were localized in the proximal, middle, and distal segments in 11, 30, and 52 patients, respectively. The mean duration of the operation was 34.51 ± 7.94 minutes (range, 24-55 minutes). Stone-free status was achieved for 90 patients (96.77%). Fluoroscopic imaging was required for 7 patients with a mean fluoroscopy time of 9 ± 4.72 seconds (range, 4-16 seconds) for the following reasons: stone migration to the kidney (3 patients), double collecting system with 2 ureters (1 patient), and ureteral orifice stricture extending to the upper segment (1 patient). No major complications were observed, but minor complications were observed in 11 patients (11.8%).

Question: Is fluoroscopic imaging mandatory for endoscopic treatment of ureteral stones?

The ureteroscopic treatment of ureteral stones can be safely and effectively performed in experienced hands, with limited or no usage of fluoroscopy except in special circumstances, such as anatomic abnormalities, upper ureteral strictures, and impacted ureteral stones leading to ureteral tortuosity, kinking, and obstruction.

Answer the question based on the following context: Identification of attributes of residency training that predict competency would improve surgical education. We hypothesized that case experience during residency would correlate with self-reported competency of recent graduates. Aggregate case log data of residents enrolled in 2 general surgery programs were collected over a 12-month period and stratified into Surgical Council on Resident Education (SCORE) categories. We surveyed recent (<5 yr) residency graduates on procedural competency. Resident case volumes were correlated with survey responses by SCORE category. In all, 75 residents performed 11 715 operations, which were distributed by SCORE category as follows: essential-common (EC) 9935 (84.8%), essential-uncommon (EU) 889 (7.6%) and complex 891 (7.6%). Alimentary tract procedures were the most commonly performed EC (2386, 24%) and EU (504, 56.7%) procedures. The least common EC procedure was plastic surgery (4, 0.04%), and the least common EU procedure was abdomen-spleen (1, 0.1%). The questionnaire response rate was 45%. For EC procedures, self-reported competency was highest in skin and soft tissue, thoracic and head and neck (each 100%) and lowest in vascular-venous (54%), whereas for EU procedures it was highest in abdomen-general (100%) and lowest in vascular-arterial (62%). The correlation between case volume and self-reported competency was poor (R = 0.2 for EC procedures).

Question: Does operative experience during residency correlate with reported competency of recent general surgery graduates?

Self-reported competency correlates poorly with operative case experience during residency. Other curriculum factors, including specific rotations and timing, balance between inpatient and outpatient surgical experience and competition for cases, may contribute to procedural competency acquisition during residency.

Answer the question based on the following context: Surgical residency has the reputation of being arduous and stressful. We sought to determine the stress levels of surgical residents, the major causes of stress and the coping mechanisms used. We developed and distributed a survey among surgical residents across Canada. A total of 169 participants responded: 97 (57%) male and 72 (43%) female graduates of Canadian (83%) or foreign (17%) medical schools. In all, 87% reported most of the past year of residency as somewhat stressful to extremely stressful, with time pressure (90%) being the most important stressor, followed by number of working hours (83%), residency program (73%), working conditions (70%), caring for patients (63%) and financial situation (55%). Insufficient sleep and frequent call was the component of residency programs that was most commonly rated as highly stressful (31%). Common coping mechanisms included staying optimistic (86%), engaging in enjoyable activities (83%), consulting others (75%) and exercising (69%). Mental or emotional problems during residency were reported more often by women (p = 0.006), who were also more likely than men to seek help (p = 0.026), but men reported greater financial stress (p = 0.036). Foreign graduates reported greater stress related to working conditions (p<0.001), residency program (p = 0.002), caring for family members (p = 0.006), discrimination (p<0.001) and personal and family safety (p<0.001) than Canadian graduates.

Question: Is Canadian surgical residency training stressful?

Time pressure and working hours were the most common stressors overall, and lack of sleep and call frequency were the most stressful components of the residency program. Female sex and graduating from a non-Canadian medical school increased the likelihood of reporting stress in certain areas of residency.

Answer the question based on the following context: A prerequisite for a valuable surgical case log is the ability to perform an accurate self-assessment. Studies have shown mixed results when examining residents' ability to self-assess on varying tasks. We sought to examine the correlation between residents' self-assessment and staff surgeons' evaluation of surgical involvement and competence in performing primary total knee (TKA) and hip arthroplasty (THA). We used the intraclass correlation coefficient (ICC) to evaluate interobserver agreement between residents' self-perception and staff surgeons' assessment of involvement. An assessment of competency was performed using a categorical global scale and evaluated with the κ statistic. We piloted a structured surgical skills assessment form as an additional objective appraisal of resident involvement. We analyzed assessment data from 65 primary TKA and THA cases involving 17 residents and 17 staff surgeons (93% response rate). The ICC for resident involvement between residents and staff surgeons was 0.80 (95% confidence interval [CI] 0.69-0.88), which represents substantial agreement. The agreement between residents and staff surgeons about residents' competency to perform the case had a κ value of 0.67 (95% CI 0.50-0.84). The ICC for resident, staff surgeon and third-party observer using the piloted skills assessment form was 0.82 (95% CI 0.75-0.88), which represents substantial agreement.

Question: Resident self-assessment of operative experience in primary total knee and total hip arthroplasty: Is it accurate?

This study supports the ability of orthopedic residents to perform self-assessments of their degree of involvement and competency in primary TKA and THA. Staff surgeons' assessment of resident involvement correlated highly with the surgical skills assessment form. Self-assessment is a valuable addition to the surgical case log.

Answer the question based on the following context: To update trends in mortality by ethnic group from the New Zealand Census-Mortality Study (NZCMS), by additionally linking 2004-06 mortality records to the 2001 Census. To investigate possible bias from this extended linkage, especially for Pacific and Asian people who emigrate more frequently. Anonymous and probabilistic record linkage of 2004-06 mortality records with the 2001 Census was undertaken. Age-standardised 1-74 year old mortality rates by sex and age group, and for all-cause and selected causes of death, were calculated using the direct method for first 30 months post 2001 Census (2001-03) and second 30 months (2003-06). Observed all-cause mortality rates continued to fall in 2003-06 compared to previous periods, but more so for Pacific (18.3% and 21.7% for males and females for 2003-06 compared to 2001-04, respectively) and Asian (22.2%, 16.7%), than for Maori (13.2%, 14.2%) and European/Other (13.0%, 10.4%). Observed rate ratios for Maori, compared to European/Other were 2.43 (95% CI 2.31-2.57) for males and 2.72 (2.56-2.89) for females, the same (males) and slightly less (7%, females) than in 2001-03. Declines in cardiovascular disease (CVD) and injury mortality were the main drivers of all-cause mortality rate reductions for all ethnic groups. Relative inequalities in CVD between Maori and European/Other remain high (three to four-fold relative risks), but reduced by 8% for both males and females from 2001-03 to 2003-06, which in turn means that absolute inequalities closed by as much as 20%.

Question: Mortality by ethnic group to 2006: is extending census-mortality linkage robust?

We suspect that analyses comparing mortality rates over time within one of the closed NZCMS cohorts (e.g. 2001-03 compared to 2003-06) is prone to bias due to our inability to censor people when they migrate out of New Zealand. This limitation means mortality rates in the NZCMS are increasingly underestimated with time since census night, particularly for Pacific and Asian people. However, previously published NZCMS trends remain valid as the duration of follow-up (3 years) is short, and cohorts were not split by time since census. Nevertheless, it is safe to conclude that mortality rates continued to decline from 2001-03 to 2003-04 for all four ethnic groups. All-cause mortality inequalities for Maori compared to European/Other over this time were probably stable in relative terms and decreasing in absolute terms, but cardiovascular disease (CVD) inequalities probably decreased in both absolute and relative terms.

Answer the question based on the following context: To choose between laparoscopic "vascular hitch" (VH) and dismembered pyeloplasty (DP) in treatment of aberrant lower pole crossing vessels potentially responsible for pelviureteric junction obstruction (PUJO) in older children. Retrospective study of 19 patients treated laparoscopically for PUJO. Based on videos of the procedures, we studied the anatomical relationship between the renal pelvis, the pelviureteric junction, and the aberrant vessels. Eight patients had laparoscopic VH and 11 had DP. All patients with DP needed drainage. In the VH group, 7/8 patients were asymptomatic and had decreased pelvic dilation. Half of them accepted MAG3 scintigraphy, and in these patients the obstructive syndrome disappeared completely. The last patient in this group was lost to follow-up. We observed three anatomical variations in the location of polar vessels: type 1 (in front of the dilated pelvis), type 2 (in front of the pelviureteric junction), type 3 (under the pelviureteric junction, resulting in ureteral kinking).

Question: Lower pole vessels in children with pelviureteric junction obstruction: laparoscopic vascular hitch or dismembered pyeloplasty?

Laparoscopic VH is a simple technique involving no urinary anastomosis or drainage, but we cannot guarantee that the crossing vessels are the sole etiology for PUJO. Following our experience, only patients with type 3 anatomical variations and with a normal pelviureteric junction should be proposed for VH.

Answer the question based on the following context: Food systems account for 18-20% of UK annual greenhouse gas emissions (GHGEs). Recommendations for improving food choices to reduce GHGEs must be balanced against dietary requirements for health. We assessed whether a reduction in GHGEs can be achieved while meeting dietary requirements for health. A database was created that linked nutrient composition and GHGE data for 82 food groups. Linear programming was used iteratively to produce a diet that met the dietary requirements of an adult woman (19-50 y old) while minimizing GHGEs. Acceptability constraints were added to the model to include foods commonly consumed in the United Kingdom in sensible quantities. A sample menu was created to ensure that the quantities and types of food generated from the model could be combined into a realistic 7-d diet. Reductions in GHGEs of the diets were set against 1990 emission values. The first model, without any acceptability constraints, produced a 90% reduction in GHGEs but included only 7 food items, all in unrealistic quantities. The addition of acceptability constraints gave a more realistic diet with 52 foods but reduced GHGEs by a lesser amount of 36%. This diet included meat products but in smaller amounts than in the current diet. The retail cost of the diet was comparable to the average UK expenditure on food.

Question: Sustainable diets for the future: Can we contribute to reducing greenhouse gas emissions by eating a healthy diet?

A sustainable diet that meets dietary requirements for health with lower GHGEs can be achieved without eliminating meat or dairy products or increasing the cost to the consumer.

Answer the question based on the following context: Clozapine is an efective antipsychotic. However, its use has been associated with agranulocitosis. For this reason, it has been restricted for the treatment of resistant schizophrenia under a strict hematologic control. The objective of this work was to assess the risk of hematologic dyscrasias in a sample of clozapine-treated patients in a 5-year period. This is a follow-up study in a cohort of clozapine-treated patients in which the risk of haematological dyscrasias was assessed. Complete blood cell count was made for each patient in a weekly basis for the first 18 weeks and thereafter monthly. 271 patients in treatment with clozapine were followed up. The mean age was 32.3 years, with 36.5% women. The mean dose was 227,6 mg, ranging from 25 to 600 mg/day. During the first 18 weeks of follow-up, we observed a 3% incidence of neutropenia and 1.3% of leucopenia. During the next two years, only one new case of neutropenia and leucopenia was observed (n=120). No new cases were observed during the rest of follow up (n=69). No cases of agranulocytosis were observed.

Question: Clozapine and agranulocitosis in Spain: do we have a safer population?

A 3% incidence of neutropenia concentrated in the first months of follow up and no cases of agranulocitosis were observed in our sample. Actual evidence on clozapine effectiveness and safety and the results of this study suggests that a critical revision of follow-up protocols is suitable.

Answer the question based on the following context: The focus on evidence-based medicine has led to calls for increased levels of evidence in surgical journals. The purpose of the present study was to review the levels of evidence in articles published in the foot and ankle literature and to assess changes in the level of evidence over a decade. All of the articles in the literature from the years 2000, 2005, and 2010 in Foot&Ankle International and Foot and Ankle Surgery, as well as all foot and ankle articles from The Journal of Bone and Joint Surgery (JBJS, American [A] and British [B]Volumes) were analyzed. Animal, cadaver, and basic science articles; editorials; surveys; special topics; letters to the editor; and correspondence were excluded. Articles were ranked by a five-point level-of-evidence scale, according to guidelines from the Centre for Evidence-Based Medicine. A total of 720 articles from forty-three different countries were analyzed. The kappa value for interobserver reliability showed very good agreement between the reviewers for types of evidence (κ = 0.816 [p&lt; 0.01]) and excellent agreement for levels of evidence (κ = 0.869 [p&lt; 0.01]). Between 2000 and 2010, the percentage of high levels of evidence (Levels I and II) increased (5.2% to 10.3%) and low levels of evidence (Levels III, IV, and V) decreased (94.8% to 89.7%). The most frequent type of study was therapeutic. The JBJS-A produced the highest proportion of high levels of evidence.

Question: Levels of evidence in foot and ankle surgery literature: progress from 2000 to 2010?

There has been a trend toward higher levels of evidence in foot and ankle surgery literature over a decade, but the differences did not reach significance.

Answer the question based on the following context: The management of operable locally advanced N2 non-small cell lung cancer (NSCLC) is a controversial topic. Concurrent chemoradiation (CT-RT) is considered the standard of care for inoperable or unresectable patients, but the role of trimodality treatment remains controversial. We present our institution's experience with the management of stage III (N2) NSCLC patients, analyzing whether the addition of surgery improves survival when compared with definitive CT-RT alone. From 1996 to 2006, 72 N2 NSCLC patients were treated. Thirty-four patients received cisplatin-based induction chemotherapy, followed by paclitaxel-cisplatin CT-RT, and 38 patients underwent surgery preceded by induction and/or followed by adjuvant therapy. Survival curves were estimated by Kaplan-Meier analysis, and the differences were assessed with the log-rank test. Most of the patients (87 %) were men. The median age was 59 years. A statistically significant association between T3-T4c and definitive CT-RT as well as between T1-T2c and surgery was noted (p<0.0001). After a median follow-up period of 35 months, the median overall survival (OS) was 42 months for the surgery group versus 41 months for the CT-RT patients (p = 0.590). The median progression-free survival (PFS) was 14 months after surgery and 25 months after CT-RT (p = 0.933). Responders to radical CT-RT had a better OS than non-responders (43 vs. 17 months, respectively, p = 0.011). No significant differences were found in the OS or PFS between the pN0 [14 (37.8 %) patients] and non-pN0 patients at thoracotomy. Three treatment-related deaths (7.8 %) were observed in the surgical cohort and none in the CT-RT group.

Question: The multimodal management of locally advanced N2 non-small cell lung cancer: is there a role for surgical resection?

The addition of surgery did not render a median OS or PFS benefit when compared with CT-RT alone in our series of stage III-N2 NSCLC patients, in accordance with previously published data. However, responses to CT-RT had a greater impact in terms of OS and PFS. Although the patients selected for management including surgery showed a favorable T clinical staging in comparison to patients exclusively treated with definitive CT-RT, similar survival outcomes were found.

