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Answer the question based on the following context: Ulcerative colitis (UC) is a systemic disease of unknown etiology with extra-intestinal manifestation. Induced sputum (IS) non-invasively assesses extrapulmonary involvement in Crohn's disease. We sought to determine whether there is a cellular marker of lung injury in UC patients detectable by IS. Nineteen UC patients (mean age 46.4+/-11.3 years, disease duration 8.6+/-7.5 years [range 1-25 years] 68.4% males) were studied, 6 with active disease and 13 in remission. Eleven received 5-ASA, 5 received steroids and/or azathioprine and 3 patients were untreated. UC patients were compared with 27 healthy non-smoker controls. IS was recovered after 20 min inhalation of 3% saline with an ultrasonic nebulizer by the selecting plugs method, and 300 cells were differentially cell counted in cytospin Giemsa-stained slides. CD4/CD8 subsets were identified by FACS. Pulmonary function tests were performed by the Jaeger Masterlab spirometer. UC patients' IS contained higher %eosinophils than controls (p=0.05) and lower FEV(1)/FVC ratios (p=0.001). Steroid- and/or azathioprine-treated patients had significantly lower FEV(1)/FVC ratios than only 5-ASA-treated patients (p=0.019). Eosinophil infiltration in airways was high in 5-ASA-treated patients compared to those receiving steroids and/or azathioprine (p=0.046) and those with less extensive disease (p=0.05). Using a cutoff of 3% eosinophils, IS had a sensitivity of 67% and specificity of 73% to differentiate patients with a cutoff of 70 eosinophils/mm(2) in biopsy.

Question: Induced sputum eosinophilia in ulcerative colitis patients: the lung as a mirror image of intestine?

The percentage of sputum eosinophils is significantly different between UC patients with proctitis and pancolitis. These immune abnormalities may be a common pattern that is present throughout the mucosae.

Answer the question based on the following context: To determine whether three-dimensional conformal partial breast irradiation (3D-PBI) spares lung tissue compared with whole breast irradiation (WBI) and to include the biologically equivalent dose (BED) to account for differences in fractionation. Radiotherapy treatment plans were devised for WBI and 3D-PBI for 25 consecutive patients randomized on the NSABP B-39/RTOG 0413 protocol at Mayo Clinic in Jacksonville, Florida. WBI plans were for 50 Gy in 25 fractions, and 3D-PBI plans were for 38.5 Gy in 10 fractions. Volume of ipsilateral lung receiving 2.5, 5, 10, and 20 Gy was recorded for each plan. The linear quadratic equation was used to calculate the corresponding dose delivered in 10 fractions and volume of ipsilateral lung receiving these doses was recorded for PBI plans. Ipsilateral mean lung dose was recorded for each plan and converted to BED. There was a significant decrease in volume of lung receiving 20 Gy with PBI (median, 4.4% vs. 7.5%; p<0.001), which remained after correction for fractionation (median, 5.6% vs. 7.5%; p = 0.02). Mean lung dose was lower for PBI (median, 3.46 Gy vs. 4.57 Gy; p = 0.005), although this difference lost significance after conversion to BED (median, 3.86 Gy(3) vs 4.85 Gy(3), p = 0.07). PBI plans exposed more lung to 2.5 and 5 Gy.

Question: Does three-dimensional external beam partial breast irradiation spare lung tissue compared with standard whole breast irradiation?

3D-PBI exposes greater volumes of lung tissue to low doses of radiation and spares the amount of lung receiving higher doses when compared with WBI.

Answer the question based on the following context: Obstructive Sleep Apnea Hypopnea Syndrome (OSAHS) is associated with glucose dysmetabolism and insulin resistance, therefore the amelioration of breathing disturbances during sleep can allegedly modify the levels of markers of glucose regulation and insulin resistance, such as glycated hemoglobin, fasting glucose, insulin and HOMA(IR). The aim of this study was to explore the association between these parameters and sleep characteristics in non-diabetic OSAHS patients, as well as the effect of 6 months CPAP therapy on these markers, according to adherence to CPAP treatment. Euglycemic patients (n=56; mean age+/-SD: 46.07+/-10.67 years) with newly diagnosed OSAHS were included. Glycated hemoglobin, fasting glucose, insulin levels and HOMA(IR) were estimated at baseline and 6 months after CPAP application. According to CPAP adherence, patients were classified as follows: group 1 (mean CPAP use 4 h/night), group 2 (mean CPAP use<4 h/night) and group 3 (refused CPAP treatment), and comparisons of levels of the examined parameters were performed. At baseline, average SpO(2) during sleep was negatively correlated with insulin levels and HOMA(IR) while minimum SpO(2) during sleep was also negatively correlated with insulin levels. After 6 months, only group 1 patients demonstrated a significant decrease in glycated hemoglobin (p=0.004) accompanied by a decrease in hs-CRP levels (p=0.002). No other statistically significant change was observed.

Question: Markers of glycemic control and insulin resistance in non-diabetic patients with Obstructive Sleep Apnea Hypopnea Syndrome: does adherence to CPAP treatment improve glycemic control?

Nighttime hypoxia can affect fasting insulin levels in non-diabetic OSAHS patients. Good adherence to long-term CPAP treatment can significantly reduce HbA(1C) levels, but has no effect on markers of insulin resistance.

Answer the question based on the following context: We reviewed our experience at the Montreal Heart Institute with early surgical and percutaneous closure of postinfarction ventricular septal defects (VSD). Between May 1995 and November 2007, 51 patients with postinfarction VSD were treated. Thirty-nine patients underwent operations, and 12 were treated with percutaneous closure of the VSD. Half of the patients were in systemic shock, and 88% were supported with an intraaortic balloon pump before the procedure. Before the procedure, 14% of patients underwent primary percutaneous transluminal coronary angioplasty. The mean left ventricular ejection fraction was 0.44 +/- 0.11, and mean Qp/Qs was 2.3 +/- 1. Time from acute myocardial infarction to VSD diagnosis was 5.4 +/- 5.1 days, and the mean delay from VSD diagnosis to treatment was 4.0 +/- 4.0 days. A moderate to large residual VSD was present in 10% of patients after correction. Early overall mortality was 33%. Residual VSD, time from myocardial infarction to VSD diagnosis, and time from VSD diagnosis to treatment were the strongest predictor of mortality. Twelve patients were treated with a percutaneous occluder device, and the hospital or 30-day mortality in this group was 42%.

Question: Postinfarction ventricular septal defects: towards a new treatment algorithm?

Small or medium VSDs can be treated definitively with a ventricular septal occluder or initially to stabilize patients and allow myocardial fibrosis, thus facilitating delayed subsequent surgical correction.

Answer the question based on the following context: The aim of this retrospective study was to evaluate the clinical outcome of treating or not treating moderate-or-more functional tricuspid regurgitation in patients with functional mitral regurgitation undergoing mitral valve surgery. From January 1988 to March 2003, 110 patients with functional mitral regurgitation undergoing mitral valve surgery showed moderate-or-more functional tricuspid regurgitation, which was treated (group T) in 51 and untreated in 59 (group UT) patients. Propensity score was used to adjust midterm results. The tricuspid valve was always repaired using the DeVega technique. The mitral valve was repaired in 84 and replaced in 26 patients; no residual moderate-or-more functional mitral regurgitation was assessed at hospital discharge. Thirty-day mortality was 5.5% (8.5% for group UT versus 2% for group T; p= 0.245). Adjusted 5-year survival was 45.0% +/- 6.1% in group UT and 74.5% +/- 5.1% in group T (p= 0.004), whereas the possibility to be alive in New York Heart Association class I or II was 39.8% +/- 6.0% in group UT versus 60.0% +/- 6.5% in group T (p= 0.044). Proportional Cox analysis, forcing propensity score into the model, demonstrated that untreated moderate-or-more tricuspid regurgitation was a risk factor for lower midterm survival (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.4) and survival in New York Heart Association class I or II (hazard ratio, 1.9; 95% confidence interval, 1.1 to 3.4). Follow-up functional tricuspid regurgitation progression rate (3+/4+) was 5% in group T versus 40% in group UT (p<0.001). The progression of functional tricuspid regurgitation grade at follow-up was a risk factor for worse survival and the possibility to be alive in New York Heart Association class I or II.

Question: Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated?

Tricuspid annuloplasty is an easy and safe procedure, mandatory in case of at least moderate functional tricuspid regurgitation to achieve better mid-term outcome in patients with functional mitral regurgitation undergoing mitral valve surgery.

Answer the question based on the following context: Dogma suggests optimal myocardial protection in cardiac surgery after prior coronary artery bypass graft surgery (CABG) with patent left internal thoracic artery (LITA) pedicle graft requires clamping the graft. However, we hypothesized that leaving a patent LITA-left anterior descending (LAD) graft unclamped would not affect mortality from reoperative cardiac surgery. Data were collected on reoperative cardiac surgery patients with prior LITA-LAD grafts from July 1995 through June 2006 at our institution. With the LITA unclamped, myocardial protection was obtained initially with antegrade cardioplegia followed by regular, retrograde cardioplegia boluses and systemic hypothermia. The Society of Thoracic Surgeons National Database definitions were employed. The primary outcome was perioperative mortality. Variables were evaluated for association with mortality by bivariate and multivariate analyses. In all, 206 reoperations were identified involving patients with a patent LITA-LAD graft. Of these, 118 (57%) did not have their LITA pedicle clamped compared with 88 (43%) who did. There were 15 nonsurvivors (7%): 8 of 188 (6.8%) in the unclamped group and 7 of 88 (8.0%) in the clamped group (p = 0.750). Nonsurvivors had more renal failure (p = 0.007), congestive heart failure (p = 0.017), and longer perfusion times (p = 0.010). When controlling for independently associated variables for mortality, namely, perfusion time (odds ratio 1.014 per minute; 95% confidence interval: 1.004 to 1.023; p = 0.004) and renal failure (odds ratio 4.146; 95% confidence interval: 1.280 to 13.427; p = 0.018), an unclamped LITA did not result in any increased mortality (odds ratio 1.370; 95% confidence interval: 0.448 to 4.191). Importantly, the process of dissecting out the LITA resulted in 7 graft injuries, 2 of which significantly altered the operation.