Answer the question based on the following context: The purpose of this study was to evaluate the relationship between body mass index and lipid profiles with breast cancer prognosis together with the relationship of these parametres with known breast cancer prognostic indices including c-erbB2 expression. Four hundred and thirty-three patients diagnosed with breast cancer at Ankara University, Faculty of Medicine, Department of Medical Oncology made up the study population. The primary endpoints were relapse and death. Body mass index at the time of diagnosis, lipid levels at the time of diagnosis, estrogen receptor status, progesterone receptor status, c-erbB2 expression, tumor grade, patient age, axillary lymph node involvement level, tumor stage, menopausal status and surgery details were taken into account. The mean body mass indices were similar in the remission, relapse and mortality groups. Patients with body mass indices higher than 30 kg/m² had a lower incidence of c-erbB2 expression when compared to patients with body mass indices < 18.5 kg/m(2) (19 vs. 50 %, p = 0.009). Survival analysis revealed that patients with body mass indices < 18.5 kg/m(2) had significantly shorter disease free survivals when compared to patients with body mass indices between 25 and 29.9 kg/m(2). Mean serum lipid levels were similar in the remission, relapse and mortality groups. A trend toward relapse was shown in patients with total cholesterol > 240 mg/dl, but this was statistically insignificant. Survival analysis revealed that patients with triglyceride levels lower than 150 mg/dl had a statistically significant longer disease-free survival when compared to the other groups. Again a trend towards shorter overall survival was seen in patients with total cholesterol > 240 mg/dl, but this relationship was also statistically insignificant.

Question: Is obesity always a risk factor for all breast cancer patients?

Most large previous studies reported adverse breast cancer outcome with obesity. However in our study, patients with lower body weight had a shorter disease-free survival. This could be explained by the low number of patients in this study, genetic profile of the patient population, possible weight changes after treatment and the inverse relationship between body mass index and c-erbB2 expression.

Answer the question based on the following context: The use of proton pump inhibitors (PPIs) is thought to increase the incidence of microscopic colitis (MC), although the exact mechanisms are not fully understood. Increased infiltration of intraepithelial lymphocytes (IELs) is a pathologic finding of MC (including collagenous or lymphocytic colitis). We investigated whether PPI use is associated with increased IEL infiltration and inflammation in the lamina propria. We retrospectively reviewed the medical records and histological reports of 78 patients receiving PPIs who had no symptoms of diarrhea, and their age- and gender- matched controls. The levels of IELs and inflammation in the lamina propria were assessed independently by two pathologists using H&E and immunohistochemical staining for CD3 and CD8. The IEL count was significantly higher in the PPI group than in controls (12.92 ± 6.27 vs. 8.10 ± 4.21 per 100 epithelial cells, p<0.001), as was the extent of inflammation (1.74 ± 0.90 vs. 0.86 ± 0.78, p<0.001). PPI use was associated with increased IEL infiltration in a multivariate analysis (OR, 3.232; 95 % CI, 1.631-6.404, p<0.001). Within the PPI group, however, the IEL count was not significantly associated with gender, age, type of PPI, or duration of PPI use.

Question: Is use of PPIs related to increased intraepithelial lymphocytes in the colon?

The use of PPIs has a significant association with increased IEL infiltration for subjects without symptoms of diarrhea. This finding suggests that changes such histological alterations seen in the early phage seen in MC possibly represent the stage of the disease even before the onset of symptoms.

Answer the question based on the following context: To determine whether ureteral segments not filled with contrast material at computed tomographic (CT) urography ever contain tumor detectable only by filling these segments with contrast material. In this institutional review board-approved, HIPAA-compliant retrospective study, with waiver of informed consent, databases were searched for all patients who underwent heminephroureterectomy or ureteroscopy between January 1, 2001, and December 31, 2009, with available CT urography findings in the 12 months prior to surgery or biopsy and patients who had undergone at least two CT urography procedures with a minimum 5-year follow-up between studies. One of two radiologists blinded to results of pathologic examination recorded location of unfilled segments, time of scan, subsequent filling, and pathologic or 5-year follow-up CT urography results. Tumors were considered missed in an unfilled segment if tumor was found at pathologic examination or follow-up CT urography in the same one-third of the ureter and there were no secondary signs of a mass with other index CT urography sequences. Estimated radiation dose for additional delayed sequences was calculated with a 32-cm phantom. In 59 male and 33 female patients (mean age, 66 years) undergoing heminephroureterectomy, 27 tumors were present in 41 partially nonopacified ureters in 20 patients. Six tumors were present in nonopacified segments (one multifocal, none bilateral); all were identifiable by means of secondary signs present with earlier sequences. Among 182 lesions biopsied at ureteroscopy in 124 male and 53 female patients (mean age, 69 years), 28 tumors were present in nonopacified segments in 25 patients (four multifocal, none bilateral), all with secondary imaging signs detectable without delayed scanning. In 64 male and 29 female patients (mean age, 69 years) who underwent 5-year follow-up CT urography, three new tumors were revealed in three patients; none occurred in the unfilled ureter at index CT urography. Estimated radiation dose from additional sequences was 4.3 mSv per patient.

Question: Targeted delayed scanning at CT urography: a worthwhile use of radiation?

Targeted delayed scanning at CT urography yielded no additional ureteral tumors and resulted in additional radiation exposure.

Answer the question based on the following context: Thanks to the development of computed tomography (CT) scanners and computer software, accurate coronary artery segmentation can be achieved with minimum user interaction. However, the question remains whether we can use these segmented images for reliable diagnosis. To retrospectively evaluate the diagnostic accuracy of coronary CT angiography (CCTA) using segmented 3D data for the detection of significant stenosis. CCTA data-sets from 30 patients were acquired with a 64-slice CT scanner and segmented using the region growing (RG) method and the "virtual contrast injection" (VC) method. Three types of images of each patient were reviewed by different reviewers for the presence of stenosis with diameter reduction of 50% or more. The evaluation was performed on four main arteries of each patient (120 arteries in total). For the original series, the reviewer was allowed to use all the 2D and 3D visualization tools available (conventional method). For the segmented results from RG and VC, only maximum intensity projection was used. Evaluation results were compared with catheter angiography (CA) for each artery in a blinded fashion. Overall, 34 arteries with significant stenosis were identified by CA. The percentage of evaluable arteries, accuracy and negative predictive value for detecting stenosis were, respectively, 86%, 74%, and 93% for the conventional method, 83%, 71%, and 92% for VC, and 64%, 56%, and 93% for RG. Accuracy was significantly lower for the RG method than for the other two methods (P<0.01), whereas there was no significant difference in accuracy between the VC method and the conventional method (P = 0.22).

Question: Can segmented 3D images be used for stenosis evaluation in coronary CT angiography?

The diagnostic accuracy for the RG-segmented 3D data is lower than those with access to 2D images, whereas the VC method shows diagnostic accuracy similar to the conventional method.

Answer the question based on the following context: Uptake of the English National Chlamydia Screening Programme is lower than predicted necessary to result in a rapid fall in chlamydia prevalence. Peer-led approaches may increase screening uptake but their feasibility and acceptability to young people is not known. Focus groups and interviews with young women and men. Following interview, chlamydia postal kits were introduced to participants and their opinions on giving these out to their peers sought. Participants were asked for their views and experiences of discussing chlamydia screening and distributing kits to their friends 4-8 weeks after the focus group/interview. All kits returned to the laboratory over a 9-month period were recorded. Six men (mean age 19 years) and six women (mean age 20 years) were recruited. In total 45 kits were distributed, 33 (73%) to female participants. 22 (67%) and 3 (25%) of kits given to females and males, respectively, were given to peers. Ten kits (22%; seven female, three male) all of which had been given out by females, were returned for testing. Participants generally felt positive about the idea of peer-led screening (PLS) using postal kits. However, embarrassment was a key theme, particularly among men. Generally women but not men were able to discuss PLS among their close friends. Both sexes felt PLS would be easier if kits were readily available in multiple sites, and chlamydia screening was more widely promoted.

Question: Could a peer-led intervention increase uptake of chlamydia screening?

Female PLS but not male PLS was successful in recruiting peers to participate in chlamydia screening. An evaluation of the acceptability and cost-effectiveness of PLS is now indicated.

Answer the question based on the following context: Depression is emerging as a leading cause of morbidity and mortality in young adults. New biological assessment strategies such as biological markers are needed to more accurately assess for depression in this age group. Vitamin D may present such an opportunity. A descriptive correlational design with convenience sampling was used to address the research question: Is there a relationship between vitamin D serum levels and depression scores in young adult women? One hundred thirty-nine participants completed a health questionnaire, Beck Depression Inventory, and had serum vitamin D, 25(OH)D, levels drawn. No statistically significant correlation between vitamin D level and depression was identified. Statistically significant differences between African American and Caucasian women were detected on vitamin D levels but not on the Beck Depression Inventory.

Question: Vitamin D and depression: is there a relationship in young women?

Based on the results of this study, vitamin D cannot be used as a biomarker for depression in women aged 18 to 24 years. Clinical implications of no relationship between vitamin D and depression will be explored and the cut-point for serum 25(OH)D levels will be discussed.

Answer the question based on the following context: To identify predictors of low hemoglobin A(1c) (HbA(1c)) (<5.0%) and to investigate the association of low HbA(1c) with cause-specific mortality and risk of liver disease hospitalization. Prospective cohort study of 13,288 participants in the Atherosclerosis Risk in Communities Study. Logistic regression was used to identify cross-sectional correlates of low HbA(1c), and Cox proportional hazards models were used to estimate the association of low HbA(1c) with cause-specific mortality. Compared with participants with HbA(1c) in the normal range (5.0 to<5.7%), participants with low HbA(1c) were younger, less likely to smoke, had lower BMI, lower white cell count and fibrinogen levels, and lower prevalence of hypercholesterolemia and history of coronary heart disease. However, this group was more likely to have anemia and had a higher mean corpuscular volume. In adjusted Cox models with HbA(1c) of 5.0 to<5.7% as the reference group, HbA(1c)<5.0% was associated with a significantly increased risk of all-cause mortality (hazard ratio [HR]: 1.32, 95% CI: 1.13-1.55) and of cancer death (1.47, 95% CI: 1.16-1.84). We also noted nonsignificant trends toward increased risk of death from cardiovascular causes (1.27, 95% CI: 0.93-1.75) and respiratory causes (1.42, 95% CI: 0.78-2.56). There was a J-shaped association between HbA(1c) and risk of liver disease hospitalization.

Question: Low hemoglobin A(1c) in nondiabetic adults: an elevated risk state?

No single cause of death appeared to drive the association between low HbA(1c) and total mortality. These results add to evidence that low HbA(1c) values may be a generalized marker of mortality risk in the general population.

Answer the question based on the following context: In paediatric emergency medicine, estimation of weight in ill children can be performed in a variety of ways. Calculation using the 'APLS' formula (weight = [age + 4] × 2) is one very common method. Studies on its validity in developed countries suggest that it tends to under-estimate the weight of children, potentially leading to errors in drug and fluid administration. The formula is not validated in Trinidad and Tobago, where it is routinely used to calculate weight in paediatric resuscitation. Over a six-week period in January 2009, all children one to five years old presenting to the Emergency Department were weighed. Their measured weights were compared to their estimated weights as calculated using the APLS formula, the Luscombe and Owens formula and a "best fit" formula derived (then simplified) from linear regression analysis of the measured weights. The APLS formula underestimated weight in all age groups with a mean difference of -1.4 kg (95% limits of agreement 5.0 to -7.8). The Luscombe and Owens formula was more accurate in predicting weight than the APLS formula, with a mean difference of -0.4 kg (95% limits of agreement 6.9 to -6.1%). Using linear regression analysis, and simplifying the derived equation, the best formula to describe weight and age was (weight = [2.5 x age] + 8). The percentage of children whose actual weight fell within 10% of the calculated weights using any of the three formulae was not significantly different.

Question: Is the APLS formula used to calculate weight-for-age applicable to a Trinidadian population?

The APLS formula slightly underestimates the weights of children in Trinidad, although this is less than in similar studies in developed countries. Both the Luscombe and Owens formula and the formula derived from the results of this study give a better estimate of the measured weight of children in Trinidad. However, the accuracy and precision of all three formulae were not significantly different from each other. It is recommended that the APLS formula should continue to be used to estimate the weight of children in resuscitation situations in Trinidad, as it is well known, easy to calculate and widely taught in this setting.

Answer the question based on the following context: Lowering low-density lipoprotein cholesterol (LDL-C) levels can reduce vascular clinical endpoints in outcome studies. Despite this evidence, previous cross-sectional analyses reported a mean LDL-C target attainment of<50%. This non-interventional, longitudinal study aimed to asses the rate of target attainment by intensified LDL-C lowering therapy in a high-risk population under routine medical care. This was an open-label, non-interventional, observational, non-comparative longitudinal study. A total of 1682 outpatients at high cardiovascular risk, not at LDL-C target despite statin therapy, were documented. Treating physicians administered an intensified therapy at their discretion. In all, 794 patients completed all the examinations at baseline after 3 and 12 months. The achieved LDL-C reductions was evaluated based on expert consensus reflecting the 2007 guidelines issued by the European Society of Cardiology (ESC) on cardiovascular disease prevention. www.clinicaltrials.gov , identification number NCT 01381679 In the study, 40.3% achieved the individual LDL-C target of<.8 mmol/L (70 mg/dl) or<2.5 mmol/L (100 mg/dl); 73% received a simvastatin/ezetimibe fixed-dose combination; 3% received add-on ezetimibe and 23% statin therapy at maintained or increased doses; 1% received no drug treatment at all. LDL-C declined after 12 months by -31.0% (ratio 0.69, 95% CI 0.67-0.71, p<0.001), triglycerides by -11.8% (ratio 0.88, 95% CI 0.85-0.91, p<0.01) and high-density lipoprotein cholesterol (HDL-C) increased by 11.9% (ratio 1.12, 95% CI 1.10-1.14, p<0.01).

Question: Can LDL-cholesterol targets be achieved in a population at high risk?

Intensified therapy was effective, but target attainment was still low at 40.3% or 13.9% with regard to the new 2011 guidelines issued by the European Atherosclerosis Society (EAS) and the ESC on dyslipidemias. Enhanced screening of LDL-C levels and the use of statins at highest tolerated dose and concomitant combination therapy is recommended in order to achieve LDL-C targets outlined by current guidelines. Limitations include the design as a non-interventional study. However, this study reflects real life conditions.

Answer the question based on the following context: Cure rate of early Hodgkin Lymphoma are high and avoidance of late toxicities is of paramount importance. This comparative study aims to assess the normal tissue sparing capability of intensity-modulated radiation therapy (IMRT) versus standard three-dimensional conformal radiotherapy (3D-CRT) in terms of dose-volume parameters and normal tissue complication probability (NTCP) for different organs at risk in supradiaphragmatic Hodgkin Lymphoma (HL) patients. Ten HL patients were actually treated with 3D-CRT and all treatments were then re-planned with IMRT. Dose-volume parameters for thyroid, oesophagus, heart, coronary arteries, lung, spinal cord and breast were evaluated. Dose-volume histograms generated by TPS were analyzed to predict the NTCP for the considered organs at risk, according to different endpoints. Regarding dose-volume parameters no statistically significant differences were recorded for heart and origin of coronary arteries. We recorded statistically significant lower V30 with IMRT for oesophagus (6.42 vs 0.33, p = 0.02) and lungs (4.7 vs 0.1 p = 0.014 for the left lung and 2.59 vs 0.1 p = 0.017 for the right lung) and lower V20 for spinal cord (17.8 vs 7.2 p = 0.02). Moreover the maximum dose to the spinal cord was lower with IMRT (30.2 vs 19.9, p<0.001). Higher V10 with IMRT for thyroid (64.8 vs 95, p = 0.0019) and V5 for lungs (30.3 vs 44.8, p = 0.03, for right lung and 28.9 vs 48.1, p = 0.001 for left lung) were found, respectively. Higher V5 and V10 for breasts were found with IMRT (V5: 4.14 vs 20.6, p = 0.018 for left breast and 3.3 vs 17, p = 0.059 for right breast; V10: 2.5 vs 13.6 p = 0.035 for left breast and 1.7 vs 11, p = 0.07 for the right breast.) As for the NTCP, our data point out that IMRT is not always likely to significantly increase the NTCP to OARs.

Question: Intensity modulated radiotherapy in early stage Hodgkin lymphoma patients: is it better than three dimensional conformal radiotherapy?

In HL male patients IMRT seems feasible and accurate while for women HL patients IMRT should be used with caution.

Answer the question based on the following context: Fusarium head blight (FHB) caused by Fusarium species like F. graminearum is a devastating disease of wheat (Triticum aestivum) worldwide. Mycotoxins such as deoxynivalenol produced by the fungus affect plant and animal health, and cause significant reductions of grain yield and quality. Resistant varieties are the only effective way to control this disease, but the molecular events leading to FHB resistance are still poorly understood. Transcriptional profiling was conducted for the winter wheat cultivars Dream (moderately resistant) and Lynx (susceptible). The gene expressions at 32 and 72 h after inoculation with Fusarium were used to trace possible defence mechanisms and associated genes. A comparative qPCR was carried out for selected genes to analyse the respective expression patterns in the resistant cultivars Dream and Sumai 3 (Chinese spring wheat). Among 2,169 differentially expressed genes, two putative main defence mechanisms were found in the FHB-resistant Dream cultivar. Both are defined base on their specific mode of resistance. A non-specific mechanism was based on several defence genes probably induced by jasmonate and ethylene signalling, including lipid-transfer protein, thionin, defensin and GDSL-like lipase genes. Additionally, defence-related genes encoding jasmonate-regulated proteins were up-regulated in response to FHB. Another mechanism based on the targeted suppression of essential Fusarium virulence factors comprising proteases and mycotoxins was found to be an essential, induced defence of general relevance in wheat. Moreover, similar inductions upon fungal infection were frequently observed among FHB-responsive genes of both mechanisms in the cultivars Dream and Sumai 3.

Question: Jasmonate and ethylene dependent defence gene expression and suppression of fungal virulence factors: two essential mechanisms of Fusarium head blight resistance in wheat?

Especially ABC transporter, UDP-glucosyltransferase, protease and protease inhibitor genes associated with the defence mechanism against fungal virulence factors are apparently active in different resistant genetic backgrounds, according to reports on other wheat cultivars and barley. This was further supported in our qPCR experiments on seven genes originating from this mechanism which revealed similar activities in the resistant cultivars Dream and Sumai 3. Finally, the combination of early-stage and steady-state induction was associated with resistance, while transcript induction generally occurred later and temporarily in the susceptible cultivars. The respective mechanisms are attractive for advanced studies aiming at new resistance and toxin management strategies.

Answer the question based on the following context: To evaluate the effect of hexaminolevulinate (HAL)-induced fluorescence during resection of noninvasive bladder cancer on tumor recurrence compared with resection under white light. Between 2008 and 2010, 102 consecutive patients with suspected bladder cancer were randomized to undergo transurethral resection with either conventional white light or combination of white light and HAL-induced fluorescence. Difference in tumor recurrence rate and recurrence-free survival between the 2 groups was evaluated. Subgroup analysis on recurrence-free survival was performed for different tumor parameters. Cystoscopy at 3 months revealed tumor recurrence in 6 of 45 (13.3%) patients of the white light group compared with only 1 of 41 patients of the HAL group (2.4%) (P<.001). The recurrence-free rates in white light patients at 12 and 18 months were 56.3% and 50.6%, respectively, compared with 91% and 82.5% in HAL patients (P = .0006). In subgroup analyses, recurrence-free survival was similar between the 2 groups when solitary tumors were treated (P = .3525). However, the HAL group had a favorable recurrence-free survival compared with the white light group when multifocal tumors (P<.001), primary tumors (P = .0237), recurrent tumors (P = .0189), nonaggressive (papillary urothelial neoplasm of low malignant potential and low grade) tumors (P = .0204), or aggressive (high grade and carcinoma in situ) tumors (P = .0134) were treated.

Question: Hexaminolevulinate-induced fluorescence versus white light during transurethral resection of noninvasive bladder tumor: does it reduce recurrences?

HAL significantly aids resection of non-muscle-invasive bladder cancer with the result of reduction in tumor recurrence rates.

Answer the question based on the following context: To analyze haemolytic episodes in patients with warm antibody autoimmune haemolytic anemia (AIHA) and compare corticosteroids treatment with intravenous immunoglobulins (IVIG) (group A) or without IVIG (group B). Observational study that includes 21 haemolytic episodes occurred in 17 patients (9 males and 12 females), with a median age of 59 years (26-82). In group A, 8 episodes received IGIV + corticosteroids and in group B, 12 episodes received only corticosteroids and one rituximab. Hemoglobin (Hb) value at diagnosis was 1.8 g/dl lower (95% confidence interval: 0.6 to 3.1; P = .007) in group A, with a median Hb of 6.3g/dl in this group vs 7.9 g/dl in group B. There were non-significant differences in red blood cells transfusion (50 vs 23%; P>.20) and global increase of Hb values (7.3 vs 5.6; P>.20). Overall hematological responses were similar: 88 vs 92% (P>.20).

Question: Are intravenous immunoglobulins useful in severe episodes of autoimmune hemolytic anemia?

Hematological response achieved in more severe episodes with the use of IVIG was similar to non-severe episodes treated without IVIG.

Answer the question based on the following context: Inhibition of platelet aggregation appears two hours after the first dose of clopidogrel, becomes significant after the second dose, and progresses to a steady-state value of 55% by day seven. Low response to clopidogrel has been associated with increased risk of stent thrombosis and ischemic events, particularly in the context of stable heart disease treated by percutaneous coronary intervention. To stratify medium-term prognosis of an acute coronary syndrome (ACS) population by platelet aggregation. We performed a prospective longitudinal study of 70 patients admitted for an ACS between May and August 2009. Platelet function was assessed by ADP-induced platelet aggregation using a commercially available kit (Multiplate(®) analyzer) at discharge. The primary endpoint was a combined outcome of mortality, non-fatal myocardial infarction, or unstable angina, with a median follow-up of 136.0 (79.0-188.0) days. The median value of platelet aggregation was 16.0U (11.0-22.5U) with a maximum of 41.0U and a minimum of 4.0U (normal value according to the manufacturer: 53-122U). After ROC curve analysis with respect to the combined endpoint (AUC 0.72), we concluded that a value of 18.5U conferred a sensitivity of 75.0% and a specificity of 68% to that result. We therefore created two groups based on that level: group A - platelet aggregation<18.5U, n=44; and group B - platelet aggregation ≥18.5U, n=26. The groups were similar with respect to demographic data (age 60.5 [49.0-65.0] vs. 62.0 [49.0-65.0]years, p=0.21), previous cardiovascular history, and admission diagnosis. There were no associations between left ventricular ejection fraction, GRACE risk score, or length of hospital stay and platelet aggregation. The groups were also similar with respect to antiplatelet, anticoagulant, proton pump inhibitor (63.6 vs. 46.2%, p=0.15) and statin therapy. The variability in platelets and hemoglobin was also similar between groups. Combined event-free survival was higher in group A (96.0 vs. 76.7%, log-rank p<0.01). Platelet aggregation higher than 18.5U was an independent predictor of the combined event (HR 6.75, 95% CI 1.38-32.90, p=0.02).

Question: Platelet aggregation at discharge: a useful tool in acute coronary syndromes?

In our ACS population platelet aggregation at discharge was a predictor of medium-term prognosis.

Answer the question based on the following context: The nature of the relationship between bipolar disorder (BD) and borderline personality disorder (BPD) is controversial. The aim of this study was to characterize the clinical profile of patients with BD and comorbid BPD in a world-wide sample selected during a major depressive episode (MDE). From a general sample of 5635 in and out-patients with an MDE, who were enrolled in the multicenter, multinational, transcultural BRIDGE study, we identified 2658 subjects who met bipolarity specifier criteria. Bipolar specifier patients with (BPD+) and without (BPD-) comorbid BPD were compared on diagnostic, socio-demographic, familial and clinical characteristics. 386 patients (14.5%) met criteria for BPD. A diagnosis of BD according to DSM-IV criteria was significantly more frequent in the BPD- than in BPD+, while similar rates in the two groups occurred using DSM-IV-Modified criteria. A subset of the BD criteria with an atypical connotation, such as irritability, mood instability and reactivity to drugs were significantly associated withthe presence of BPD. BPD+ patients were significantly younger than BPD- bipolar patients for age, age at onset of first psychiatric symptoms and age at first diagnosis of depression. They also reported significantly more comorbid Alcohol and Substance abuse, Anxiety disorders, Eating Disorder and Attention Deficit Hyperactivity Disorder. In comparison with BPD-, BPD+ patients showed significantly more psychotic symptoms, history of suicide attempts, mixed states, mood reactivity, atypical features, seasonality of mood episodes, antidepressants induced mood lability and irritability, and resistance to antidepressant treatments. Centers were selected for their strong mood disorder clinical programs, recall bias is possible with a cross-sectional design, and participating psychiatrists received limited training.

Question: Is comorbid borderline personality disorder in patients with major depressive episode and bipolarity a developmental subtype?

We confirm in a large sample of BD patients with MDE the high prevalence of patients who meet DSM-IV criteria for BPD. Further prospective researches should clarify whether the mood reactivity and instability captured by BPD DSM-IV criteria are distinguishable from the subjective mood of an instable, dysphoric, irritable manic/hypomanic/mixed state or simply represent a phenotypic variant of BD, related to developmental factors.

Answer the question based on the following context: Deficits in executive functioning (EF) are implicated in neurobiological and cognitive-processing theories of depression. EF deficits are also associated with Attention-deficit/hyperactivity disorder (ADHD) in adults, who are also at increased risk for depressive disorders. Given debate about the ecological validity of laboratory measures of EF, we investigated the relationship between depression diagnoses and symptoms and EF as measured by both rating scales and tests in a sample of adults referred for evaluation of adult ADHD. Data from two groups of adults recruited from an ADHD specialty clinic were analyzed together: Adults diagnosed with ADHD (N=146) and a clinical control group of adults referred for adult ADHD assessment but not diagnosed with the disorder ADHD (N=97). EF was assessed using a rating scale of EF deficits in daily life and a battery of tests tapping various EF constructs. Depression was assessed using current and lifetime SCID diagnoses (major depression, dysthymia) and self-report symptom ratings. EF as assessed via rating scale predicted depression across measures even when controlling for current anxiety and impairment. Self-Management to Time and Self-Organization and Problem-Solving showed the most robust relationships. EF tests were weakly and inconsistently related to depression measures. Prospective studies are needed to rigorously evaluate EF problems as true risk factors for depressive onset.

Question: Does executive functioning (EF) predict depression in clinic-referred adults?

EF problems in everyday life were important predictors of depression. Researchers and clinicians should consistently assess for the ADHD-depression comorbidity. Clinicians should consider incorporating strategies to address EF deficits when treating people with depression.

Answer the question based on the following context: Although left ventricular assist devices (LVADs) are now commonly used as a bridge to orthotopic heart transplantation (OHT), the upper patient age limit for this therapy has not been defined. Smaller studies have suggested that advanced age should not be a contraindication to bridge to transplantation (BTT) LVAD placement. The purpose of this study was to examine outcomes in patients 60 years and older undergoing BTT with continuous-flow LVADs. The United Network for Organ Sharing (UNOS) database was reviewed to identify first-time OHT recipients 60 years of age and older (2005-2010). Patients were stratified by preoperative support: continuous-flow LVAD, intravenous inotropic agents, and direct transplantation. Survival after OHT was modeled using the Kaplan-Meier method. All-cause mortality was examined using multivariable Cox proportional hazard regression. Of 2,554 patients, 1,142 (44.7%) underwent direct transplantation, 264 (10.3%) had LVAD BTT, and 1,148 (45.0%) had BTT with inotropic agents. The mean age was 64±3 years, and 460 (18.0%) patients were women. Mean follow-up was 29±19 months. Survival differed significantly among the 3 groups. Patients with LVAD BTT had significantly lower survival after OHT compared with the other groups at 30 days and 1 year. This survival difference was no longer significant at 2 years after OHT or when deaths in the first 30 days were censored. LVAD BTT increased the hazard of death at 1 year by 50% (hazard ratio [HR], 1.50; 95% confidence interval [CI], 1.05-2.15; p=0.03), compared with patients who underwent direct transplantation.

Question: Should patients 60 years and older undergo bridge to transplantation with continuous-flow left ventricular assist devices?

This study represents the largest modern cohort in which survival after OHT has been evaluated in patients 60 years or older who received BTT. Older patients have lower short-term survival after OHT when BTT is carried out with a continuous-flow LVAD compared with inotropic agents or direct transplantation.

Answer the question based on the following context: This study investigated the left atrial appendage (LAA) by computed tomography (CT) and magnetic resonance imaging (MRI) to categorize different LAA morphologies and to correlate the morphology with the history of stroke/transient ischemic attack (TIA). LAA represents one of the major sources of cardiac thrombus formation responsible for TIA/stroke in patients with atrial fibrillation (AF). We studied 932 patients with drug-refractory AF who were planning to undergo catheter ablation. All patients underwent cardiac CT or MRI of the LAA and were screened for history of TIA/stroke. Four different morphologies were used to categorize LAA: Cactus, Chicken Wing, Windsock, and Cauliflower. CT scans of 499 patients and MRI scans of 433 patients were analyzed (age 59 ± 10 years, 79% were male, and 14% had CHADS(2) [Congestive heart failure, hypertension, Age>75, Diabetes mellitus, and prior stroke or transient ischemic attack] score ≥2). The distribution of different LAA morphologies was Cactus (278 [30%]), Chicken Wing (451 [48%]), Windsock (179 [19%]), and Cauliflower (24 [3%]). Of the 932 patients, 78 (8%) had a history of ischemic stroke or TIA. The prevalence of pre-procedure stroke/TIA in Cactus, Chicken Wing, Windsock, and Cauliflower morphologies was 12%, 4%, 10%, and 18%, respectively (p = 0.003). After controlling for CHADS2 score, gender, and AF types in a multivariable logistic model, Chicken Wing morphology was found to be 79% less likely to have a stroke/TIA history (odd ratio: 0.21, 95% confidence interval: 0.05 to 0.91, p = 0.036). In a separate multivariate model, we entered Chicken Wing as the reference group and assessed the likelihood of stroke in other groups in relation to reference. Compared with chicken wing, cactus was 4.08 times (p = 0.046), Windsock was 4.5 times (p = 0.038), and Cauliflower was 8.0 times (p = 0.056) more likely to have had a stroke/TIA.

Question: Does the left atrial appendage morphology correlate with the risk of stroke in patients with atrial fibrillation?

Patients with Chicken Wing LAA morphology are less likely to have an embolic event even after controlling for comorbidities and CHADS2 score. If confirmed, these results could have a relevant impact on the anticoagulation management of patients with a low-intermediate risk for stroke/TIA.