Question: Do you need to clamp a patent left internal thoracic artery-left anterior descending graft in reoperative cardiac surgery?

In cardiac surgery after CABG, leaving the LITA graft unclamped did not change mortality but may reduce the risk of patent graft injury, which may alter an operation.

Answer the question based on the following context: Central venous catheter insertion is a common procedure. A secure dressing is essential to prevent early line displacement. Many different dressings are used, but there is no consensus in choosing an optimal dressing. A sandwich, loop-line, or bridge technique was used to apply each of the dressings. Two mechanisms of displacement were tested: dressing adherence to skin and dressing adherence to line. Dressing to skin adherence was tested on a relatively hairless part of the upper arm. Weights were added sequentially until the dressing peeled off. Dressing to line adherence was tested by applying the dressing to a 7F Dual Lumen Bard Hickman line passing through a piece of foam (measuring 13 x 12 cm). Weights were attached to the line until the cuff was pulled through the foam. Dressing to skin adherence was poorest for the clear dressings, followed by Mefix and Sleek, and greatest for a combination of Tegaderm and Mefix. Dressing to line adherence was improved using a sandwich technique instead of a loop-line technique and most secure when a bridge technique was used to the thicker shaft of the line.

Question: Central venous line dressings: can you stick it?

The dressings used for securing Hickman lines are not all equally secure. The least effective is the IV 3000 loop-line dressing. Tegaderm-Mefix bridge and Tegaderm-Mefix-Sleek combination dressings are the most secure and cost effective.

Answer the question based on the following context: The aberrations in facial structure with concave midface are a well-recognized feature characterizing cleft palate patients. Several explanations have been given as to the aberration causes, including surgical interference or the primary tissue deficiency in the congenital cleft. The aim of this study was to determine intrinsic effects of congenital cleft palate on craniofacial morphology by retrospectively comparing craniofacial features between children with unoperated submucous cleft palate and noncleft children with normal occlusion in prepuberty. Twelve Japanese children (7 girls and 5 boys) with unoperated submucous cleft palate at age 9 were examined cephalometrically. None of them had undergone any orthodontic treatments. Their craniofacial morphologies were compared with those in 60 Japanese noncleft children (30 girls and 30 boys) with normal occlusion at age 9. In cleft children, anteroposterior length of the maxilla was significantly short, and the posterior part of the maxilla was more in the anterior position compared with noncleft children. Also, the anterior parts of the maxilla tended to be slightly retruded in cleft children.

Question: Does congenital cleft palate intrinsically influence craniofacial morphology?

In the current study, we recognized characteristic differences in the craniofacial morphology between the unoperated submucous cleft palate children and the noncleft children in prepuberty, and showed that the craniofacial deviation in the cleft children can be defined as the intrinsic effects of congenital cleft palate itself.

Answer the question based on the following context: Fewer emergency department (ED) visits may be a potential indicator of quality of care during the end of life. Receipt of palliative care, such as that offered by the adult Palliative Care Service (PCS) in Halifax, Nova Scotia, is associated with reduced ED visits. In June 2004, an integrated service model was introduced into the Halifax PCS with the objective of improving outcomes and enhancing care provider coordination and communication. The purpose of this study was to explore temporal trends in ED visits among PCS patients before and after integrated service model implementation. PCS and ED visit data were utilized in this secondary data analysis. Subjects included all adult patients enrolled in the Halifax PCS between January 1, 1999 and December 31, 2005, who had died during this period (N = 3221). Temporal trends in ED utilization were evaluated dichotomously as preintegration or postintegration of the new service model and across 6-month time blocks. Adjustments for patient characteristics were performed using multivariate logistic regression. Fewer patients (29%) made at least one ED visit postintegration compared to the preintegration time period (36%, p<0.001). Following adjustments, PCS patients enrolled postintegration were 20% less likely to have made at least one ED visit than those enrolled preintegration (adjusted OR 0.8; 95% confidence interval 0.6-1.0).

Question: Can the introduction of an integrated service model to an existing comprehensive palliative care service impact emergency department visits among enrolled patients?

There is some evidence to suggest the introduction of the integrated service model has resulted in a decline in ED visits among PCS patients. Further research is needed to evaluate whether the observed reduction persists.

Answer the question based on the following context: The dietary diversity score (DDS) is a good indicator of diet quality as well as of diet-disease relationships; therefore, the present study was undertaken to reveal the effect of a lifestyle intervention on this index. A baseline and three evaluation studies were conducted in two intervention districts (Isfahan and Najaf-Abad) and a reference area (Arak), all located in central Iran. The Isfahan Healthy Hearth Programme (IHHP) targeted the entire population of nearly 2 million in urban and rural areas of the intervention communities. One of the main strategies of the lifestyle intervention phase in the IHHP was healthy nutrition. Usual dietary intake was assessed using a forty-nine-item FFQ. A diversity score for each food group was calculated and the DDS was considered the sum of the diversity scores of the food groups. There were significant increases in DDS in both intervention areas (P = 0.0001) after controlling for confounding factors. There was a significant interaction between area and evaluation stage with regard to DDS (P = 0.0001). The effect of the intervention on the diversity scores of all food groups was also significant (P = 0.0001 for all) after adjusting for socio-economic status.

Question: Do lifestyle interventions affect dietary diversity score in the general population?

The community-based lifestyle intervention in the IHHP was successful in improving DDS which might be related to an increase of diet quality of the population that in turn might decrease the risks of chronic diseases.

Answer the question based on the following context: Depression occurs commonly in coronary artery disease (CAD) and is associated with substantial disability. Modifiable cognitive determinants of depression in this population have not been identified. We investigated the impact of potentially modifiable illness beliefs about CAD on depressive symptomatology. We also examined the association between these beliefs and health-related quality of life (HRQOL) and socio-demographic variations in illness beliefs. A prospective study of 193 recently hospitalized CAD patients was conducted. Data were collected from medical records and by self-report 3 and 9 months post-discharge. Socio-demographic differences were analysed with independent sample t-tests. Predictive models were tested in a series of hierarchical linear regression equations that controlled for known clinical, psychosocial, and demographic correlates of outcome. Negative illness beliefs, particularly those associated with the consequences of CAD, were significantly predictive of higher levels of depressive symptomatology at 3 and 9 months. Positive illness perceptions were significantly associated with better HRQOL outcomes. Older and less socially advantaged patients demonstrated more negative illness beliefs.

Question: Are illness perceptions about coronary artery disease predictive of depression and quality of life outcomes?

Illness beliefs are significantly associated with depressive symptomatology and HRQOL in CAD patients. These beliefs can be easily identified and constitute a meaningful and clinically accessible avenue for improving psychological morbidity and HRQOL in CAD patients. Older and more socially vulnerable patients may require heightened monitoring of their illness beliefs. Research needs to translate these and other predictive findings into interventions.

Answer the question based on the following context: To investigate the role of CD40 ligand and P-selectin in the mechanism of decreased incidence of cardiovascular disease in Gilbert's syndrome (GS). The soluble forms of CD40 ligand (sCD40L) and P-selectin (sP-selectin), and high sensitive C reactive protein (hs-CRP) levels were investigated in subjects with GS (n=25) and compared to healthy controls (n=53). sCD40L and hs-CRP levels were significantly lower in GS compared to the controls (0.33+/-0.27 vs 0.71+/-0.37 ng/mL, p<0.001 and 0.51+/-0.45 vs 1.16+/-1.31 mg/L, p=0.046, respectively). Both sCD40L and hs-CRP were negatively correlated with total bilirubin (r=-0.5, p<0.001 and r=-0.34, p=0.002, respectively). sP-selectin levels were lower in GS when compared to the controls but the difference did not reach statistical significance (p=0.052). No correlation was found between the plasma levels of sCD40L, sP-selectin and hs-CRP.

Question: Soluble CD40 ligand and soluble P-selectin levels in Gilbert's syndrome: a link to protection against atherosclerosis?

These novel findings suggest that reduced sCD40L and hs-CRP concentrations may have a role in the mechanism of protection against atherosclerosis in GS.

Answer the question based on the following context: To examine population trends in lifestyle walking in New South Wales (NSW), Australia between 1998 and 2006. Computer Assisted Telephone Interviewing surveys were conducted in 1998 and annually from 2002 to 2006. The weighted and standardized prevalence estimates of any walking (AW) for exercise, recreation or travel (i.e.>or =10 min/week) and of regular walking (RW) (i.e.>or =150 mins/week over>or =5 occasions) in population sub-groups were determined for each year. Adjusted annual change was calculated using multiple regression analyses. The prevalence of AW was high in 1998 (80.0%, 95% CI: 79.4%-80.6%) and increased to 83.5% (95% CI: 82.7%-84.3%) in 2006. The prevalence of RW was stable between 1998 and 2003 ( approximately 29%), and gradually increased between 2004 (32.9%, 95% CI: 32.0%-33.8%) and 2006 (36.5%, 95% CI: 35.4%-37.6%). The yearly increases differed in magnitude but were significant for all population sub-groups including 75 years and older, the obese, people living in remote locations and those in the most disadvantaged socio-economic status quintile. Socio-economic differential in RW was no longer significant in 2006.