Answer the question based on the following context: Rest is usually recommended in acute pericarditis, as it could help to lower heart rate (HR) and contribute to limit "mechanical inflammation". Whether HR on admission could be correlated and perhaps participate to inflammation has not been reported. Between March 2007 and February 2010, we conducted a retrospective study on all patients admitted to our center for acute pericarditis. Diagnosis criteria included two of the following ones: typical chest pain, friction rub, pericardial effusion on cardiac echography, or typical electrocardiogram (ECG) findings. Primary endpoint was biology: CRP on admission, on days 1, 2, 3, and especially peak. We included 73 patients. Median age was 38 years (interquartiles 28-51) and median hospitalization duration was 2.0 days (1.5-3.0). Median heart rate was 88.0 beats per minute (bpm) on admission (interquartiles 76.0-100.0) and 72.0 on discharge (65.0-80.0). Heart rate on admission was significantly correlated with CRP peak (p<0.001), independently of temperature on admission, hospitalization duration and age. Recurrences occurred within 1 month in 32% of patients. Heart rate on hospital discharge was correlated with recurrence, independently of age.

Question: Could heart rate play a role in pericardial inflammation?

In acute pericarditis, heart rate on admission is independently correlated with CRP levels and heart rate on discharge seems to be independently correlated to recurrence. This could suggest a link between heart rate and pericardial inflammation.

Answer the question based on the following context: Insurance-related outcomes disparities are well-known, but associations between distinct insurance types and trauma outcomes remain unclear. Prior studies have generally merged various insurance types into broad groups. The purpose of this study is to determine the association of specific insurance types with mortality after blunt injury. Cases of blunt injury among adults aged 18-64 y with an injury severity score>9 were identified using the 2007-2009 National Trauma Data Bank. Crude mortality was calculated for 10 insurance types. Multivariable logistic regression was employed to determine difference in odds of death between insurance types, controlling for injury severity score, Glasgow Coma Scale motor, mechanism of injury, sex, race, and hypotension. Clustering was used to account for possible inter-facility variations. A total of 312,312 cases met inclusion criteria. Crude mortality ranged from 3.2 to 6.0% by insurance type. Private Insurance, Blue Cross Blue Shield, Workers Compensation, and Medicaid yielded the lowest relative odds of death, while Not Billed and Self Pay yielded the highest. Compared with Private Insurance, odds of death were higher for No Fault (OR 1.25, P = 0.022), Not Billed (OR 1.77, P<0.001), and Self Pay (OR 1.77, P<0.001). Odds of death were higher for Medicare (OR 1.52, P<0.001) and Other Government (OR 1.35, P = 0.049), while odds of death were lower for Medicaid (OR 0.89, P = 0.015).

Question: Disparities in mortality after blunt injury: does insurance type matter?

Significant differences in mortality after blunt injury were seen between insurance types, even among those commonly grouped in other studies. Policymakers may use this information to implement programs to monitor and reduce insurance-related disparities.

Answer the question based on the following context: Data about strategies for improving the diagnostic ability of capsule endoscopy readers are lacking.AIM: (1) To evaluate the detection rate and the interobserver agreement among readers with different experience; (2) to verify the impact of a specific training (hands-on training plus expert tutorial) on these parameters. 17 readers reviewed 12 videos twice; between the two readings they underwent the training. The identified small bowel findings were described by a simplified version of Structured Terminology and classifies as clinically significant/non-significant. Findings identified by the readers were compared with those identified by three experts (Reference Standard). The Reference Standard identified 26 clinically significant findings. The mean detection rate of overall readers for significant findings was low (about 50%) and did not change after the training (46.2% and 46.4%, respectively). There was no difference in the detection rate among readers with different experience. The interobserver agreement with the Reference Standard in describing significant findings was moderate (k = 0.44; CI95%: 0.39-0.50) and did not change after the training (k = 0.44; CI95%: 0.38-0.49) or stratifying readers according to their experience.

Question: Can we improve the detection rate and interobserver agreement in capsule endoscopy?

Both the interobserver agreement and the detection rate of significant findings are low, regardless of the readers' experience. Our training did not significantly increase the performance of readers with different experience.

Answer the question based on the following context: The frequency of Human T lymphotropic Virus-1 (HTLV 1) is 2-3% in the general population and 0.7% in blood donors in northeast Iran. It is very important that we recognize the contributing factors in the pathogenesis of this virus. There are many reports that show that susceptibility to some infections is closely linked to the expression of certain blood group antigens. This study was performed to evaluate any association between minor blood group antigens and HTLV-I infection in northeast Iran. In this case and control study major and minor blood group antigens were typed by commercial antibodies in 100 HTLV-I infected individuals and 332 healthy blood donors in Mashhad, Iran, from 2009-2010. Blood group antigens were determined by tube method less than 24h after blood collection. Finally, the results of HTLV-I positive subjects and control groups were compared by using SPSS software. The prevalence of Le(a), Le(b), P1, Fy(a), Fy(b), M, N, Jka, Jkb, K and k antigens in case group were 39.0%, 56.0%, 72.0%, 67.0%, 52.0%, 90.0%, 57.0%, 79.0%, 71.0%, 10.0%, 96.0%, respectively and the frequency of these blood group antigens in control group were 38.8%, 55.8%, 66.2%, 72.0%, 58.7%, 87.0%, 56.7%, 79.8%, 63.0%, 10.6%, 97.0%, respectively. We did not find any significant differences between the case and control group for frequency of minor blood group antigens.

Question: Is there any relationship between expressions of minor blood group antigens with HTLV-I infection?

Our study showed minor blood group antigens are not associated with an increased risk of HTLT-1 infection in northeast Iran.

Answer the question based on the following context: To determine whether adult disease severity subclassification systems for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are concordant with the decision to treat pediatric patients with cyclophosphamide (CYC). We applied the European Vasculitis Study (EUVAS) and Wegener's Granulomatosis Etanercept Trial (WGET) disease severity subclassification systems to pediatric patients with AAV in A Registry for Childhood Vasculitis (ARChiVe). Modifications were made to the EUVAS and WGET systems to enable their application to this cohort of children. Treatment was categorized into 2 groups, "cyclophosphamide" and "no cyclophosphamide." Pearson's chi-square and Kendall's rank correlation coefficient statistical analyses were used to determine the relationship between disease severity subgroup and treatment at the time of diagnosis. In total, 125 children with AAV were studied. Severity subgroup was associated with treatment group in both the EUVAS (chi-square 45.14, p<0.001, Kendall's tau-b 0.601, p<0.001) and WGET (chi-square 59.33, p<0.001, Kendall's tau-b 0.689, p<0.001) systems; however, 7 children classified by both systems as having less severe disease received CYC, and 6 children classified as having severe disease by both systems did not receive CYC.

Question: Do adult disease severity subclassifications predict use of cyclophosphamide in children with ANCA-associated vasculitis?

In this pediatric AAV cohort, the EUVAS and WGET adult severity subclassification systems had strong correlation with physician choice of treatment. However, a proportion of patients received treatment that was not concordant with their assigned severity subclass.

Answer the question based on the following context: Classically, the vertical-style reduction mammaplasty utilizing a superomedial pedicle has been limited to smaller reductions secondary to concerns for poor wound healing and nipple necrosis. The authors reviewed a large cohort of patients who underwent a vertical-style superomedial pedicle reduction mammaplasty in an attempt to demonstrate its safety and efficacy in treating symptomatic macromastia. A retrospective review was performed of 290 patients (558 breasts) who underwent a vertical-style superomedial pedicle reduction mammaplasty. All procedures were conducted by one of 4 plastic surgeons over 6 years (JDR, MAA, DLV, DRA). The average resection weight was 551.7 g (range, 176-1827 g), with 4.6% of resections greater than 1000 g. A majority of patients (55.2%) concomitantly underwent liposuction of the breast. The total complication rate was 22.7%, with superficial dehiscence (8.8%) and hypertrophic scarring (8.8%) comprising the majority. Nipple sensory changes occurred in 1.6% of breasts, with no episodes of nipple necrosis. The revision rate was 2.2%. Patients with complications had significantly higher resection volumes and nipple-to-fold distances (P = .014 and .010, respectively).

Question: Vertical reduction mammaplasty utilizing the superomedial pedicle: is it really for everyone?

The vertical-style superomedial pedicle reduction mammaplasty is safe and effective for a wide range of symptomatic macromastia. The nipple-areola complex can be safely transposed, even in patients with larger degrees of macromastia, with no episodes of nipple necrosis. The adjunctive use of liposuction should be considered safe. Last, revision rates were low, correlating with a high level of patient satisfaction.

Answer the question based on the following context: Small, autogamous flowers have evolved repeatedly in the plant kingdom. While much attention has focused on the mechanisms that promote the shift to autogamy, there is still a paucity of information on the factors that underlie the reduction of flower size so prevalent in selfing lineages. In this study of Crepis tectorum, I examine the role of inbreeding, acting alone or together with selection, in promoting evolutionary reduction of flower size. Experimental crosses were performed to produce progeny populations that differed in inbreeding and (or) selection history. Progenies were grown in two different environments and scored for flower size and other characters. Inbreeding depressed flower and fruit size, but also caused changes in flowering time and the number of heads produced. Despite some inconsistencies in the results for the last progeny generation, the decline in flower size was persistent over generations, consistent across environments, and similar in magnitude to the effects of selection for small flower size and the floral reduction inferred to have taken place during the shift toward autogamy within the study species. The floral size reduction was largely independent of changes in overall vigor, and there was considerable adaptive potential in flower size (measured by sib analyses and parent-offspring comparisons) after inbreeding.

Question: Does inbreeding promote evolutionary reduction of flower size?

The results of this study indicate that inbreeding can promote evolutionary reduction of flower size and highlight the close, persistent association between flower and fruit size in the study species.

Answer the question based on the following context: A stated goal of the DSM-5 Work Group on Personality and Personality Disorders (PDs) has been to reduce the high rate of comorbidity among PDs. Few studies have examined whether the diagnosis of multiple PDs has clinical significance. In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services project, we tested the hypothesis that patients with>1 DSM-IV PD would have more severe forms of psychopathology than patients who were diagnosed with only 1 DSM-IV PD. A total of 2,150 psychiatric outpatients were evaluated with semi-structured diagnostic interviews for DSM-IV Axis I and Axis II disorders and measures of psychosocial morbidity. For 8 of the 10 PDs, the majority of patients had at least 1 additional PD, although at least 20% of patients diagnosed with each PD were diagnosed with only 1 PD. Compared with patients with 1 PD, patients with ≥2 PDs had significantly more psychosocial morbidity.

Question: Does the diagnosis of multiple Axis II disorders have clinical significance?

The co-occurrence of PDs conveys clinically significant information. Moreover, despite high levels of comorbidity, each PD also existed as a stand-alone entity. These findings raise questions about the DSM-5 Work Group's emphasis on reducing comorbidity in Axis II.

Answer the question based on the following context: Symptoms of lactose intolerance are often attributed to lactose malabsorption but, as this relationship has not been demonstrated when a small dose of lactose similar to that contained in one cup of milk is ingested by intolerant patients, psychological factors may play a role in altered symptom perception.AIM: To assess the hypothesis that the psychological profile influences the symptoms of lactose intolerance. One hundred and two consecutive patients underwent a 15 g lactose hydrogen breath test to assess lactose malabsorption. The patients recorded the presence and severity of symptoms of lactose intolerance during the breath test using visual analogue scales. The psychological profile was assessed using a psychological symptom checklist, and health-related quality of life by means of the short-form health survey. Lactose malabsorption and intolerance were diagnosed in, respectively, 18% and 29% of the patients. The two conditions were not associated, and the severity of intolerance was even less in the patients with malabsorption. Multivariate logistic analysis showed that a high somatisation t-score was significantly associated with lactose intolerance (odds ratio 4.184; 1.704-10.309); the effects of the other psychological variables and of lactose malabsorption were not statistically significant. Health-related quality of life was significantly reduced in the patients with somatisation, but not in those with lactose malabsorption.

Question: Is the subjective perception of lactose intolerance influenced by the psychological profile?

The symptoms of lactose intolerance during hydrogen breath testing at a low physiological lactose load, are unrelated to lactose malabsorption, but may reveal a tendency towards somatisation that could impair the quality of life.

Answer the question based on the following context: To explore the reliability and validity of the new generation of infrared tympanic thermometers, comparing with rectal and core temperature, and to decide their applicability to clinical practice. Digital contact thermometers for rectal measurements and infrared tympanic thermometers are the most common way to measure patients' temperature. Previous studies of the infrared tympanic thermometers revealed misdiagnosis, and validity of early models was questioned. Reliability and validity study. Temperature was measured with two infrared tympanic thermometers brands in both ears and compared with rectal temperature twice a day at the ward (n = 200). At the intensive care unit, patients (n = 42) underwent the same measurement procedures every fourth hour for 24 hours. In addition, core temperature was measured. Statistical analyses included descriptive and mixed models analyses. Ward: Infrared tympanic thermometers measured the temperature lower than the rectal temperature. Descriptive statistics indicate higher variation in temperature measurements made in the ear. No statistically significant difference in temperature was found for left ear vs. right ear. Intensive care unit: The mean rectal temperature was higher than the mean core and ear temperature. Mixed models analyses of the temperatures at the ward and the intensive care unit showed the same overall trends, but with less discrepancy between the two infrared tympanic thermometers brands, compared with the rectal temperature. Only rectal temperature measurements differed significantly from the core temperature.

Question: Can we trust the new generation of infrared tympanic thermometers in clinical practice?

Our study shows good reliability using the new generation of infrared tympanic thermometers. We found good agreement between core and infrared tympanic thermometers at the intensive care unit, but the measuring inaccuracy for infrared tympanic thermometers was greater than expected.

Answer the question based on the following context: Adolescence through emerging adulthood is a developmental stage made more challenging when the person has type 1 diabetes. Little research has investigated if individuals with high and low levels of metabolic control in this age group perceive their disease differently. Qualitative descriptive. In this study, 14 participants, ages 11-22 years were interviewed in 2008 about their perceptions of living with type 1 diabetes. Through a process of induction, major themes were identified.RESULTS/ Participants with high and low metabolic control levels reported similar themes related to reactions of others, knowledge about type 1 diabetes, and believed healthcare providers used authoritarian interactions. However, high metabolic control level participants believed type 1 diabetes would be cured; had negative initial responses to being diagnosed; rarely received parental support in managing their diabetes; and were negligent in self-care activities. Participants with low metabolic control levels did not believe a cure was imminent or have negative responses to being diagnosed; received parental support in managing diabetes; and were diligent in self-care activities.

Question: A qualitative study of young people's perspectives of living with type 1 diabetes: do perceptions vary by levels of metabolic control?

Nurses should give information to young people with type 1 diabetes beyond initial diagnosis and help and support this age group learn appropriate ways to manage their disease, develop positive relationships with healthcare professionals, and participate in interactions with others their age successfully managing type 1 diabetes.