Question: Are messages about lifestyle walking being heard?

Over time, everyday walking has the potential to reduce health inequalities that is due to inactivity. Public health efforts to promote active living and address obesity, as well as a rise in gasoline prices, might have contributed to this trend.

Answer the question based on the following context: The intractability of renal dysfunction following thoracic and thoraco-abdominal aortic repair leads us to believe that the accepted mechanisms of renal injury - ischaemia and embolism - are incompletely explanatory. We studied postoperative myoglobinaemia and renal dysfunction following aortic surgery. Between September 2006 and February 2008, we studied serum myoglobin in 109 patients requiring thoracic/thoraco-abdominal repair for three postoperative days. Forty-two of the 109 (38%) patients were female. The median age was 67 years (range 23-84 years). As we have focussed more attention on renal function, our independent renal consultants have dialysed more aggressively. We divided dialysis into: (1) creatinine indication, (2) non-creatinine indication and (3) no dialysis. Thirteen of the 109 (12%) patients met creatinine indication for dialysis (>4 mg dl(-1)) and an additional 28 (26%) were dialysed for other reasons. Overall mortality was 12 out of 109 (11%) cases: 11 out of 41 (27%) in dialysed patients and one out of 68 (1.5%) in non-dialysed patients. Mortality did not differ between the indications for dialysis. Predictors of mortality were baseline glomerular filtration rate (GFR), postoperative myoglobin and dialysis. The only predictor of dialysis was postoperative myoglobin.

Question: Serum myoglobin and renal morbidity and mortality following thoracic and thoraco-abdominal aortic repair: does rhabdomyolysis play a role?

A strong relationship between postoperative serum myoglobin and renal failure suggests a rhabdomyolysis-like contributing aetiology following thoraco-abdominal aortic repair. We postulate a novel mechanism of renal injury for which mitigation strategies should be developed.

Answer the question based on the following context: Trauma is a significant cause of mortality among elderly patients, with blunt mechanisms accounting for the majority of deaths in this population. Penetrating trauma promises to evolve as an increasingly important aetiology of mortality in the elderly; particularly as the age composition of the overall population continues to shift. Unfortunately, very little data regarding outcomes following penetrating trauma in the elderly exists. The purpose of this study was to define the relationship between age and mortality following penetrating injuries and determine if differences between outcomes of elderly patients sustaining penetrating and blunt trauma exist. After IRB approval, we conducted a retrospective trauma registry review at an urban Level 1 trauma centre between January 1, 1998 and December 31, 2005. Demographic, injury, and mortality data for all patients were recorded. The relationship between age and mortality for both blunt and penetrating injuries was examined by comparison of age-specific mortality and relative risk of mortality for both mechanisms at 10 year age intervals. Additionally, the relative risk and 95% confidence interval for mortality in each age group were compared. There were 26,333 blunt trauma admissions and 8843 penetrating trauma admissions during the 8-year study period. The mortality following both blunt and penetrating trauma remained stable until the age of 55 and increased steadily thereafter. When differences in mortality following blunt and penetrating mechanisms were examined, the overall mortality of penetrating trauma was found to be 2.63 times that of blunt (11.0% vs. 4.2%, RR 2.63; 95% CI: 2.42, 2.85, p<0.0001). After adjustment for age and other confounding factors, the relative risk of mortality due to penetrating mechanisms was 1.65 (95% CI: 0.88, 2.89, p=0.10) that of blunt mechanism counterparts. Although statistically higher in penetrating trauma, the relative risk of mortality between penetrating and blunt trauma decreased with increasing age.

Question: Does age matter?

The mortality rate with respect to penetrating trauma remains relatively constant until the age of 55, increasing thereafter. When compared to blunt trauma, the relationship between age and mortality in penetrating trauma is similar except that the relative mortality in penetrating trauma is significantly higher for each age group.

Answer the question based on the following context: Recent media interest in stabbings and shootings has lead to the general assumption that injury and death secondary to deliberate penetrating trauma are rising. The aim of this study was to establish the prevalence of deliberate penetrating trauma within a London-based physician-led pre-hospital trauma service, and evaluate whether the perceived increase reported by the media translates into a real increase in penetrating trauma caseload. A retrospective review of a physician-led pre-hospital care trauma database was conducted to identify all patients who sustained stabbing or shooting injuries over a 16-year period. Patients who died in the pre-hospital phase and paediatric patients were included. Other local and national datasets were examined to determine whether similar trends were observed. 1564 penetrating trauma victims were identified, including 92 children. 1358 patients (86.8%) sustained stab wounds; 206 patients were shot (13.2%). Penetrating injury accounted for 9.9% of the overall trauma caseload during the study period. The annual increase in patients sustaining stabbing injuries was 23.2%. Gun shot wounds increased by 11.0% per year.

Question: Is the prevalence of deliberate penetrating trauma increasing in London?

The study demonstrates a significant annual rise in the number of cases of deliberate penetrating trauma managed by a UK physician-led pre-hospital trauma service.

Answer the question based on the following context: To provide the first insights into the potential role of urocortin in mammalian spermatogenesis, we studied the expression of urocortin and corticotropin-releasing factor receptors 1 and 2 in the human testis. Urocortin is a bioactive peptide with antiapoptotic and antiproliferative properties. The proper regulation of apoptosis and proliferation is of high physiologic relevance in the control of spermatogenesis in adulthood and of the noncycling stage of gonocytes in fetal life. Using polymerase chain reaction analysis and immunohistochemistry, the expression and tissue localization of urocortin on mRNA and at the peptide level was studied in 9 normal adult, 5 fetal, and 5 Sertoli cell-only testicular specimens. Tissue localization of corticotropin-releasing factor receptors in normal adults was considered using immunohistochemistry. We found that urocortin mRNA was present in all adult specimens tested and that the urocortin peptide was expressed in elongating spermatids, mature spermatozoa, and peritubular myoid cells, and to a lesser extent in Leydig cells. Corticotropin-releasing factor receptor 1 was mainly expressed in spermatogonia, spermatocytes, and Leydig cells, and corticotropin-releasing factor receptor 2 was mostly expressed in spermatogonia. The antibodies against urocortin produced a nuclear staining in fetal gonocytes. No significant immunopositivity for urocortin could be observed in the Sertoli cell-only specimens.

Question: Differential expression of urocortin in human testicular germ cells in course of spermatogenesis: role for urocortin in male fertility?

The expression of urocortin in normal adult and fetal testicular germ cells in the cell division arrest phases suggests a probable role for this peptide in the pathophysiology of germ cell differentiation and division. In human germ cells, the separate location of urocortin and its receptors indicates a receptor-independent action of urocortin in the course of spermatogenesis.

Answer the question based on the following context: To describe the accuracy of SLN mapping in patients with a preoperative diagnosis of grade 1 endometrial cancer. A prospective, non-randomized study of women with a preoperative diagnosis of endometrial cancer and clinical stage I disease was conducted. A subset analysis of patients with a preoperative diagnosis of grade 1 endometrial endometrioid cancer was performed. All patients had preoperative lymphoscintigraphy with Tc99m on the day of or day before surgery followed by an intraoperative injection of 2 cm(3) of isosulfan or methylene blue dye deep into the cervix or both cervix and fundus. All patients underwent hysterectomy, bilateral salpingo-oophorectomy, and regional nodal dissection. Hot and/or blue nodes were labeled as SLNs and sent for histopathological analysis. Forty-two patients with a preoperative diagnosis of grade 1 endometrial carcinoma treated from 3/06 to 8/08 were identified. Twenty-five (60%) had laparoscopic surgery; 17 (40%) were treated by laparotomy. Preoperative lymphoscintigraphy visualized SLNs in 30 patients (71%); intraoperative localization of the SLN was possible in 36 patients (86%). A median of 3 SLNs (range, 1-14) and 14.5 non-SLNs (range, 4-55) were examined. In all, 4/36 (11%) had positive SLNs-3 seen on H&E and 1 as cytokeratin-positive cells on IHC. All node-positive cases were picked up by the SLN; there were no false-negative cases. The sensitivity of the SLN procedure in the 36 patients who had an SLN identified was 100%.

Question: Sentinel lymph node mapping for grade 1 endometrial cancer: is it the answer to the surgical staging dilemma?

Sentinel lymph node mapping using a cervical injection with combined Tc and blue dye is feasible and accurate in patients with grade 1 endometrial cancer and may be a reasonable option for this select group of patients. Regional lymphadenectomy remains the gold standard in many practices, particularly for the approximately 15% of cases with failed SLN mapping.

Answer the question based on the following context: The Resonance metallic ureteral stent (Cook Medical, Bloomington, Indiana, USA) has been introduced for the management of extrinsic-etiology ureteral obstruction for time periods up to 12 mo. The current study aims to determine short- and medium-term effectiveness of the Resonance stent in malignant and benign ureteral obstruction. In total, 50 patients with extrinsic malignant obstruction (n=25), benign ureteral obstruction (n=18), and previously obstructed mesh metal stents (n=7) were prospectively evaluated. All patients were treated by Resonance stent insertion. Twenty stents were inserted in antegrade fashion, and the remaining stents were inserted in a retrograde approach. No patient dropped out of the study. The follow-up evaluation included biochemical and imaging modalities. We evaluated the technical success rate, stricture patency rate, complications, and the presence and type of encrustation. The technical success rate of transversal and stenting of the strictures was 100%. In 19 patients, balloon dilatation was performed prior to stenting. The mean follow-up period was 8.5 mo. The stricture patency rate in patients with extrinsic malignant ureteral obstruction was 100% and in patients with benign ureteral obstruction 44%. Failure of Resonance stents in all cases of obstructed metal stents was observed shortly after the procedure (2-12 d). In nine cases, stent exchange was demanding. Encrustation was present in 12 out of 54 stents.

Question: Ureteral obstruction: is the full metallic double-pigtail stent the way to go?

The Resonance stent provides safe and sufficient management of malignant extrinsic ureteral obstruction. Resonance stent use in benign disease needs further evaluation, considering the untoward results of the present study.

Answer the question based on the following context: Post-partum mastitis is a common infection in breastfeeding women, with an incidence of 9.5-16% in recent literature. Over the past decade, community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a significant pathogen in soft-tissue infections presenting to the emergency department. The incidence of mastitis caused by MRSA is unknown at this time, but likely increasing. We review the data on prevention and treatment of mastitis and address recent literature demonstrating increases in MRSA infections in the post-partum population and how we should change our practices in light of this emerging pathogen. We present a case of simple mastitis in a health care worker who failed to improve until treated with antibiotics appropriate for a MRSA infection.

Question: Mastitis and methicillin-resistant Staphylococcus aureus (MRSA): the calm before the storm?

Recent evidence suggests that just as MRSA has become the prominent pathogen in other soft-tissue infections, mastitis is now increasingly caused by this pathogen. Physicians caring for patients with mastitis need to be aware of this bacteriologic shift to treat appropriately.

Answer the question based on the following context: The aim of this study was to determine whether post-ischemic left ventricular (LV) delayed relaxation could be detected by using strain imaging (SI) derived from 2-dimensional speckle-tracking echocardiography in patients with stable effort angina. Regional LV delayed relaxation during early diastole is a sensitive sign of acute myocardial ischemia and may persist beyond recovery of exercise-induced ischemia. Regional LV transverse strain changes during the first one-third of diastole duration (strain imaging diastolic index [SI-DI]) were determined at baseline and 5 and 10 min after the exercise test in 162 patients with stable effort angina. The ratio of SI-DI before and after exercise (SI-DI ratio) was used to identify regional LV delayed relaxation. A total of 117 patients had significant (>or =50% of luminal diameter) coronary stenoses. The mean SI-DI decreased from 78.0 +/- 9.7% to 27.6 +/- 16.0% (p<0.0001) in 191 territories perfused by coronary arteries with significant stenoses 5 min after the treadmill exercise, whereas it remained unchanged in 280 territories perfused by arteries with nonsignificant stenoses. Ten minutes after exercise, regional delayed relaxation was still observed in 85% of territories perfused by stenotic coronary arteries. An SI-DI ratio with a cutoff value of 0.74 had a sensitivity of 97% and a specificity of 93% to detect significant coronary stenosis in the receiver-operator characteristic curve.

Question: Exercise-induced post-ischemic left ventricular delayed relaxation or diastolic stunning: is it a reliable marker in detecting coronary artery disease?

Detection of post-ischemic regional LV delayed relaxation or diastolic stunning after treadmill exercise using SI is a sensitive and reliable method for the detection of coronary artery disease.

Answer the question based on the following context: To evaluate the sensitivity and specificity of various predictors of hypotension during onset of spinal anesthesia in elderly patients. Prospective study. 32 ASA physical status I, II, and III patients, aged>or=60 years, scheduled for elective lower limb surgery with spinal anesthesia. Patients received spinal anesthesia with 10-17.5 mg of bupivacaine. No prophylactic ephedrine or fluid preloading was used. A 5-minute baseline was recorded and during onset of spinal anesthesia, hemodynamic changes were measured every 10 seconds from the radial artery pressure curve. Data collection ended when patients were ready for surgery, or if ephedrine was given to increase mean arterial pressure. 21 patients had hypotension. Baseline blood pressure variability low-frequency band power (BPV LF)>8 mmHg(2) and near-infrared spectroscopy (NIRS) reduction>or=5% had high sensitivity (0.73 and 0.90, respectively) and specificity (0.78 and 0.64, respectively), and were significantly associated with the development of hypotension.

Question: Is it possible to predict hypotension during onset of spinal anesthesia in elderly patients?

Only NIRS and BPV LF could significantly predict hypotension among the elderly.

Answer the question based on the following context: Racial/ethnic disparities in nocturia prevalence have been reported previously. We estimated nocturia prevalence rates by race/ethnicity and determined the contribution of socioeconomic status to potential differences by race/ethnicity. The Boston Area Community Health Survey used a multistage stratified design to recruit a random sample of 5,501 adults, including 2,301 men and 3,200 women, who were 30 to 79 years old. Nocturia was defined as voiding more than once per night in the last week or voiding more than once per night fairly often, usually or almost always in the last month. Self-reported race/ethnicity was defined as black, Hispanic and white. Socioeconomic status was defined as a combination of education and household income. The overall prevalence of nocturia was 28.4% with a higher prevalence in black and Hispanic participants compared to white participants (38.6% and 30.7%, respectively, vs 23.2%), a trend that was consistent by gender. After adjusting for socioeconomic status the increased odds of nocturia in Hispanic men disappeared (adjusted OR 1.04, 95% CI 0.71, 1.52), while the OR in black men was attenuated but remained statistically significant (OR 1.57, 95% CI 1.12, 2.21). In women the association between race/ethnicity and nocturia was attenuated but remained statistically significant after adjusting for socioeconomic status.

Question: Are racial/ethnic disparities in the prevalence of nocturia due to socioeconomic status?

Socioeconomic status accounts for part of the racial/ethnic disparities in prevalence of nocturia. The effect of socioeconomic status was more pronounced in men and in Hispanic participants, while differences in nocturia prevalence remained significant in black men and women.

Answer the question based on the following context: Imaging follow-up (FU) after endovascular aneurysm repair (EVAR) is usually performed by periodic contrast-enhanced computed tomography (CT) scans. This study aims to evaluate the effectiveness of CT-FU after EVAR. In this study, 279 of 304 consecutive patients (261 male, aged 74 years (interquartile range (IQR): 70-79 years) with a median abdominal aortic aneurysm (AAA) diameter of 58 mm (IQR: 53-67 mm)) underwent at least one of the yearly CT scans and plain abdominal films after EVAR. All patients received Zenith stent-grafts for non-ruptured AAAs at a single institution. Patients were considered asymptomatic when a re-intervention was done solely due to an imaging FU finding. The data were prospectively entered in a computer database and retrospectively analysed. As a follow-up, 1167 CT scans were performed at a median of 54 months (IQR: 34-74 months) after EVAR. Twenty-seven patients exhibited postoperative AAA expansion (a 5-year expansion-free rate of 88+/-2%), and 57 patients underwent 78 postoperative re-interventions with a 5-year secondary success rate of 91+/-2%. Of the 279 patients, 26 (9.3%) undergoing imaging FU benefitted from the yearly CT scans, since they had re-interventions based on asymptomatic imaging findings: AAA diameter expansion with or without endoleaks (n=18), kink in the stent-graft limbs (n=4), endoleak type III due to stent-graft limb separation without simultaneous AAA expansion (n=2), isolated common iliac artery expansion (n=1) and superior mesenteric artery malperfusion due to partial coverage by the stent-graft fabric (n=1).

Question: Is there a benefit of frequent CT follow-up after EVAR?

Less than 10% of the patients benefit from the yearly CT-FU after EVAR. Only one re-intervention due to partial coverage of a branch by the stent-graft would have been delayed if routine FU had been based on simple diameter measurements and plain abdominal radiograph. This suggests that less-frequent CT is sufficient in the majority of patients, which may simplify the FU protocol, reduce radiation exposure and the total costs of EVAR. Contrast-enhanced CT scans continue, nevertheless, to be critical when re-interventions are planned.

Answer the question based on the following context: To examine three opinions voiced by nightshift emergency department (ED) staff. First, that a significant proportion of adult patients arriving by emergency ambulance lack a clear indication for emergency transport. Second, that at night a high proportion of ambulance arrivals are drunk, abusive or leave without treatment. Third, that at night a high proportion of ambulance arrivals have been assaulted or have deliberately harmed themselves. A retrospective audit of all 5421 new patient attendances to Glasgow Royal Infirmary ED in February 2007, including 1743 arriving by ambulance. 19.5% of ambulance arrivals lacked a clear indication for emergency transport. Between midnight and 05:00 hours: 52.5% of ambulance arrivals were intoxicated; 6.2% were abusive to staff; 14.0% left before treatment was completed; 21.4% had been assaulted and 7.4% had deliberately harmed themselves.

Question: Are emergency department staffs' perceptions about the inappropriate use of ambulances, alcohol intoxication, verbal abuse and violence accurate?

The majority of ambulances were called appropriately; however, there remains a significant proportion who could travel by other means. A high proportion of ambulance arrivals between midnight and 05:00 hours were intoxicated, abusive or victims of assault. This supported staff's perception that such patients form a substantial proportion of departmental workload at night.