Answer the question based on the following context: Common bile duct stenting is widely performed for bridging benign and malignant obstructions. A major limitation is early stent occlusion making regular stent exchange necessary. Covalent binding of glycosaminoglycanes to polyethylene stents proved to reduce encrustation in urological implants. Since development of urological and biliary stent occlusion shows parallels, the aim of the study was to evaluate the efficacy of heparin coating of biliary endoprostheses in preventing encrustation. In a prospective randomized trial, heparin-coated and native stents were endoscopically placed for almost 90 days on average. After removal, all stents were dried (50°C, 24 h), weighed and after longitudinal incision visible encrustation and discoloration recorded. Fifty-three patients (21 females/32 males, 70 ± 12 (42-87) years) were included; 13 patients (4 females/9 males, 58-79 years) completed the study according to the protocol. After removal, mean weight of encrustation in native stents was more than double as high as of covered stents (native: 37.9 ± 19.8 (16-93) mg; covered: 17.6 ± 6.7 (9-33) mg). In 12 of 13 cases, the encrustation weight of the native stent was higher than that of the corresponding covered stent in the same patient. Premature stent explantation became necessary in 3 of 13 native stents, because of recurrent jaundice or cholangitis but only in 1 of 13 covered stents. After longitudinal incision, the three uncovered stents showed excessive encrustation whereas no significant encrustation was found in the covered prosthesis. Altogether, covered stents showed less visible accumulation of clogging material and discoloration than native stents.

Question: Does heparin coating reduce encrustation of biliary plastic endoprostheses?

Covalent bound heparin is highly effective in preventing encrustation of biliary polyethylene endoprostheses.

Answer the question based on the following context: There is ample evidence that residential neighbourhoods can influence mental well-being (MWB), with most studies relying on census or similar data to characterize communities. Few studies have actively investigated local residents' perceptions. Concept mapping was conducted with residents from five Toronto neighbourhoods representing low income and non-low income socio-economic groups. These residents participated in small groups and attended two sessions per neighbourhood. The first session (brainstorming) generated neighbourhood characteristics that residents felt influenced their MWB. A few weeks later, participants returned to sort these neighbourhood characteristics and rate their relative importance in affecting residents' 'good' and 'poor' MWB. The data from the sorting and rating groups were analyzed to generate conceptual maps of neighbourhood characteristics that influence MWB. While agreement existed on factors influencing poor MWB (regardless of neighbourhood, income, gender and age), perceptions related to factors affecting good MWB were more varied. For example, women were more likely to rank physical beauty of their neighbourhood and range of services available as more important to good MWB, while men were more likely to cite free access to computers/internet and neighbourhood reputation as important. Low-income residents emphasized aesthetic attributes and public transportation as important to good MWB, while non-low-income residents rated crime, negative neighbourhood environment and social concerns as more important contributors to good MWB.

Question: Are residents of downtown Toronto influenced by their urban neighbourhoods?

These findings contribute to the emerging literature on neighbourhoods and MWB, and inform urban planning in a Canadian context.

Answer the question based on the following context: Oral myiasis is a rare infection for which treatment protocol has not yet been established. This article presents 2 cases treated with a combination of topical application of sulfuric ether and surgery. The reasons for the use of surgical therapy, as well as the possible advantages and disadvantages of drug-based treatments, are discussed. Two cases of oral myiasis are described, the first being observed in a 9-year-old child with hypotonic cerebral palsy, and the second in a 52-year-old adult, alcohol-dependent, both showing infection in the gingival sulcus. Both cases were successfully treated in a process that involved topical application of sulfuric ether, mechanical removal of larvae, and surgical debridement.

Question: Oral myiasis: does an indication for surgical treatment still exist?

Oral myiasis can be treated effectively with surgery after topical application of sulfuric ether. The use of drugs may suggest a therapeutic alternative, but still requires further study and experience to be implemented, especially in individuals with neurological disorders.

Answer the question based on the following context: Elevated serum phosphorus (P) levels have been linked to increased morbidity and mortality in dialysis patients with secondary hyperparathyroidism (SHPT) but may be difficult to control if parathyroid hormone (PTH) is persistently elevated. We conducted a post hoc analysis of data from an earlier interventional study (OPTIMA) to explore the relationship between PTH control and serum P. The OPTIMA study randomized dialysis patients with intact PTH (iPTH) 300-799 pg/mL to receive conventional care alone (vitamin D and/or phosphate binders [PB]; n=184) or a cinacalcet-based regimen (n=368). For patients randomized to conventional care, investigators were allowed flexibility in using a non-cinacalcet regimen (with no specific criteria for vitamin D analogue dosage) to attain KDOQI™ targets for iPTH, P, Ca and Ca x P. For those assigned to the cinacalcet-based regimen, dosages of cinacalcet, vitamin D sterols, and PB were optimized over the first 16 weeks of the study, using a predefined treatment algorithm. The present analysis examined achievement of serum P targets (≤ 4.5 and ≤ 5.5 mg/dL) in relation to achievement of iPTH ≤ 300 pg/mL during the efficacy assessment phase (EAP; weeks 17-23). Patients who achieved iPTH ≤ 300 pg/mL (or a reduction of ≥ 30% from baseline) were more likely to achieve serum P targets than those who did not, regardless of treatment group. Of those who did achieve iPTH ≤ 300 pg/mL, 43% achieved P ≤ 4.5 mg/dL and 70% achieved P ≤ 5.5 mg/dL, versus 21% and 46% of those who did not achieve iPTH ≤ 300 pg/mL. Doses of PB tended to be higher in patients not achieving serum P targets. Patients receiving cinacalcet were more likely to achieve iPTH ≤ 300 pg/mL than those receiving conventional care (73% vs 23% of patients). Logistic regression analysis identified lower baseline P, no PB use at baseline and cinacalcet treatment to be predictors of achieving P ≤ 4.5 mg/dL during EAP in patients above this threshold at baseline.

Question: Is serum phosphorus control related to parathyroid hormone control in dialysis patients with secondary hyperparathyroidism?

This post hoc analysis found that control of serum P in dialysis patients was better when serum PTH levels were lowered effectively, regardless of treatment received.

Answer the question based on the following context: Statins are increasingly prescribed to prevent cardiovascular disease (CVD) in asymptomatic individuals. Yet, it is unknown whether those at higher CVD risk - i.e. individuals in lower socio-economic position (SEP) - are adequately reached by this high-risk strategy. We aimed to examine whether the Danish implementation of the strategy to prevent cardiovascular disease (CVD) by initiating statin (HMG-CoA reductase inhibitor) therapy in high-risk individuals is equitable across socioeconomic groups. Cohort study. Applying individual-level nationwide register information on socio-demographics, dispensed prescription drugs and hospital discharges, all Danish citizens aged 20+ without previous register-markers of CVD, diabetes or statin therapy were followed during 2002-2006 for first occurrence of myocardial infarction (MI) and a dispensed statin prescription (N = 3.3 mill). Stratified by gender, 5-year age-groups and socioeconomic position (SEP), incidence of MI was applied as a proxy for statin need. Need-standardized statin incidence rates were calculated, applying MI incidence rate ratios (IRR) as need-weights to adjust for unequal needs across SEP.Horizontal equity in initiating statin therapy was tested by means of Poisson regression analysis. Applying the need-standardized statin parameters and the lowest SEP-group as reference, a need-standardized statin IRR > 1 translates into horizontal inequity favouring the higher SEP-groups. MI incidence decreased with increasing SEP without a parallel trend in incidence of statin therapy. According to the regression analyses, the need-standardized statin incidence increased in men aged 40-64 by 17%, IRR 1.17 (95% CI: 1.14-1.19) with each increase in income quintile. In women the proportion was 23%, IRR 1.23 (1.16-1.29). An analogous pattern was seen applying education as SEP indicator and among subjects aged 65-84.

Question: Is the high-risk strategy to prevent cardiovascular disease equitable?

The high-risk strategy to prevent CVD by initiating statin therapy seems to be inequitable, reaching primarily high-risk subjects in lower risk SEP-groups.

Answer the question based on the following context: We explore how alternative and complementary care use is affected by wait list length and availability of conventional care in Canada. We use data from the 2003 Canadian Community Health Survey, Statistics Canada and the Fraser Institute to explore the effect of longer wait times on the use of alternative therapies in general and for specific therapies: Registered Massage Therapy, Chiropractics, Physiotherapy, Homeopathy and Acupuncture. We use binary variables indicating whether the individual used various types of alternative care in the year preceding the survey. Wait times for specialists are associated with lower probabilities of using alternative care, but the effect are usually not statistically significant. Longer wait times for non-emergency surgery are associated with lower probabilities of using alternative care when using data from CANSIM, but very small higher probabilities of using alternative care when using data from the Fraser Institute which includes wait times for treatments for other procedures than non-emergency surgery. We find positive but extremely small effects for total wait times from the Fraser Institute. Individuals reporting unmet health care needs are more likely to use alternative care while individuals who do not have a regular physician are less likely to use it.

Question: Substitutes or complements?

Reporting unmet health care needs or no family physician have more of an impact on the use of alternative therapies than wait lists do. The evidence is not clear as to whether alternative care is sometimes used as a substitute to conventional care rather than a complement.

Answer the question based on the following context: In the endovascular era, elderly patients are offered repair of their aortoiliac aneurysms (AAA) more frequently than in the past. Our objective is to compare age groups and draw inferences for AAA repair outcomes. We identified 20,095 patients who underwent AAA repair between 2005 and 2010 using the American College of Surgeons NSQIP national database. Preoperative characteristics and outcomes were compared among age groups (group A: 0 to 64 years; B: 65 to 79 years; C: 80 to 89 years; and D: 90 years and older). The age distribution of the cohort was A: 17.1%, B: 57.2%, C: 24%, and D: 1.7%. Nonagenarians presented significantly more often as emergencies in comparison with groups A to C (A: 13.8%, B: 10.8%, C: 12.9%, D: 22.1%; p<0.001). Endovascular aneurysm repair was performed more frequently in older patients (A: 55.2%, B: 63.7%, C: 74.6%, D: 77.9%; p<0.001). Risk of any complication was significantly different among groups, becoming more prevalent with advanced age (A: 22.8%, B: 23.4%, C: 24.7%, D: 27.8%; p = 0.041). Nonsurgical complications (A: 14.7%, B: 16.4%, C: 18%, D: 19.8%; p<0.001) and cardiovascular complications (A: 3.9%, B: 4.5%, C: 5.5%, D: 5.2%; p = 0.003) were also higher with advanced age. Overall mortality was 3.1%, 4.9%,7.2%, and 13.2% for groups A to D, respectively (p<0.001). Mortality after elective AAA repair was significantly higher for open surgery compared with endovascular aneurysm repair in all age groups (open surgery vs endovascular aneurysm repair, A:1.9% vs 0.5%; p = 0.001; B: 3.9% vs 1.2%; p<0.001; C: 7.4% vs 2%; p<0.001; D: 18.8% vs 3.8%; p = 0.004). After adjusting for confounders in the entire cohort, advanced age persisted as an independent factor for postoperative mortality with a higher risk of death of 1.8 (95% CI, 1.3-2.5), 2.7 (95% CI, 1.9-3.8), and 3.3 (95% CI, 1.8-6.1) times for groups B, C, and D, respectively (group A reference).

Question: Age-stratified results from 20,095 aortoiliac aneurysm repairs: should we approach octogenarians and nonagenarians differently?

Advanced age is independently associated with higher risk of death after AAA repair and indication for surgery should be adjusted for different age groups accordingly. Endovascular aneurysm repair should be preferred for octogenarians and nonagenarians with indication to undergo repair of their AAA.

Answer the question based on the following context: Patient dissatisfaction has been previously associated with motor block in shoulder surgery patients receiving brachial plexus block. For elective minor wrist and hand surgery, we tested whether a regional block accelerating the early return of upper extremity motor function would improve patient satisfaction compared with a long-acting proximal brachial plexus block. A total of 177 patients having elective 'minor' wrist and hand surgery under awake regional block randomly received adrenalized infraclavicular lidocaine 2% 10 ml+ropivacaine 0.75% 20 ml ('long acting', n=90), or adrenalized infraclavicular lidocaine 1.5% 30 ml+long-acting distal median, radial, and ulnar nerve blocks selected according to the anticipated area of postoperative pain ('short acting', n=87). A blinded observer questioned patients on day 1 for numerically rated (0-10) subjective outcomes. With 95% power, there was no evidence for a 1-point satisfaction shift in the short acting group: satisfaction was similarly high for both groups [median (inter-quartile range)=10 (8-10) vs 10 (8-10), P=0.71], and also demonstrated strong evidence for equivalence [mean difference (95% confidence interval)=-0.18 (-0.70 to 0.35)]. There was no difference between the groups for weakness- or numbness-related dissatisfaction (low for both groups), or for numerically rated or time to first pain. Surgical anaesthesia success was similar between the groups (short acting, 97% vs 93%, P=0.50), although more patients in the short acting group had surgery initiated in ≤25 min (P=0.03).

Question: Does motor block related to long-acting brachial plexus block cause patient dissatisfaction after minor wrist and hand surgery?

Patient satisfaction is not improved after elective minor wrist and hand surgery with a regional block accelerating the early return of motor function. For this surgery, motor block related to a long-acting brachial plexus block does not appear to cause patient dissatisfaction. Clinical Trial Registration number. ACTRN12610000749000, https://www.anzctr.org.au/registry/trial_review.aspx?ID=335931.

Answer the question based on the following context: Transcatheter aortic valve implantation (TAVI) is a therapeutic option for old and multimorbid patients with severe aortic stenosis. When applying the groin first approach by transfemoral implantation, patients in the transapical group are highly selected with even higher morbidity. We report outcome of the transapical group. Between April 2008 and May 2011, 267 patients underwent TAVI through either a transfemoral (n = 201 CoreValve, n = 33 Edwards Sapien prostheses; mean age 81 ± 6 years, logistic EuroSCORE 19.5 ± 12.6 %; 4-76, STS score 7.2 ± 4 %; 1.5-28.9) or transapical approach (n = 33 Edwards Sapien prostheses; mean age 80 ± 1 years, logistic EuroSCORE 31.6 ± 17.1 %; 9.4-69.1, STS score 12.8 ± 7.1 %; 2.5-28.8). The transapical access was chosen only when transfemoral implantation was not possible. EuroSCORE and STS score were significantly higher in the transapical group (p = 0.001, respectively). A 30-day survival was comparable with 87.9 % in the transapical versus 92 % in the transfemoral group (p = 0.52). In the transapical group, female gender was predominant (n = 23; 70 %). Eight patients underwent previous cardiac surgery. All transapical implantations were successful. No bleeding or neurological complications occurred. Six patients required postoperative pacemaker implantation. Cardiac decompensation with concomitant pneumonia was the underlying cause for early mortality, except for one patient with abdominal malperfusion. Follow-up (0-37 months) was complete in 100 %, nine patients died after 30 days postoperatively (6 cardiac and 3 non-cardiac related). Echocardiography revealed good valve function with not more than mild paravalvular incompetence.

Question: The groin first approach for transcatheter aortic valve implantation: are we pushing the limits for transapical implantation?

Groin first approach is reasonable due to less invasive implantation technique. However, despite even higher predicted mortality, transapical aortic valve implantation is non-inferior to transfemoral approach.

Answer the question based on the following context: Physicians should be principal recipients of quality reports because they play a major role in referral decisions. The purpose of this study was to determine physicians' awareness and use of Germany's mandatory hospital quality reports. A retrospective observational study was carried out through structured telephone interviews of a stratified random sample of 300 physicians working in ambulatory care in Germany. We analysed absolute and relative frequencies of physicians' awareness and use of quality reports. Additionally we analysed physicians' awareness and use of quality reports in relation to age, sex, specialty, practice type and region of practice using binary regression analysis. Less than half of the physicians were aware of the quality reports. Younger physicians were significantly more aware of the reports but did not use them more often than their older colleagues. Overall 10 % of the physicians already used them for counselling patients. Taking physicians' use of online comparative hospital guides into account, the combined total use was 14 %.