Answer the question based on the following context: The Manchester Triage System (MTS) is a 5-point triage scale used to triage patients presenting to the emergency department. It was introduced in the UK in 1996 and is now widespread, especially in Europe, and has been in use in our hospital since 2000 via a computerised protocol. A study was undertaken to determine whether the subgroups created by the application of MTS have different propensities for indirect triage outcomes such as death in the A&E department or being admitted to hospital. A database of 321 539 patients triaged during a 30-month period (from January 2005 to June 2007) was used. MTS codes, death outcomes, admission and admission route were used to estimate the proportions and association between MTS codes and the remaining variables by chi(2) univariate analysis. There was a clear association between the priority group and short-term mortality as well as with the proportion of patients admitted to hospital.

Question: Is Manchester (MTS) more than a triage system?

The MTS provides information that extends beyond its immediate usefulness as a prioritisation mechanism. It is a powerful tool for distinguishing between patients with high and low unadjusted risk of short-term death as well as those who will stay in hospital for at least 24 h and those who will return home. Its discriminatory power is not equal for medical and surgical specialities, which may be linked to the nature of its inbuilt discriminators.

Answer the question based on the following context: An "aborted" myocardial infarction is defined as an acute coronary syndrome where there is rapid resolution of existing ST segment elevation associated with a rise in creatine kinase (CK) less than twice the upper limit of normal or a small troponin release compatible with minimal myocyte necrosis. Previous research has shown that earlier thrombolysis is associated with a higher rate of aborted infarction. It is also known that prehospital thrombolysis reduces the pain-to-needle time.AIM: To test the hypothesis that prehospital thrombolysis is associated with a higher incidence of aborted infarction in a UK setting. A retrospective analysis was performed for all patients given prehospital thrombolysis in the Avon sector catchment area of the Great Western Ambulance Service and Frimley Park Hospital between April 2004 and October 2006. The control group were patients given in-hospital thrombolysis at Frenchay Hospital or Frimley Park Hospital over the same period. Data reporting 12 h troponin levels, call-to-needle time, pain-to-needle time, door-to-needle time and incidence of aborted infarction were collected. Of the patients receiving prehospital thrombolysis, 69% had a pain-to-needle time of 2 h or less compared with 40.4% of patients receiving in-hospital thrombolysis (p<0.001). The overall incidence of aborted infarction was 16.5%. Of those with aborted infarction for whom pain-to-needle times were available, 54% had a pain-to-needle time of<2 h. Despite the difference in pain-to-needle times in favour of prehospital thrombolysis, there was no difference in the incidence of aborted myocardial infarction between the prehospital thrombolysis cohort and the in-hospital cohort, with 18.2% of in-hospital patients having a troponin I level<0.5 ng/ml compared with 11.8% of the prehospital cohort (p = 0.124).

Question: Does prehospital thrombolysis increase the proportion of patients who have an aborted myocardial infarction?

Although prehospital thrombolysis improved pain-to-needle time and a shorter pain-to-needle time increased the incidence of aborted infarction, prehospital thrombolysis was not associated with an increase in the proportion of aborted myocardial infarctions. Further work is required to understand this unexpected finding.

Answer the question based on the following context: Posterior reversible encephalopathy syndrome (PRES) is a clinico-neuroradiological entity, characterized by typical neurological deficits, distinctive magnetic resonance imaging (MRI) features, and a usually benign clinical course. Although frequently seen in association with hypertensive conditions, many other predisposing factors, notably cytotoxic and immunosuppressant drugs have been associated with PRES. The aim of this study was to determine differences in the MR appearance of PRES according to various risk factors. Thirty consecutive patients with clinical and MRI findings consistent with PRES were included. We identified 24 patients with hypertension-related conditions, including 14 patients with preeclampsia-eclampsia, and six patients without hypertension, in whom PRES was associated with exposition to neurotoxic substances. Lesion distribution, extent of disease, and number of affected brain regions were compared between patients with PRES with and without hypertension, and patients with PRES with and without preeclampsia-eclampsia, respectively. No statistically significant differences in distribution of lesions and extent of disease were observed between patients with PRES with or without hypertension, and patients with or without preeclampsia-eclampsia, respectively. The number of affected brain regions was significantly higher in patients with preeclampsia-eclampsia (p = 0.046), and the basal ganglia region was more frequently involved in these patients (p = 0.066).

Question: Posterior reversible encephalopathy syndrome: do predisposing risk factors make a difference in MRI appearance?

Apart from a significant higher number of involved brain regions and a tendency for basal ganglia involvement in patients with PRES associated with preeclampsia-eclampsia, the MRI appearance of patients with PRES does not seem to be influenced by predisposing risk factors.

Answer the question based on the following context: Conventional techniques used to harvest and culture bladder smooth muscle cells (SMCs) have been thought to yield homogeneous populations of SMCs. In order to delineate the cellular composition of tissue derived bladder cells, this study was conducted to determine whether current culturing techniques result in a uniform population of bladder SMCs that may be utilized for bladder tissue engineering. Patient derived bladder muscle was isolated and manually minced followed by enzymatic digestion. Cells were cultured in D: -valine alpha-MEM with decreasing levels of fetal bovine serum then fixed and permeabilized for flow cytometric and immunofluorescent analyses. Antibody staining of cultured cells consisted of alpha-SMA, von Willebrand factor, pan-cytokeratin, CD31, and CD90. Cells were visualized using directly conjugated fluorescein isothiocyanate primary or IgG-Alexa-555 conjugated secondary antibodies. Flow cytometric analyses revealed mixed populations of cells expressing non-SMC epitopes as corroborated by immunofluorescent studies. High density oligonucleotide array analysis revealed expression levels of known bladder SMC genes and the expression of endothelial and fibroblast related markers (P<0.005).

Question: Do current bladder smooth muscle cell isolation procedures result in a homogeneous cell population?

Phenotypic analyses demonstrate cell heterogeneity when SMCs are acquired and cultured through conventional methods. Standardized criteria based upon objective experimentation need to be established in order to better characterize bladder SMCs that are to be utilized for bladder tissue engineering.

Answer the question based on the following context: For direct laryngoscopy, we compared midline and left-molar approaches with respect to ease of intubation, using a Macintosh blade. We investigated the relationship between failure of the left-molar approach and preoperative risk factors for difficult intubation. With local ethics committee approval, 200 consecutive adult, nonpregnant patients were included in the study. The demographic data, body mass index, Mallampati modified score, interincisor gap, and mentohyoid and thyromental distances were measured preoperatively. First, the Macintosh blade was inserted using the midline approach, and then optimal external laryngeal manipulation (OELM) was applied. Second, the blade was inserted using the left-molar approach. The glottic views were assessed according to the Cormack-Lehane classification before and after OELM in both approaches. In cases where tracheal intubation failed with the left-molar approach, the midline approach was applied again and endotracheal intubation took place. The grade I glottic view obtained using the midline approach without OELM did not change in 94.3% of the patients with the left-molar approach without OELM; in addition, the grade II glottic view improved to grade I in 52.8% of the patients with the same technique (P<0.001). Although the number of patients with a grade I or II glottic view in the left-molar approach was 197, only 37 patients could be intubated using the left-molar approach. In addition, 59.5% of them were intubated at the second attempt with the left-molar approach, while the incidence of a second attempt was 1.2% with the midline approach (P<0.001). There was no correlation between the preoperative risk factors for difficult intubation and failure of the left-molar approach.

Question: Left-molar approach for direct laryngoscopy: is it easy?

Difficulty in the insertion of the endotracheal tube limits the efficacy of the left-molar approach. It is not possible to predict the failure of intubation with the left-molar approach by considering the preoperative risk factors.

Answer the question based on the following context: The benefits of adding chemotherapy to surgery in patients with hepatic colorectal metastases at moderate and high risk for recurrence and the optimal sequence of administration are undetermined. We followed the overall-survival and event-free survival rates after operation in patients with resectable colorectal metastases confined to the liver. The adjuvant patients first underwent surgery and then treatment, whereas the neoadjuvant patients underwent treatment, surgery, and re-treatment. Assignment was by oncologist and patient preferences. Chemotherapy was oxaliplatin (FOLFOX) or irinotecan (FOLFIRI) based. Fifty-six of 105 patients who underwent liver resections for colorectal metastases (2002-2005) are included. The two groups were comparable for demographics, characteristics of disease (including recurrence risk), treatment protocols, and follow-up. The respective 1-, 2-, and 3-year overall survival rates were 91%, 91%, and 84%, and the event-free survival rates were 63%, 49%, and 49% for the 19 adjuvant patients, and 95%, 91%, and 70%, and 94%, 50%, and 50% for the 37 neoadjuvant patients.

Question: Is there a survival benefit to neoadjuvant versus adjuvant chemotherapy, combined with surgery for resectable colorectal liver metastases?

The midterm overall survival and disease-free survival rates in this group of patients with resectable colorectal metastases to the liver, who were treated with combination of resection and chemotherapy, were similar, regardless of the sequence of treatment.

Answer the question based on the following context: Previous research has reported robust associations between child problem behaviours and parental health in families with a child with intellectual disabilities. A recent study found that socioeconomic position may moderate this relationship. This paper examines moderating effects using more diverse indicators of socioeconomic position and parental health and in a cross-cultural context. Structured interviews were conducted with 123 UK South Asian mothers of a child with severe intellectual disabilities. Socioeconomic position did not moderate the association between child problem behaviours and maternal distress. Socioeconomic position did moderate associations between child problem behaviours and maternal anxiety, depression and self-assessed health.

Question: Does socioeconomic position moderate the impact of child behaviour problems on maternal health in South Asian families with a child with intellectual disabilities?

Future research should systematically investigate the influence of socioeconomic position on family functioning.

Answer the question based on the following context: Peutz-Jeghers Syndrome (PJS) is a rare dominantly inherited disease characterized by hamartomatous small bowel polyposis, mucocutaneous hyperpigmentation, and increased risk of cancer. Differentiated thyroid cancers (DTCs) present mainly as sporadic, but they may have also a familial component. We present a case of PJS in a caucasian 25 years-old woman, who developed a DTC. The patient had a palpable nodule in the right side of the thyroid region and an endocrinological evaluation, including hormonal assays, neck ultrasound (US) and fine needle aspiration (FNAB) of the nodule was performed. US confirmed a single nodular lesion in the right thyroid lobe (14 mm). Cytological analysis at FNAB revealed a pattern compatible with papillary thyroid carcinoma. The histological analysis after total thyroidectomy confirmed the diagnosis of a Hurtle cell variant of papillary thyroid carcinoma, with follicular architecture.

Question: Differentiated thyroid carcinoma (DTC) in a young woman with Peutz-Jeghers syndrome: are these two conditions associated?

Even though rare, the association between PJS and DTC can be possible. In clinical practice it must be borne in mind that the wide spectrum of possible cancer diseases occurring in PJS could also include DTC, that the latter can occur earlier in life in PJS population and with a more aggressive histological pattern. Furthermore, in patients with PJS, US of the thyroid should be performed whenever thyroid disease is suspected at physical examination or based on patient's medical history. Due to lack of established data allowing for a real esteem of the association between PJS and DTC, US of the thyroid, should not be recommended as a routine screening for all subjects with PJS.

Answer the question based on the following context: The purpose was to evaluate long-term outcome following balloon angioplasty for coarctation in adults. Long-term results of balloon angioplasty for native coarctation in adults remain incomplete, especially concerning the occurrence of aneurysm formation. Long-term follow-up data were collected in consecutive patients retrospectively. Results of balloon angioplasty (29 patients, age 15-71 years, during 1995-2005) for discrete, native coarctation were evaluated, including MRI or CT. Mean follow-up ranged from 2.2 to 13 years (mean 8.5 +/- 3.2). Immediate success was obtained in all patients. Early mortality or complications were not encountered. Peak systolic pressure gradient decreased from 52 +/- 21 to 7.2 +/- 7.6 mm Hg (P<0.001). Intima tear was detected in eight procedures angiographically, without signs of dissection. Three-month follow-up angiography in these patients showed unchanged (4/8 patients) or diminished abnormalities (4/8 patients). One asymptomatic patient, known with left ventricular dysfunction due to significant aortic valve insufficiency, died suddenly 5 years after balloon angioplasty. Recoarctation occurred in one patient (3%). Late aneurysm formation was excluded by MR in 24/29 and CT in remaining 5/29 patients during follow-up, including those patients in whom intima tear was encountered immediately postangioplasty. In three of seven patients an irregular aortic contour persisted, without indication of progression or aneurysm formation. Hypertension was completely relieved in 67% (14/21 patients) and improved in 33% (7/21 patients).

Question: Long-term outcome after balloon angioplasty of coarctation of the aorta in adolescents and adults: Is aneurysm formation an issue?

Balloon angioplasty for native coarctation yields low reintervention probability in adult patients. Despite occurrence of angiographically established intimal tearing, aortic dissection and aneurysm formation were not encountered.

Answer the question based on the following context: Some authors states that the removal of lymph node would only contribute towards assessing the lymph node status and regional disease control, without any benefit for the patients' survival. The aim of this paper was to assess the influence of the number of surgically dissected pelvic lymph nodes (PLN) on disease-free survival. Retrospective cohort study on 42 women presenting squamous cell carcinoma (SCC) of the uterine cervix, with metastases in PLN treated by radical surgery. The Cox model was used to identify risk factors for recurrence. The model variables were adjusted for treatment-related factors (year of treatment, surgical margins and postoperative radiotherapy). The cutoff value for classifying the lymphadenectomy as comprehensive (15 PLN or more) or non-comprehensive (<15 PLN) was determined from analysis of the ROC curve. Fourteen recurrences (32.6%) were recorded: three pelvic, eight distant, two both pelvic and distant, and one at an unknown location. The following risk factors for recurrence were identified: invasion of the deep third of the cervix and number of dissected lymph nodes<15.

Question: Extent of pelvic lymphadenectomy in women with squamous cell carcinoma of the uterine cervix: is there any prognostic value?

Deep invasion and non-comprehensive pelvic lymphadenectomy are possible risk factors for recurrence of SCC of the uterine cervix with metastases in PLN.

Answer the question based on the following context: Patients aged>or = 80 years who are diagnosed with advanced ovarian cancer (OC) have been reported to have a poor prognosis. In the current study, chemotherapy-related toxicity data were evaluated between patients aged>or = 80 years and those aged<80 years. Patients with OC who underwent cytoreductive surgery with chemotherapy were included. Self-reported toxicity data were obtained from National Cancer Institute Common Toxicity Criteria (CTC) forms. Objective indicators of status including albumin level, weight, and creatinine clearance were abstracted both before and after therapy. Data were compared between patients by decade of age. A total of 246 patients were included. A presenting Karnofsky performance status>2 was recorded in 17% of patients aged>or = 80 years versus 0% to 4% of patients aged<80 years (P = .002). Platinum-based chemotherapy was used in all patients. For patients aged<80 years, combination chemotherapy was used in>90% versus 69% in those aged>or = 80 years (P<.0001). Standard-dose combination therapy was used in 72% to 86% of patients aged<80 years versus 28% of patients aged>or =80 years (P<.0001). Patients aged>or =80 years completed>or =6 cycles of therapy approximately 57% of the time versus 84% to 97% of the time for those aged<80 years (P = .0001). CTC forms identified no self-reported toxicities to be more common among patients aged>or =80 years. Multivariate logistic regression identified creatinine clearance<65 mL/minute (odds ratio [OR] of 4.6), 5% weight loss (OR of 2.5), prechemotherapy albumin level of<2 g/dL (OR of 3.65), and initiation of therapy with a single agent (OR of 3.9) as independent predictors of failure to complete chemotherapy.

Question: Adjuvant chemotherapy for the "oldest old" ovarian cancer patients: can we anticipate toxicity-related treatment failure in a vulnerable population?

Despite initial treatment modifications as well as toxicity assessment, only 57% of patients aged>or =80 years completed planned chemotherapy. It was confirmed that further studies into the pharmacokinetics of chemotherapy in the elderly and more sensitive assessment of therapy-related toxicity are required.

Answer the question based on the following context: The overall health care costs for managing patients with community-acquired pneumonia (CAP) in U.S. hospitals is burdensome. While pharmacy costs comprise only a minor proportion of these costs, hospital length of stay (LOS) is the greatest contributor. Infections due to antimicrobial-resistant pathogens are also associated with increased overall health care cost. Therefore, strategies that aim to minimize antimicrobial resistance and reduce hospital LOS may have the greatest impact in reducing overall health care costs in managing patients with CAP. To evaluate how antimicrobial resistance can impact health care costs associated with CAP and review strategies to minimize the risk of resistance development while promoting appropriate antimicrobial therapy (including optimized dosing) and decreasing hospital LOS. Antimicrobial resistance can increase the risk of clinical failure and result in higher overall health care costs. Further development of antimicrobial resistance during therapy should, therefore, be minimized. This can be achieved through optimized antimicrobial dosing strategies- using a higher dose of concentration-dependent agents or prolonged infusion of time-dependent agents - that increase the probability of attaining pharmacokinetic-pharmacodynamic targets for eradication of the pathogen and hence successful clinical outcomes. Decreasing LOS must be a priority when attempting to reduce hospital costs. Active intravenous-to-oral switch therapy has been shown to effectively reduce LOS. Appropriate short-course regimens may also offer the opportunity for effective treatment while reducing or eliminating unnecessary antimicrobial exposure that not only reduces the potential for drug-related adverse events, but may also minimize the selection of resistant organisms.

Question: Containing costs and containing bugs: are they mutually exclusive?

Clinical failure and antimicrobial resistance can significantly increase the cost of managing patients with CAP, primarily by increasing LOS. Therefore, strategies should be employed to minimize the risk of resistance development and reduce LOS. These include early appropriate therapy, optimized dosing based on pharmacodynamic principles, and efficient IV-to-PO switch therapy when appropriate.

Answer the question based on the following context: To compare the health of young unemployed Australians during a period of low unemployment (April 2007: rate 4.4%) against published Australian norms for 18-24 year olds and unemployed people during a time of higher unemployment (February 1995 to January 1996: rate 8.1% to 8.9%). Two hundred and fifty-one unemployed 18-25 year olds residing in New South Wales completed the SF36 Health Survey version 2 (SF36v2) during a time of low unemployment. SF36v2 subscale and component summary scores were compared with published norms for 18-24 year olds and for unemployed persons during a time of higher unemployment. Young unemployed people during a period of low unemployment reported poorer health in all areas when compared with age-matched norms and poorer psychological health when compared with the published norms for unemployed people from a time when unemployment rates were higher.