Question: Do physicians know and use mandatory quality reports?

Germany's mandatory hospital quality reports play only a minor role in physicians counselling of patients who need hospital care because too few physicians know and use the reports.

Answer the question based on the following context: Arterio-venous fistulae (AVFs) are accepted as the best form of haemodialysis vascular access (VA) but are plagued by high primary failure. Accessory drainage veins (ADVs) may account for up to 40% of these failures. Furthermore, they may also lead to low flow in 'mature' AVFs. We analysed the results of 42 patients who underwent endovascular coiling of ADVs at our centre over a 4-year period. Indications were failure to mature in 34%, low flow or cannulation difficulty in 56% and thrombosis in 10% of cases. 95% procedures involved a combination of angioplasty and coiling with only 5% patients having coiling of ADV alone. Forearm AVFs constituted the majority of the cases as opposed to upper arm AVFs (74% vs. 26% respectively). Primary patency at 3, 6, 12, 18 and 24 months was 90%, 87%, 76%, 70% and 55% respectively. Successful dialysis was achieved in 10 of the 14 fistulae that had hitherto failed to mature. Coil migration was observed in 1 patient, which led to fistula occlusion.

Question: Arteriovenous fistula failure: is there a role for accessory draining vein embolization?

Coil embolisation of ADVs is an effective treatment option for dysfunctional fistulae that can be performed at the same time as angioplasty.

Answer the question based on the following context: Sepsis is a major cause of death in hospitalized patients. Early goal-directed therapy is the standard of care. When primary intensive care units (ICUs) are full, sepsis patients are cared for in overflow ICUs. To determine if process-of-care measures in the care of sepsis patients differed between primary and overflow ICUs at our institution. We conducted a retrospective study of all adult patients admitted with sepsis between July 2009 and February 2010 to either the primary ICU or the overflow ICU. Baseline patient characteristics and multiple process-of-care measures, including diagnostic and therapeutic interventions. There were 141 patients admitted with sepsis to our hospital; 100 were cared for in the primary ICU and 41 in the overflow ICU. Baseline acute physiology and chronic health evaluation (APACHE II) scores were similar. Patients received similar processes-of-care in the primary ICU and overflow ICU with the exception of deep vein thrombosis (DVT) and gastrointestinal (GI) prophylaxis within 24 hours of admission, which were better adhered to in the primary ICU (74% vs 49%, P = 0.004, and 68% vs 44%, P = 0.012, respectively). There were no significant differences in hospital and ICU length of stay between the 2 units (9.68 days vs 9.73 days, P = 0.98, and 4.78 days vs 4.92 days, P = 0.97, respectively).

Question: Does sepsis treatment differ between primary and overflow intensive care units?

Patients with sepsis admitted to the primary ICU and overflow ICU at our institution were managed similarly. Overflowing sepsis patients to non-primary intensive care units may not affect guideline-concordant care delivery or length of stay.

Answer the question based on the following context: Evidence and rationale supporting return of bowel sounds as an unreliable indicator of the end of postoperative ileus after abdominal surgery are provided. A loss of gastrointestinal motility, commonly known as postoperative ileus (POI), occurs after abdominal surgery. Since the 1900s, nurses and other clinicians have been taught to listen for return of bowel sounds to indicate the end of POI. Evidence-based nursing literature has challenged this long-standing traditional nursing practice. The purpose of this study was to provide evidence from a randomized clinical trial and rationale supporting evidence-based inquiry concerning return of bowel sounds as an unreliable indicator of the end of POI after abdominal surgery. Time (days) of return of bowel sounds after abdominal surgery was compared to the time (days) of first postoperative flatus, an indicator of the end of POI, in 66 patients recovering from abdominal surgery randomized to receive standard care compared to those who received standard care plus a rocking chair intervention. Pearson's correlation between time to first flatus and return of bowel sounds for combined groups was not significant (r = 0.231, p = 0.062, p<0.05) indicating that time to return of bowel sounds and time to first flatus were not associated.

Question: Return of bowel sounds indicating an end of postoperative ileus: is it time to cease this long-standing nursing tradition?

The results of this study provide support to evidence-based inquiry that questions the relevance of traditional nursing practice activities such as listening to bowel sounds as an indicator of the end of POI.

Answer the question based on the following context: Iron deficiency (IDA) and beta thalassemia trait (TT) are the most common causes of hypochromia and microcytosis. Many indices have been defined to quickly discriminate these similar entities via parameters obtained from automated blood cell analyzers. However, studies in the pediatric age group are scarce and their results are controversial. We calculated eight discrimination indices [Mentzer Index (MI), England and Fraser Index (E&F), Srivastava Index (S), Green and King Index (G&K), Shine and Lal Index (S&L), red blood cell (RBC) count, RBC distribution width, and red blood cell distribution width Index (RDWI)] in 100 patients. We calculated sensitivity (SENS), specificity (SPEC), positive and negative predictive value (PPV and NPV), and Youden's Index (YI) of each discrimination index. None of the discrimination indices showed a SENS and SPEC of 100%. The highest SENS was obtained with S&L (87.1%), while the highest SPEC was obtained with E&F formula (100%). The highest YI value was obtained with E&F formula (58.1%).

Question: Indices used in differentiation of thalassemia trait from iron deficiency anemia in pediatric population: are they reliable?

In our study, none of the formulas appears reliable in discriminating between TT and IDA patients. The evaluation of iron status and measurement of hemoglobin A(2) (HbA(2)) remain the most reliable investigations to differentiate between TT and IDA patients.

Answer the question based on the following context: Malaria is a major cause of morbidity and mortality in Kenya, where it is the fifth leading cause of death in both children and adults. Effectively managing malaria is dependent upon appropriate treatment. In Kenya, between 17 to 83 percent of febrile individuals first seek treatment for febrile illness over the counter from medicine retailers. Understanding medicine retailer knowledge and behaviour in treating suspected malaria and dispensing anti-malarials is crucial. To investigate medicine retailer knowledge about anti-malarials and their dispensing practices, a survey was conducted of all retail drug outlets that sell anti-malarial medications and serve residents of the Webuye Health and Demographic Surveillance Site in the Bungoma East District of western Kenya. Most of the medicine retailers surveyed (65%) were able to identify artemether-lumefantrine (AL) as the Kenyan Ministry of Health recommended first-line anti-malarial therapy for uncomplicated malaria. Retailers who correctly identified this treatment were also more likely to recommend AL to adult and paediatric customers. However, the proportion of medicine retailers who recommend the correct treatment is disappointingly low. Only 48% would recommend AL to adults, and 37% would recommend it to children. It was discovered that customer demand has an influence on retailer behaviour. Retailer training and education were found to be correlated with anti-malarial drug knowledge, which in turn is correlated with dispensing practices. Medicine retailer behaviour, including patient referral practice and dispensing practices, are also correlated with knowledge of the first-line anti-malarial medication. The Kenya Ministry of Health guidelines were found to influence retailer drug stocking and dispensing behaviours.

Question: Does anti-malarial drug knowledge predict anti-malarial dispensing practice in drug outlets?

Most medicine retailers could identify the recommended first-line treatment for uncomplicated malaria, but the percentage that could not is still too high. Furthermore, knowing the MOH recommended anti-malarial medication does not always ensure it is recommended or dispensed to customers. Retailer training and education are both areas that could be improved. Considering the influence that patient demand has on retailer behaviour, future interventions focusing on community education may positively influence appropriate dispensing of anti-malarials.

Answer the question based on the following context: In Queensland, Australia, the incidence of cancer (all cancers combined) is 21% lower for Indigenous people compared with non-Indigenous people but mortality is 36% higher. Support services play an important role in helping cancer patients through their cancer journey. Indigenous cancer patients are likely to face greater unmet supportive care needs and more barriers to accessing cancer care and support. Other barriers include the higher proportion of Indigenous people who live remotely and in regional areas, a known difficulty for access to health services. This study describes the availability of cancer support services in Queensland for Indigenous patients and relevant location. Using a set criteria 121 services were selected from a pre-existing database (n = 344) of cancer services. These services were invited to complete an online questionnaire. ArcGIS (http://www.esri.com/software/arcgis/index.html) was used to map the services' location (using postcode) against Indigenous population by local government area. Services were classified as an 'Indigenous' or 'Indigenous friendly' service using set criteria. Eighty-three services (73.6%) completed the questionnaire. Mapping revealed services are located where there are relatively low percentages of Indigenous people compared with the whole population. No 'Indigenous-specific' services were identified; however, 11 services (13%) were classed 'Indigenous-friendly'. The primary support offered by these services was 'information'. Fewer referrals were received from Indigenous liaison officers compared with other health professionals. Only 8.6% of services reported frequently having contact with an Indigenous organisation; however, 44.6% of services reported that their staff participated in cultural training. Services also identified barriers to access which may exist for Indigenous clientele, including no Indigenous staff and the costs involved in accessing the service, but were unable to address these issues due to restricted staff and funding capacity.

Question: Cancer support services--are they appropriate and accessible for Indigenous cancer patients in Queensland, Australia?

Further research into the best models for providing culturally appropriate cancer support services to Indigenous people is essential to ensure Indigenous patients are well supported throughout their cancer journey. Emphasis should be placed on providing support services where a high Indigenous population percentage resides to ensure support is maintained in rural and remote settings. Further efforts should be placed on relationships with Indigenous organisations and mainstream support services and encouraging referral from Indigenous liaison officers.

Answer the question based on the following context: There is a growing problem of physical inactivity in America, and approximately a quarter of the population report being completely sedentary during their leisure time. In the U.S., TV viewing is the most common leisure-time activity. Stepping in place during TV commercials (TV Commercial Stepping) could increase physical activity. The purpose of this study was to examine the feasibility of incorporating physical activity (PA) into a traditionally sedentary activity, by comparing TV Commercial Stepping during 90 min/d of TV programming to traditional exercise (Walking). A randomized controlled pilot study of the impact of 6 months of TV Commercial Stepping versus Walking 30 min/day in adults was conducted. 58 sedentary, overweight (body mass index 33.5 ± 4.8 kg/m2) adults (age 52.0 ± 8.6 y) were randomly assigned to one of two 6-mo behavioral PA programs: 1) TV Commercial Stepping; or 2) Walking 30 min/day. To help facilitate behavior changes participants received 6 monthly phone calls, attended monthly meetings for the first 3 months, and received monthly newsletters for the last 3 months. Using intent-to-treat analysis, changes in daily steps, TV viewing, diet, body weight, waist and hip circumference, and percent fat were compared at baseline, 3, and 6 mo. Data were collected in 2010-2011, and analyzed in 2011. Of the 58 subjects, 47 (81%) were retained for follow-up at the completion of the 6-mo program. From baseline to 6-mo, both groups significantly increased their daily steps [4611 ± 1553 steps/d vs. 7605 ± 2471 steps/d (TV Commercial Stepping); 4909 ± 1335 steps/d vs. 7865 ± 1939 steps/d (Walking); P < 0.05] with no significant difference between groups. TV viewing and dietary intake decreased significantly in both groups. Body weight did not change, but both groups had significant decreases in percent body fat (3-mo to 6-mo), and waist and hip circumference (baseline to 6-mo) over time.

Question: Can sedentary behavior be made more active?

Participants in both the TV Commercial Stepping and Walking groups had favorable changes in daily steps, TV viewing, diet, and anthropometrics. PA can be performed while viewing TV commercials and this may be a feasible alternative to traditional approaches for increasing daily steps in overweight and obese adults.

Answer the question based on the following context: There is limited evidence to evaluate the influence of competitive food and beverage legislation on school meal program participation and revenues. A representative sample of 56 California high schools was recruited to collect school-level data before (2006–2007) and the year after (2007–2008) policies regarding limiting competitive foods and beverages were required to be implemented. Data were obtained from school records, observations, and questionnaires. Paired t-tests assessed significance of change between the two time points. Average participation in lunch increased from 21.7% to 25.3% (p<0.001), representing a 17.0% increase, while average participation in breakfast increased from 8.9% to 10.3% (p = 0.02), representing a 16.0% increase. There was a significant (23.0%) increase in average meal revenue, from $0.70 to $0.86 (per student per day) (p<0.001). There was a nonsignificant decrease (18.0%) in average sales from à la carte foods, from $0.45 to $0.37 (per student per day). Compliance with food and beverage standards also increased significantly. At end point, compliance with beverage standards was higher (71.0%) than compliance with food standards (65.7%).

Question: Does competitive food and beverage legislation hurt meal participation or revenues in high schools?

Competitive food and beverage legislation can increase food service revenues when accompanied by increased rates of participation in the meal program. Future studies collecting expense data will be needed to determine impact on net revenues.

Answer the question based on the following context: South Africa is experiencing a critical shortage of human resources for health (HRH) at a time when the population and the burden of ill-health, primarily due to HIV, AIDS and TB, are on the increase. This shortage is particularly severe within the nursing profession, which has witnessed significant emigration due to poor domestic working conditions and remuneration. Salaries and other benefits are an obvious pull factor towards foreign countries, given the often extreme international wage differentials. The introduction of the Occupation Specific Dispensation (OSD) in 2007 sought to improve the public services' ability to attract and retain employees thereby reducing incentives to emigrate. Using a representative basket of commonly bought goods (including food, entertainment, fuel and utilities), a purchasing power parity (PPP) ratio is an exchange rate between two currencies that equalises the international price of buying that basket. Our study makes comparisons, using such a PPP index, and allows the identification of real differences in salaries for our selected countries (South Africa, United States, United Kingdom, Canada, Australia and Saudi Arabia) for the same HRH professions. If PPP adjusted earnings are indeed different then this indicates an economic incentive to emigrate. Salaries of most South African HRH, particularly registered nurses, are dwarfed by their international counterparts (notably United States, Canada and Saudi Arabia), although the OSD has gone some way to reduce that disparity. All selected foreign countries generally offer higher salaries on a PPP adjusted basis. The United Kingdom ($43202) and Australia ($38622), in the category of Medical Officer, are the only two examples where the PPP adjustment brings the salary below what is being offered in South Africa ($50013 post OSD). The PPP adjusted salary differences between registered nurses is very slight for South Africa ($18884 post OSD), Australia ($21784) and the United Kingdom ($20487). All other foreign countries show large salary advantages across the HRH categories examined.

Question: Is there really a pot of gold at the end of the rainbow?

Whilst South African salaries remain lower than their foreign counterparts by and large, the introduction and implementation of the OSD has made significant progress in reducing the gap between salaries of HRH in South Africa (SA) and the rest of the world. Given that the OSD has narrowed the gap between SA and overseas salaries whilst in the context of continued out migration of SA HRH, further research into push factors effecting migration needs to be undertaken.