Question: Is the health of young unemployed Australians worse in times of low unemployment?

The health of young unemployed individuals during a time of low unemployment was poor when compared to both the general population and to unemployed people during a time of higher unemployment.

Answer the question based on the following context: To use continuous glucose monitoring (CGMS) to compare glucose profiles in people with type 1 diabetes following injection of insulin into an area affected by lipohypertrophy vs. an area not affected by lipohypertrophy. Eight patients with type 1 diabetes underwent 72 h of CGMS while following a standardized diet and injecting all insulin either into an area with or without lipohypertrophy. Patients underwent two testing periods in random order, separated by 4 days. On day 1 of each test subjects were admitted for measurement of insulin and plasma glucose levels immediately prior to, and hourly for 4 h following, a standardized lunch. Insulin area under the curve (AUC)(0-4 h) was similar for both test periods; 656; interquartile range (IQR): 518-1755 (normal tissue) vs. 602; IQR: 382-1436 (lipohypertrophic tissue), z = 1.7, p = 0.09. There was also no difference in the median time to maximal insulin concentration (Time(max) 2 h; IQR: 2-3 h; z = 0.6; p = 0.6). There was a 37.5% increase in mean plasma glucose levels following a standardized meal; however this was not significant between sites (AUC(0-4 h)t = -1.7; p = 0.1). Moreover, there was no difference in CGMS profiles (AUC(1-72 h)t = -0.9; p = 0.4) across the 72-h monitoring period. Overall the prevalence of hypoglycaemia (CGMS readings<4 mmol/l) was similar between injection sites (11.6 vs. 10.6%, p = 0.1).

Question: Lipohypertrophy: does it matter in daily life?

The pharmacokinetic and pharmacodynamic effect of injecting into lipohypertrophic tissue is small in comparison to the usual clinical variation observed with insulin injections.

Answer the question based on the following context: The objective of this study is to examine the existence and shape of epistemic communities for (heart) health promotion at the international, national, provincial and regional levels in Canada. Epistemic community may be defined as a network of experts with an authoritative claim to policy relevant knowledge in their area of expertise. An interpretive policy analysis was employed using 60 documents (48 provincial, 8 national and 4 international) and 66 interviews (from 5 Canadian provinces). These data were entered into NUD*IST, a qualitative software analysis package, to assist in the development of codes and themes. These codes form the basis of the results. A scientific and policy epistemic community was identified at the international and Canadian federal levels. Provincially and regionally, the community is present as an idea but its implementation varies between jurisdictions.

Question: An epistemic community comes and goes?

The importance of economic, political and cultural factors shapes the presence and shape of the epistemic community in different jurisdictions. The community waxes and wanes but appears robust.

Answer the question based on the following context: To examine cross-sectional and longitudinal associations between socioeconomic status (SES), gender, sports participation and moderate-to-vigorous physical activity (MVPA) in adolescents. Project EAT (Eating Among Teens), a population-based longitudinal study followed a socioeconomically and ethnically diverse sample of 1709 adolescents in 1998-1999 (Time 1) and 2003-2004 (Time 2). Mixed model regression analyses were used to examine longitudinal trends in MVPA as a function of SES and previous sports involvement. For both genders, participation in organized sports and weekly hours of MVPA were positively associated with SES. On average, MVPA decreased between high school and young adulthood for both genders. Adolescents who participated in sports during high school showed a steeper decline in weekly hours of MVPA than their non-sports-participating counterparts. SES had a significant moderating effect on the change in MVPA over time for boys who participated in organized sports, with low SES boys showing a steeper decline in MVPA between time periods than higher SES boys. Although on average, a statistically significant difference in MVPA between previous sports participants and nonparticipants remained at Time 2, for all SES groups and both genders, the gap between hours of MVPA was either overcome or significantly narrowed by young adulthood.

Question: Does participation in organized sports predict future physical activity for adolescents from diverse economic backgrounds?

Increased dependence on organized sports for MVPA may be insufficient to meet the needs of youth following high school, especially for low SES youth. Designing physical activity promotions that reach and address the unique needs of lower SES youth and families is a public health priority.

Answer the question based on the following context: Vascular endothelial growth factor (VEGF) is a potent hypoxia-regulated angiogenic factor. Its soluble receptor soluble (s)Flt-1 binds VEGF with high affinity inhibiting the angiogenic function of VEGF. The role of circulating VEGF in atherosclerosis is unclear. In 909 healthy subjects (511 male, 398 female) from the Salzburg Atherosclerosis Prevention Program in Subjects at High Individual Risk (SAPHIR) we determined fasting plasma VEGF and sFlt-1 concentration, cardiovascular risk factors and carotid atherosclerosis. VEGF levels were lower and sFlt-1 levels higher in men than in women. VEGF and sFlt-1 showed a positive correlation. In the entire population VEGF correlated positively with age, BMI, insulin resistance, white blood cell and platelet count, C-reactive protein (CRP) and carotid intima media thickness (IMT). After adjustment for age, VEGF showed a weak positive correlation with BMI, liver enzymes, CRP and platelet count in males. In females VEGF correlated negatively with LDL-cholesterol and positively with insulin resistance and platelet count. After adjustment for age, no significant correlation with carotid atherosclerosis could be detected.

Question: Are plasma VEGF and its soluble receptor sFlt-1 atherogenic risk factors?

Plasma VEGF and sFlt-1 are only weakly correlated with cardiovascular risk factors, suggesting that circulating VEGF levels do have only a minor impact on the development of atherosclerosis.

Answer the question based on the following context: Diabetes or insulin resistance, overweight, arterial hypertension, and dyslipidaemia are recognized risk factors for cardiovascular (CV) disease. However, their predictive value and hierarchy in elderly subjects remain uncertain. We investigated the impact of cardiometabolic risk factors on mortality in a prospective cohort study of 331 elderly high-risk subjects (mean age+/-SD: 85+/-7 years). Two-year total mortality was predicted by age, diabetes, low BMI, low diastolic blood pressure (DBP), low total and HDL cholesterol, and previous CV events. The effect of diabetes was explained by previous CV events. In non-diabetic subjects, mortality was predicted by high insulin sensitivity, determined by HOMA-IR and QUICKI indices. In multivariate analyses, the strongest mortality predictors were low BMI, low HDL cholesterol and previous myocardial infarction. Albumin, a marker of malnutrition, was associated with blood pressure, total and HDL cholesterol, and HOMA-IR. The inflammation marker CRP was associated with low total and HDL cholesterol, and high HOMA-IR.

Question: Cardiometabolic determinants of mortality in a geriatric population: is there a "reverse metabolic syndrome"?

In very old patients, low BMI, low DBP, low total and HDL cholesterol, and high insulin sensitivity predict total mortality, indicating a "reverse metabolic syndrome" that is probably attributable to malnutrition and/or chronic disorders. These inverse associations limit the relevance of conventional risk factors. Previous CV events and HDL cholesterol remain strong predictors of mortality. Future studies should determine if and when the prevention and treatment of malnutrition in the elderly should be incorporated into conventional CV prevention.

Answer the question based on the following context: Lumbar chemical sympathectomy (LCS) is used principally in inoperable peripheral vascular disease (PVD) to alleviate symptoms of rest pain and as an adjunct to other treatments for ulcers. No guidelines currently exist in the UK for its use in PVD. The aim of this study was to evaluate the role of LCS with regard to indications and outcomes in the UK and Irish vascular surgical practice. Specifically designed questionnaires were sent to Vascular Surgical Society members. The questions related to their current use of LCS including indications, outcome parameters, use in diabetics and complications encountered. Four hundred and ninety postal questionnaires were sent out and 242 responses (49%) were received. Seventy five percent of the respondents (n=183) felt that LCS had a role in current practice. Seventy eight percent (n=144) performed less than 10 procedures per year and 3% (n=5) more than 20 per year. Eighty percent (n=145) were performed by anaesthetists, 12% (n=23) by radiologists and 8% (n=15) by surgeons. Inoperable peripheral vascular disease with rest pain was the main indication in over 80% of responses with 27% using it for the treatment of ulcers. Only 21% used LCS in diabetics. Clinical improvement was used to assess the outcome following LCS in 96% of responses. Complications included neuralgia, ureteric damage and paraplegia following inadvertent extradural injection.

Question: Lumbar chemical sympathectomy in peripheral vascular disease: does it still have a role?

Although no clear guidance exists for the use of LCS in PVD, the majority of respondents continue to use it. Indications and outcomes are documented in this study of UK and Irish vascular surgical practice.

Answer the question based on the following context: Older people in rural areas have been labelled as physically inactive on the basis of leisure-time physical activity research. However, more research is needed to understand the total physical activity pattern in older adults, considering all domains of physical activity, including leisure, work, and domestic life. We hypothesised that: (a) total physical activity would be the same for older people in urban and rural areas; and (b) urban and rural residency, along with gender and age, would be associated with differences in domain-specific physical activities. Cross-sectional data were collected in Icelandic rural and urban communities from June through to September 2004. Participants were randomly selected, community-dwelling, 65-88 years old, and comprised 68 rural (40% females) and 118 urban (53% females) adults. The Physical Activity Scale for the Elderly (PASE) was used to obtain a total physical activity score and subscores in leisure, during domestic life, and at work. The total PASE score was not associated with rural vs. urban residency, but males were, in total, more physically active than females, and the 65-74-year-olds were more active than the 75-88-year-olds. In the leisure domain, rural people had lower physical activity scores than urban people. Rural males were, however, most likely of all to be physically active in the work domain. In both urban and rural areas, the majority of the physical activity behaviour occurred in relation to housework, with the rural females receiving the highest scores.