Answer the question based on the following context: The pathogenesis of pulmonary hypertension (PH) in hemodialysis is still unclear. The aim of this study was to identify the risk factors associated with the presence of PH in chronic hemodialysis patients and to verify whether these factors might explain the highest mortality among them. We conducted a retrospective study of hemodialysis patients who started treatment from August 2001 to October 2007 and were followed up until April 2011 in a Brazilian referral medical school. According to the results of echocardiography examination, patients were allocated in two groups: those with PH and those without PH. Clinical parameters, site and type of vascular access, bioimpedance, and laboratorial findings were compared between the groups and a logistic regression model was elaborated. Actuarial survival curves were constructed and hazard risk to death was evaluated by Cox regression analysis. PH>35 mmHg was found in 23 (30.6%) of the 75 patients studied. The groups differed in extracellular water, ventricular thickness, left atrium diameter, and ventricular filling. In a univariate analysis, extracellular water was associated with PH (relative risk = 1.194; 95% CI of 1.006 - 1.416; p = 0.042); nevertheless, in a multiple model, only left atrium enlargement was independently associated with PH (relative risk =1.172; 95% CI of 1.010 - 1.359; p = 0.036). PH (hazard risk = 3.008; 95% CI of 1.285 - 7.043; p = 0.011) and age (hazard risk of 1.034 per year of age; 95% CI of 1.000 - 7.068; p = 0.047) were significantly associated with mortality in a multiple Cox regression analysis. However, when albumin was taken in account the only statistically significant association was between albumin level and mortality (hazard risk = 0.342 per g/dL; 95% CI of 0.119 - 0.984; p = 0.047) while the presence of PH lost its statistical significance (p = 0.184). Mortality was higher in patients with PH (47.8% vs 25%) who also had a statistically worse survival after the sixth year of follow up.

Question: Could albumin level explain the higher mortality in hemodialysis patients with pulmonary hypertension?

PH in hemodialysis patients is associated with parameters of volume overload that sheds light on its pathophysiology. Mortality is higher in hemodialysis patients with PH and the low albumin level can explain this association.

Answer the question based on the following context: Interpersonal continuity of care is valued by patients, but there is concern that it has declined in recent years.AIM: To determine how often patients express preference for seeing a particular GP and the extent to which that preference is met. Analysis of data from the 2009/2010 English GP Patient Survey. A stratified random sample of adult patients registered with 8362 general practices in England (response rate 39%, yielding 2,169,718 responses). Weighted estimates were calculated of preference for and success in seeing a particular GP. Multilevel logistic regression was used to identify characteristics associated with these two outcomes. Excluding practices with one GP, 62% of patients expressed a preference for seeing a particular GP. Of these patients, 72% were successful in seeing their preferred GP most of the time. Certain patient groups were associated with more preference for and success in seeing a particular GP. These were older patients (preference odds ratio [OR] = 1.7, success OR = 1.8), those with chronic medical conditions (preference OR = 1.9, success OR = 1.3), those with chronic psychological conditions (preference OR = 1.6, success OR = 1.3), and those recently requesting only non-urgent versus urgent appointments (preference OR = 1.4, success OR = 1.6). Patient groups that had more frequent preference but less success in seeing a preferred GP were females (preference OR = 1.5, success OR = 0.9), patients in larger practices (preference OR = 1.3, success OR = 0.5), and those belonging to non-white ethnic groups.

Question: Do English patients want continuity of care, and do they receive it?

The majority of patients value interpersonal continuity, yet a large minority of patients and specific patient groups are not regularly able to see the GP they prefer.

Answer the question based on the following context: To determine the association of serum cholesterol levels with Child-Pugh class in patients with decompensated chronic liver disease due to viral hepatitis. Cross-sectional analytical study. Jinnah Postgraduate Medical Centre, Karachi, Medical Unit-III, Ward-7 from June to December 2010. Consecutive patients attending outpatient department or admitted in medical unit III were eligible if they had a diagnosis of cirrhosis secondary to viral hepatitis. Patients were excluded if alcoholic, diabetic, hypertensive, or with non-alcoholic fatty liver disease, autoimmune, metabolic, cardiovascular, cerebrovascular or kidney diseases and recent use of lipid-regulating drugs. Serum lipid profile was determined after an overnight fast of 12 hours. On the basis of serum total cholesterol, patients were divided into four groups; Group I with serum total cholesterol ² 100 mg/dl, Group II with level of 101-150 mg/dl, Group III with level of 151-200 mg/dl and Group IV with serum total cholesterol level of>200 mg/dl. Hepatic dysfunction was categorized according to Child-Pugh scoring system. Chi-square and Spearman's correlation testing with p<0.05 was accepted as significant. One hundred and fourteen patients met the inclusion criteria with a mean age of 40.32 ± 13.59 years. Among these 32 were females (28.1%) while 82 were males (71.9%). According to Child-Pugh class; 34 patients (29.8%) presented with Child-Pugh class A, 34 (29.8%) in class B and 46 (40.4%) were in class C. Serum cholesterol (total) and triglycerides had significant association with Child-Pugh class (p = 0.0001 and p = 0.004 respectively) suggesting that as severity of liver dysfunction increases; serum cholesterol and triglycerides levels decrease. Results also revealed that males were significantly more hypocholesterolemic than females (p = 0.006).

Question: Serum cholesterol: could it be a sixth parameter of Child-Pugh scoring system in cirrhotics due to viral hepatitis?

Hypocholesterolemia is a common finding in decompensated chronic liver disease and has got significant association with Child-Pugh class. It may increase the reliability of Child-Pugh classification in assessment of severity and prognosis in chronic liver disease patients.

Answer the question based on the following context: Postmastectomy radiation therapy (PMRT) remains controversial for patients with pathologic stage T3N0 (pT3N0) breast cancer. A Surveillance, Epidemiology, and End Results (SEER) database analysis suggested that PMRT might benefit patients older than age 50. However, the relevance between estrogen receptor (ER), progesterone receptor (PR), race, and PMRT in patients younger than age 50 is unknown. The impact of PMRT treatment on cause-specific survival (CSS) and overall survival (OS) were analyzed for women in the SEER database from 1998 to 2007. Approximately half (47%) of the 1104 patients who met the study requirements received PMRT. We performed univariate analysis to compare CSS between the PMRT and no-PMRT groups for all patients and further stratified by age, race, tumor size, tumor grade, and ER/PR status. No difference in CSS or OS was detected between women treated with or without PMRT. Black/other race, ER-, and PR-, all suggested a trend toward decreased CSS. In univariate analysis, PMRT seems to be beneficial in patients younger than age 40 (hazard ratio=0.65; P=0.25; a nonsignificant trend in favor of PMRT).

Question: Is there a cause-specific survival benefit of postmastectomy radiation therapy in women younger than age 50 with T3N0 invasive breast cancer?

This SEER database analysis of patients younger than age 50 and with pT3N0 breast cancer showed that PMRT did not significantly affect CSS at 5 years; however, it implied a trend of benefit for patients younger than 40. The findings that patients with African heritage and negative ER/PR status showing decreased CSS warrant further investigation to determine the role of personalized PMRT in these high-risk cohorts.

Answer the question based on the following context: To evaluate prostate cancer gene 3 (PCA3) score accuracy in preoperative staging of cases of single microfocus of prostate cancer (PCa; less than 5% with Gleason score ≤6) diagnosed after repeat saturation biopsy (median 30 cores). From January 2009 to March 2012, 38 patients (median 64 years) with a microfocus of PCa, median PSA of 9.1 ng/ml and T1c clinical stage underwent radical retropubic prostatectomy. PCA3 score (cut-off of 20 vs. 35) was evaluated in predicting insignificant PCa (pIPCa: cancer volume<0.5 ml and Gleason score ≤6) versus organ-confined (OC) versus non-OC PCa. Median PCA3 score results were equal to 10 versus 53 (p<0.05) versus 108 (p<0.05) in the presence of pIPCa (13.2%), versus OC (65.8%) versus non-OC PCa (21%), respectively. PCA3 scores were significantly correlated with tumor volume.

Question: Is PCA3 score useful in preoperative staging of a single microfocus of prostate cancer diagnosed at saturation biopsy?

A PCA3 score cut-off>20 in the presence of a microfocus of PCa is highly predictive of significant PCa (diagnostic accuracy equal to 86.8%) at definitive specimen.

Answer the question based on the following context: Hemoglobin A1c (HbA1c) levels are known to be consistently higher in black persons than in white persons at any given glycemic level. Whether the optimal diagnostic threshold of HbA1c should differ between blacks and whites is unclear. To compare the relationships between HbA1c level and the prevalence of retinopathy in black and white U.S. adults. Cross-sectional study. A nationally representative sample of the National Health and Nutrition Examination Survey from 2005 through 2008. 2804 white persons and 1008 black persons aged 40 years or older in the United States. Prevalence of retinopathy. Logistic regression models and restricted cubic spline models were constructed separately for white and black populations to test the HbA1c levels at which risk for retinopathy begins to increase. After adjustment for age, sex, hypertension, body mass index, family history of diabetes, and use of antidiabetes medications or insulin, the lowest HbA1c category for which the prevalence of retinopathy was significantly higher than the reference category (&lt;5.5%) was 6.0% to 6.4% for white persons (risk difference, 4.8% [95% CI, 0.5% to 9.1%]) and 5.5% to 5.9% for black persons (risk difference, 5.3% [CI, 1.0% to 9.5%]). The restricted cubic spline models indicated that the risk for retinopathy increased at lower HbA1c levels in black persons than in white persons. The cross-sectional design of the study precluded examining the effect of the duration at each HbA1c level.

Question: Should the hemoglobin A1c diagnostic cutoff differ between blacks and whites?

The prevalence of retinopathy begins to increase at a lower HbA1c level in black Americans than in white Americans. The findings do not support increasing the diagnostic threshold of HbA1c in black persons.

Answer the question based on the following context: To investigate the course of health-related quality of life (HQL) over time in patients with peritoneal carcinomatosis (PC) after complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). Prospective, single-center, nonrandomized cohort study using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire. Ninety patients who underwent CRS and HIPEC for PC in our institution were enrolled in the study. Mean age was 56 years (range 27-77 years) (61% female). Primary tumor was colorectal in 21%, ovarian in 19%, pseudomyxoma peritonei in 16%, an appendix tumor in 16%, gastric cancer in 10%, and peritoneal mesothelioma in 13% of cases. Mean peritoneal carcinomatosis index was 22 (range 2-39). Mean global health status score was 69±25 preoperatively and 55±20, 66±22, 66±23, 71±23, and 78±21 at months 1, 6, 12, 24, and 36, respectively. Physical and role function recovered significantly at 6 months and were close to baseline at the 24-month measurement. Emotional function starting from a low baseline recovered to baseline by month 12. Cognitive and social function had slow recovery on follow-up. Fatigue, diarrhea, dyspnea, and sleep disturbance were symptoms persistent at 6-month follow-up, improving later on in survivors.

Question: Quality of life in patients after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy: is it worth the risk?

Survivors after CRS and HIPEC have postoperative quality of life similar to preoperatively, with most of the reduced elements recovering after 6-12 months. We conclude that reduced quality of life of patients after CRS and HIPEC should not be used as an argument to deny surgical therapy to these patients.

Answer the question based on the following context: The goal of this study was to investigate alternative strategies to the sternal resection in the treatment of post-sternotomy osteomyelitis. We report our experience in the treatment of chronic infection of median sternotomy following open heart surgery without sternal resection. A 4-year retrospective study was performed, consisting of 70 patients affected by post-sternotomy sternocutaneous fistulas due to chronic osteomyelitis: 45 patients underwent only medical treatment and 25 underwent steel wire removal and surgical debridement (conservative surgery). Of the 25, 7 patients underwent an additional vacuum assisted closure (VAC) therapy due to widespread infected subcutaneous tissue. The diagnosis of osteomyelitis was supported via 3D CT scan images. Complete wound healing was achieved in 67 patients including a patient who achieved healing after being affected by a fistula for over 24 years before coming under our observation, another, affected by mycobacteria other than tuberculosis osteomyelitis, who needed antimicrobial treatment for a period of 30 months and 2 who were affected by Aspergillus infection and needed radical cartilage removal. Fistula relapses were observed in 6 patients of the total 70, possibly due to the too short-term antibiotic therapy used in the presence of coagulase-negative Staphylococcus (CoNS) with multiple resistances and in the presence of Corynebacterium species.

Question: Post-sternotomy chronic osteomyelitis: is sternal resection always necessary?

Post-sternotomy chronic osteomyelitis can be successfully treated mainly by systemic antimicrobial therapy alone, without mandatory surgical treatments, provided that accurate microbiological and radiological studies are performed. The presence of CoNS and Corynebacterium species seemed to be associated with a need for a prolonged combined antimicrobial therapy with a minimum of 6 months up to a maximum of 18 months. The CT scan and the 3D reconstruction of the sternum proved to be a good method to evaluate the status of the sternum and support the treatments. The VAC therapy was not useful in treating osteomyelitis, although, if used appropriately in the postoperative deep sternal wound infection with the sponge fitted between the sternal edges, it seems to be an effective method to eradicate the infection in the sternum and to prevent chronic osteomyelitis.

Answer the question based on the following context: The use of validated outcome questionnaires and magnetic resonance imaging (MRI) when assessing outcomes after surgical treatment of proximal hamstring avulsions has been limited. To comprehensively evaluate clinical, functional, and radiological outcomes in patients treated with surgical repair for complete proximal hamstring avulsions. Case series; Level of evidence, 4. A retrospective review of 15 consecutive patients was performed. Outcome measures included the Single Assessment Numeric Evaluation (SANE), visual analog scale (VAS) for pain, Proximal Hamstring Injury Questionnaire, Lower Extremity Functional Scale (LEFS), Harris Hip Score (HHS), and Tegner Activity Scale (TAS). Physical examination was performed by an independent sports medicine fellow. Magnetic resonance imaging of the lower extremity was used to assess tendon healing and muscle quality after repair. Thirteen of 15 (87%) eligible patients were available for follow-up at a mean 36.9 months (range, 27-63 months), including 8 men and 6 left-sided injuries. The average age was 44.6 years (range, 26-58 years). Twelve of 13 patients underwent surgical repair within 60 days of injury. Mean (± standard deviation) postoperative functional outcome scores were as follows: LEFS, 74.9 ± 7.8 (range, 59-80); HHS, 90.7 ± 13.9 (range, 67-100); SANE, 93.6 ± 7.5 (range, 75-100); VAS for pain, 1.3 ± 1.9 (range, 0-5); and TAS, 4.6 ± 2.3 (range, 1-7). All 11 patients who participated in sports before surgery were able to return to sport, but 45% reported a decrease in their current level of activity. Isokinetic muscle testing demonstrated that injured hamstring strength recovered up to 78% ± 6.1% (range, 74%-88%) of the contralateral side. The MRI examinations revealed that 100% of patients had a healed proximal hamstring repair, with signs of tendinopathy and mild atrophy in 3 of 12 patients.

Question: Clinical and magnetic resonance imaging outcomes after surgical repair of complete proximal hamstring ruptures: does the tendon heal?

The current findings indicate that surgical repair of complete hamstring ruptures provides reliable pain relief, good functional outcomes, high satisfaction rates, and excellent healing rates (MRI) but does not fully restore hamstring function and sports activity to preinjury levels.

Answer the question based on the following context: Area social deprivation is associated with unfavorable health outcomes of residents across the full clinical course of cancer from the stage at diagnosis through survival. We sought to determine whether area social factors are associated with the area health care supply. We studied the area supply of health services required for the provision of guideline-recommended care for patients with breast cancer and colorectal cancer (CRC) in each of the following three distinct clinical domains: screening, treatment, and post-treatment surveillance. We characterized area social factors in 3,096 urban zip code tabulation areas by using Census Bureau data and the health care supply in the corresponding 465 hospital service areas by using American Hospital Association, American Medical Association, and US Food and Drug Administration data. In two-level hierarchical models, we assessed associations between social factors and the supply of health services across areas. We found no clear associations between area social factors and the supply of health services essential to the provision of guideline recommended breast cancer and CRC care in urban areas. The measures of health service included the supply of physicians who facilitate screening, treatment, and post-treatment care and the supply of facilities required for the same services.

Question: Do socially deprived urban areas have lesser supplies of cancer care services?

Because we found that the supply of types of health care required for the provision of guideline-recommended cancer care for patients with breast cancer and CRC did not vary with markers of area socioeconomic disadvantage, it is possible that previously reported unfavorable breast cancer and CRC outcomes among individuals living in impoverished areas may have occurred despite an apparent adequate area health care supply.

Answer the question based on the following context: In young children with a unilateral congenital inguinal hernia, the relatively high incidence of an occult contralateral patent processus vaginalis (CPPV) has led to the practice of laparoscopic contralateral exploration. The effect on postoperative complications such as surgical site infection from performing the laparoscopy has not been previously reported. A retrospective review was conducted on all patients who underwent a unilateral inguinal hernia repair from January 1, 2000 to March 1, 2010. We compared those children who underwent laparoscopic evaluation of the contralateral inguinal ring with those who did not. Patient demographics and operative data outcomes were evaluated. Student's t test was used to compare continuous variables, and the chi-squared test with Yates's correction was used for discrete variables. There were 1164 patients who underwent a unilateral inguinal hernia repair during the 10-year study period, and laparoscopy was used in 1010 patients. There were no intraoperative complications from the laparoscopy. In the group who underwent laparoscopy, the mean age was 4.0±3.6 years old, and 88% were male. At laparoscopic exploration, 315 (31%) patients were found to have a CPPV. There were 10 patients (1.0%) who developed a surgical site infection. Infection developed in the side used for laparoscopic exploration in 9 patients and in the contralateral side in 1 patient. All patients with surgical site infections were treated initially with oral antibiotics. Abscesses developed in 2 patients, requiring incision and drainage. No patient required hospital admission or reoperation. In the 154 patients who did not undergo laparoscopy, mean age was 4.3±4.4 years (P=.35), and 85.8% were male (P=.54). There was one wound infection identified in this control group (0.6%) (P=1.00). There was no difference in rate of recurrence (control group, 0%; exploration group, 0.6%; P=.72).

Question: Is there an increased risk of complications with laparoscopy looking for a contralateral patent processus vaginalis?

There is minimal risk of infection or recurrence following unilateral inguinal hernia repair, and this risk is not increased with the use of contralateral exploration using laparoscopy.

Answer the question based on the following context: Research is conflicting on whether receiving medical care at a hospital with more aggressive treatment patterns improves survival. The aim of this study was to examine whether nursing home residents admitted to hospitals with more aggressive patterns of feeding tube insertion had improved survival. Using the 1999-2007 Minimum Data Set matched to Medicare claims, we identified hospitalized nursing home residents with advanced cognitive impairment who did not have a feeding tube inserted prior to their hospital admissions. The sample included 56,824 nursing home residents and 1773 acute care hospitals nationwide. Hospitals were categorized into nine groups based on feeding tube insertion rates and whether the rates were increasing, staying the same, or decreasing between the periods of 2000-2003 and 2004-2007. Multivariate logit models were used to examine the association between the hospital patterns of feeding tube insertion and survival among hospitalized nursing home residents with advanced cognitive impairment. Nearly one in five hospitals (N=366) had persistently high rates of feeding tube insertion. Being admitted to these hospitals with persistently high rates of feeding tube insertion was not associated with improved survival when compared with being admitted to hospitals with persistently low rates of feeding tube insertion. The adjusted odds ratios were 0.93 (95% confidence interval [CI]: 0.87, 1.01) and 1.02 (95% CI: 0.95, 1.09) for one-month and six-month posthospitalization survival, respectively.

Question: Do patients with advanced cognitive impairment admitted to hospitals with higher rates of feeding tube insertion have improved survival?

Hospitals with more aggressive patterns of feeding tube insertion did not have improved survival for hospitalized nursing home residents with advanced cognitive impairment.

Answer the question based on the following context: Atrial fibrillation (AF) is an independent risk factor for stroke. Recent studies have demonstrated that the CHA(2)DS(2)-VASc scheme is useful for selecting patients who are truly at low risk. The goal of the present study was to compare the risk of ischemic stroke among AF patients with a CHA(2)DS(2)-VASc score of 0 (male) or 1 (female) with those without AF. The study enrolled 509 males (CHA(2)DS(2)-VASc score=0) and 320 females (CHA(2)DS(2)-VASc score=1) with AF who did not receive any antithrombotic therapy. Patients were selected from the National Health Insurance Research Database in Taiwan. For each study patient, 10 age-matched and sex-matched subjects without AF and without any comorbidity from the CHA(2)DS(2)-VASc scheme were selected as controls. The clinical end point was the occurrence of ischemic stroke. During a follow-up of 57.4 ± 35.7 months, 128 patients (1.4%) experienced ischemic stroke. The event rate did not differ between groups with and without AF for male patients (1.6% vs 1.6%; P=0.920). In contrast, AF was a significant risk factor for ischemic stroke among females (hazard ratio, 7.77), with event rates of 4.4% and 0.7% for female patients with and without AF (P<0.001).

Question: Atrial fibrillation and the risk of ischemic stroke: does it still matter in patients with a CHA2DS2-VASc score of 0 or 1?

AF males with a CHA(2)DS(2)-VASc score of 0 were at true low risk for stroke, which was similar to that of non-AF patients. However, AF females with a score of 1 were still at higher risk for ischemic events than non-AF patients.

Answer the question based on the following context: The Six-Minute Walk Test (6MWT) is commonly used to assess the fitness level of healthy adults and of older adults with disabilities. It can also be used as an intervention to increase walking endurance. However, its use may be limited in certain rehabilitation settings due to space requirements. If it can be shown that the measured linear distance walked in the 6-minute walk is comparable to the distance walked as measured by a pedometer, the test may be more widely used in a variety of rehabilitation settings. In addition, questions exist as to whether the method of instruction ("walk as far as you can" vs "walk as fast as you can") can impact the rate of perceived exertion of the person performing the test. The purposes of this study were to assess for differences in the measured linear distance and from the gender-based predicted value when compared to the pedometer measurement. In addition, we assessed the difference, if any, in the rate of perceived exertion (RPE) using the 2 different methods of administration. Furthermore, the distance in meters walked using the 2 different methods of instruction was compared; likewise, comparisons were made of these values to predicted values. A group of 26 older adults participated in this descriptive study. After a practice trial, each person completed 2 linear trials using different methods of instruction, ("walk as fast as you can" or "walk as far as you can") of the 6MWT while wearing a DIGI-WALKER SW-651 pedometer. Vital signs were taken before and after each trial. Linear distance, pedometer distance, and numeric value RPE were recorded. Paired t tests demonstrated no gender differences. An intraclass correlation coefficient (2,1) of 0.822 was calculated between all dependent variables. A repeated measures MANOVA was conducted to assess for differences between all variables resulting in no differences (F = 1.98; P = .13). Pairwise comparisons were also insignificant for the distance measurements except predicted value and pedometer fast P = .024. Paired t tests also demonstrated differences between RPE between trials (t = 2.15; P = .041).

Question: The 6MWT: will different methods of instruction and measurement affect performance of healthy aging and older adults?

There was good agreement between these distance measures for the 6MWT. The use of a pedometer was found to be a valid measure of walking distance during the 6MWT. It was also found that the method of instruction made no differences in walking distance. Although the change was minimal on the Borg scale, the RPE was found to be significantly different between far and fast trials in healthy adults. From this study, it appears that that either mode of instruction is valid in healthy community-dwelling populations. Future studies should include populations with impairments.

Answer the question based on the following context: Predominant etiology of ectopic gestation is tubal damage, notably salpingitis, which may be of tubercular etiology. To compare the incidence of genital tuberculosis (GTB) in two groups of adolescent patients: one undergoing surgery for acute ectopic pregnancy, the other undergoing suction evacuation for spontaneous miscarriage and to evaluate GTB as a risk factor for ectopic pregnancy in adolescent girls from low socioeconomic status presenting to a tertiary care hospital in Northern India. Prospective case-control study with 17 adolescent subjects from low socioeconomic status with acute presentation of ectopic pregnancy (group 1, study) undergoing laparotomy with 20 adolescent subjects with spontaneous miscarriage (group 2, control) undergoing suction evacuation. Subjects were tested for presence of GTB by presence of tubercular granuloma and/or positive growth on BACTEC radiometric assay from sample obtained from endometrial aspirate and products of conception in groups 1 and 2, respectively. Incidence of GTB was 35.29% (6 out of 17) in the study group compared with 5% in the control group (1 out of 20) (P=0.03).

Question: Genital tuberculosis in adolescent girls from low socioeconomic status with acute ectopic pregnancy presenting at a tertiary care hospital in urban Northern India: are we missing an opportunity to treat?

The sample size of this pilot study is too small to arrive at the definite conclusion whether GTB is risk factor for acute ectopic in this population of patients. Larger studies are needed to validate this hypothesis. However, in the presence of risk factors/suggestive intraoperative findings, testing for TB in this set of population presenting with ectopic pregnancy may be justified to prevent further morbidity by initiating anti-tubercular therapy in high prevalence areas.

Answer the question based on the following context: The costs for treating kypho- and vertebroplasty patients were evaluated at up to 2 years postsurgery. There were no significant differences in adjusted costs in the first 9 months postsurgery, but kyphoplasty patients were associated with significantly lower adjusted treatment costs by 6.8-7.9% in the remaining periods through 2 years postsurgery. Vertebral augmentation has been shown to be safe and effective for treating vertebral compression fractures. Comparative cost studies of initial treatment costs for kypho- and vertebroplasty have been mixed. The purpose of our study was to compare the costs for treating kypho- and vertebroplasty patients at up to 2 years postsurgery. Vertebroplasty and kyphoplasty patients diagnosed with pathologic or closed lumbar/thoracic vertebral fractures were identified from the 5% sample of the Medicare dataset (2006-2009). The final study cohort with at least 2 years follow-up comprised of 1,609 vertebroplasty and 2,878 kyphoplasty patients. The cumulative treatment costs (adjusted to June 2011 US$) were determined from the payer perspective. Differences in costs and length of stay were assessed by generalized linear mixed model regression, adjusting for covariates. The average adjusted costs for vertebroplasty patients within the first quarter and the first 2 years postsurgery were $14,585 [95% confidence interval (CI), $14,109-15,078] and $44,496 (95% CI, $42,763-46,299), respectively. The corresponding average adjusted costs for kyphoplasty patients were $15,117 (95% CI, $14,752-15,491) and $41,339 (95% CI, $40,154-42,560). There were no significant differences in adjusted costs in the first 9 months postsurgery, but kyphoplasty patients were associated with significantly lower adjusted treatment costs by 6.8-7.9% in the remaining periods through 2 years postsurgery.

Question: Two-year cost comparison of vertebroplasty and kyphoplasty for the treatment of vertebral compression fractures: are initial surgical costs misleading?

Our present study addresses some of the limitations in previous comparative cost studies of vertebroplasty and kyphoplasty. The higher adjusted costs for vertebroplasty patients than kyphoplasty patients by 1 year following the surgery reflect greater utilization of medical resources.

Answer the question based on the following context: A systematic review. To determine whether different indications or reasons for spinal fusion are associated with different risks of subsequent adjacent segment pathology (ASP) in the lumbar and cervical spine. Pre-existing degeneration at levels adjacent to an arthrodesis may play a role in the development of symptomatic adjacent segment pathology. Although most spinal arthrodeses occur in patients with degenerative spinal disease, spinal fusion occurs in the pediatric and trauma population, and also congenitally. Evaluating the risk of ASP in these populations may shed light on its etiology. A systematic search was conducted in PubMed and the Cochrane Library for articles published between January 1, 1990, and December 31, 2011. We included all articles that described the risk of radiographical adjacent segment pathology (RASP) following surgical fusion for degenerative disease, for trauma, or for conditions requiring fusion in pediatrics in the lumbar or cervical spine. In addition, we included studies recording ASP in patients with congenital fusion. Nineteen studies met our inclusion criteria. In patients who underwent fusion in the lumbar spine for degenerative reasons, the RASP rate averaged 12.4% during an average of 5.6-year follow-up. For patients who underwent fusion in the cervical spine for degenerative reasons, the average RASP rate was 25.3% during a 2.3-year follow-up. For patients with Klippel-Feil syndrome and congenital fusion, the RASP rate averaged 49.7% during an average of 23.5-years of follow-up. In patients who were fused for scoliosis, the average RASP rate was 20.3% of 3.9-year follow-up. However there is significant variation between studies in patient population, follow-up, and definition of RASP.

Question: Indication for spinal fusion and the risk of adjacent segment pathology: does reason for fusion affect risk?

In the cervical spine, the rate of RASP in patients with fusion for degenerative reasons indications is greater than the rate of RASP in patients with congenital fusion suggesting that the pre-existing health and status of the adjacent level at the time of fusion may play a contributory role in the development of ASP. There is insufficient evidence in the literature to determine whether the indication/reason for fusion affects the risk of RASP in the lumbar spine

Answer the question based on the following context: Systematic review. To answer the following clinical questions: (1) What is the risk of adjacent-level ossification development (ALOD) in patients receiving noninstrumented cervical fusion, instrumented cervical fusion with a plate, or cervical total disc arthroplasty?; (2) What are the risk factors for ALOD?; (3) What is the time course for the development of ALOD?; and (4) Does ALOD affect outcomes and rates of reoperation? Anterior cervical plating, total disc arthroplasty, and noninstrumented fusion have all been used in the treatment of cervical disc disease. There are numerous reports that identify ALOD, a form of heterotopic ossification, as a major risk factor after performing these procedures. Few studies have compared these 3 procedures to evaluate the risk, timing, and outcomes related to postoperation ALOD. A systematic search was conducted in PubMed and the Cochrane Library for articles published between January 1, 1990, and December 31, 2011. We included all articles that described the risk of or risk factors for ALOD after surgical treatment of the cervical spine. Studies with patients older than 18 years or those treated for tumor or trauma were excluded from the study. In addition, those with posterior fusions, case reports, and case series with less than 10 patients were excluded. A total of 5 studies met the inclusion criteria for our systematic review. The risk of ALOD with anterior cervical discectomy and fusion ranged from 41% to 64%, whereas the risk of ALOD after total disc replacement ranged from 6% to 24%. When ALOD did occur, there was a 2-fold higher risk of development at the cranial adjacent segment. The most important risk factor for the development of ALOD was the use of instrumentation and the plate-to-disc distance, although the surgical procedure type (corpectomy vs. discectomy and fusion) neared but did not reach statistical significance. Insufficient evidence was available to delineate the time course for its development and how ALOD affected outcomes.

Question: The risk of adjacent-level ossification development after surgery in the cervical spine: are there factors that affect the risk?

The current body of literature suggests that ALOD will develop with the use of instrumentation and especially so if anterior instrumentation is placed within 5 mm of the adjacent cranial disc segment. In addition, total disc replacement showed lower rates for the development of ALOD compared with anterior cervical discectomy and fusion at both short- and long-term follow-up.