Question: Are rural older Icelanders less physically active than those living in urban areas?

Older Icelanders in rural areas should not be labelled as less physically active than those who live in urban areas. Urban vs. rural living may, however, influence the physical activity patterns among older people, even within a fairly socioeconomically and culturally homogeneous country such as Iceland. This reinforces the need to pay closer attention to the living environment when studying and developing strategies to promote physical activity.

Answer the question based on the following context: Adiponectin is an adipocyte-derived collagen-like protein, highly specific to adipose tissue and may represent an important link between obesity and atherosclerosis. The present study was designed to investigate a possible association between serum adiponectin levels and early vascular changes in obese patients as determined by intima media thickness (IMT) and arterial pulse-wave contour analysis. Obese subjects (n=47) were evaluated for arterial structure and function, metabolic parameters and serum adiponectin levels. IMT was measured by ultrasound. Arterial elasticity was evaluated using pulse-wave contour analysis. Insulin resistance was assessed by homeostasis model assessment (HOMA-IR). diponectin was significantly, inversely associated with mean IMT (r=-0.369, P=0.011) and significantly positively associated with large artery elasticity index (LAEI) (r=0.467, P=0.001) as well as small artery elasticity index (SAEI) (r=0.462, P=0.001). In separate multivariate models, adiponectin remained significantly associated with mean IMT, LAEI and SAEI even after adjustment for cardiovascular confounders. Among metabolic parameters, adiponectin was significantly positively associated with HDL cholesterol and inversely associated with triglycerides. Adiponectin was significantly inversely associated with fasting insulin and HOMA-IR. In addition, a marginally inverse association between adiponectin and ALT was observed.

Question: Adiponectin and vascular properties in obese patients: is it a novel biomarker of early atherosclerosis?

In this study, serum adiponectin levels were significantly associated with indices of subclinical atherosclerosis, such as IMT and arterial compliance in obese patients. This association was independent of traditional cardiovascular risk factors.

Answer the question based on the following context: Colorectal carcinoma is the most common malignancy of the gastrointestinal tract. It remains controversial for adjuvant chemotherapy in patients with stage II colon cancer. This study was designed to identify the risk factors of tumor recurrence in stage II colon cancer. Furthermore, the benefit of adjuvant chemotherapy for high-risk stage II colorectal cancer will be investigated. From May 1998 until August 2004, 375 patients with stage II (T3N0M0, T4N0M0) colon cancer received curative operation in a single hospital. The clinical data were extracted from the prospectively collected colorectal cancer database. The disease-free survival curves were calculated with Kaplan-Meier's analysis, and the survival difference was determined by log-rank test. The p value less than 0.05 was considered to be significant. Of 375 stage II colon cancer, 66 patients received 5-FU-based adjuvant chemotherapy, either oral or intravenous (IV) form. Within the median of 48.5 months of follow-up, recurrence developed in 35 patients (9.3%). T4 lesion (p=0.024), lymphovascular invasion (p=0.022), obstruction at presentation (p=0.008), and mucinous component more than 50% (p=0.032) were associated with significantly decreased disease-free survival. High-risk patients (n=102), but not other patients with stage II colon cancer, benefited from adjuvant therapy (3-year disease-free survival: 96.4% vs. 84.7%, p=0.045; 5-year overall survival: 100% vs. 86.4%, p=0.015).

Question: Is adjuvant chemotherapy beneficial to high risk stage II colon cancer?

Adjuvant therapy for high-risk stage II colon cancer may be beneficial, and we suggest adjuvant therapy should be considered in high-risk stage II colon cancer patients.

Answer the question based on the following context: To compare Clostridium difficile infection (CDI) rates determined with use of a traditional definition (ie, with healthcare-onset CDI defined as diagnosis of CDI more than 48 hours after hospital admission) with rates determined with use of expanded definitions, including both healthcare-onset CDI and community-onset CDI, diagnosed within 48 hours after hospital admission in patients who were hospitalized in the previous 30 or 60 days, and to determine whether differences exist between patients with CDI onset in the community and those with CDI onset in a healthcare setting. Prospective cohort. Tertiary acute care facility. General medicine patients who received a diagnosis of CDI during the period January 1, 2004, through December 31, 2005. CDI was classified as healthcare-onset CDI, healthcare facility-associated CDI after hospitalization within the previous 30 days, and/or healthcare facility-associated CDI after hospitalization within the previous 60 days. Patient demographic characteristics and medication exposures were obtained. The CDI incidence with use of each definition, CDI rate variability, patient demographic characteristics, and medication exposures were compared. The healthcare-onset CDI rate (1.6 cases per 1,000 patient-days) was significantly lower than the 30-day healthcare facility-associated CDI rate (2.4 cases per 1,000 patient-days; P<.01) and the 60-day healthcare facility-associated CDI rate (2.6 cases per 1,000 patient-days; P<.01). There was good correlation between the healthcare-onset CDI rate and both the 30-day (correlation, 0.69; P<.01) and 60-day (correlation, 0.70; P<.01) healthcare facility-associated CDI rates. There were no months in which the CDI rate was more than 3 standard deviations from the mean. Compared with patients with healthcare-onset CDI, patients with community-onset CDI were less likely to have received a fourth-generation cephalosporin (P= .02) or intravenous vancomycin (P+ .01) during hospitalization.

Question: Hospital-associated Clostridium difficile infection: is it necessary to track community-onset disease?

Compared with the traditional definition, expanded definitions identify more patients with CDI. There is good correlation between traditional and expanded CDI definitions; therefore, it is unclear whether expanded surveillance is necessary to identify an abnormal change in CDI rates. Cases that met the expanded definitions were less likely to have occurred in patients with fourth-generation cephalosporin and vancomycin exposure.

Answer the question based on the following context: To evaluate screening cystoscopy as the long-term follow up in patients with an enterocystoplasty for>or =10 years. We performed a prospective analysis of 92 consecutive patients who attended our endoscopy suite for regular check cystoscopy as per standard follow-up. This is performed for all patients with cystoplasty performed at our institute after 10 years. The data were recorded on patient demographics, original diagnosis and type of cystoplasty. In all, 53 of these patients consented to undergo bladder biopsies at the same time. The median (range) follow-up was 15 (10-33) years. No cancer was identified with either surveillance cystoscopy or on routine biopsies. Chronic inflammation was identified in 25 biopsies (27%). Villous atrophy was present in 12 (55%) ileal patch and three (12.5%) colonic patch biopsies. During this study, the first and only case of malignancy in a cystoplasty at our institution was diagnosed in a symptomatic patient. She had intermittent haematuria and recurrent urinary tract infections (UTIs). She previously had a normal surveillance cystoscopy.

Question: Routine surveillance cystoscopy for patients with augmentation and substitution cystoplasty for benign urological conditions: is it necessary?

We feel that it is not necessary to perform yearly check cystoscopies in patients with augmented bladders at least in the first 15 years, as cancer has not yet been detected with surveillance cystoscopy in this patient group. However, if the patient develops haematuria or other worrisome symptoms including suprapubic pain and recurrent unexplained UTIs a full evaluation, including cystoscopy and computerized tomography should be undertaken.

Answer the question based on the following context: Clinicians are generally advised to consider several risk factors when evaluating patients' cardiovascular disease (CVD) risk. Our aim was to study whether combined assessment of five traditional risk factors might help doctors demarcate a relatively distinct and manageable group of high-risk individuals. We selected five modifiable risk factors and estimated the proportion of a well-defined population with 'unfavourable' levels of at least two of them, as defined by four internationally renowned guidelines. The impact of including so-called 'prehypertension' among the risk factors was specifically addressed, and the results are discussed in a wider perspective. Guideline implementation was modelled on data from a cross-sectional Norwegian population study comprising 62 104 adults aged 20-79 years (The Nord-Tröndelag Health Study 1995-7). Total, age- and gender-specific point prevalences of individuals with zero, one, two, three or more factors, in addition to established disease, were calculated. One single CVD risk factor was exhibited by 12.4% of the population; two factors by 21.5%; and three or more by 49.7%. Established CVD or diabetes mellitus was reported by 12.5%. In total, 83.7% of the population exhibited a risk or disease profile with at least two factors, if prehypertension was included.

Question: Can individuals with a significant risk for cardiovascular disease be adequately identified by combination of several risk factors?

If guideline recommendations are literally applied, as many as 84% of adults in Norway could exhibit two or more CVD or risk factors and thus be considered in need of individual, clinical attention. This challenges the widely held presumption that 'the net will close' around a manageable group of individuals-at-risk if several risk factors are jointly considered. As the finding of this study arises in one of the world's most long- and healthy-living populations, it raises several practical as well as ethical questions.

Answer the question based on the following context: The Hospital Anxiety and Depression Scale (HADS) was developed explicitly for use in non-psychotic populations, yet is routinely used for screening patients with psychotic illness. The utility of the HADS as a screening instrument for use in patients with schizophrenia was investigated. Exploratory factor analysis and confirmatory factor analysis were conducted on the HADS to determine its psychometric properties in 100 patients with a primary ICD-10 diagnosis of schizophrenia. Three distinct factors were identified within the HADS. Support was found for the clinical use of the HADS anxiety subscale to assess anxiety in patients with schizophrenia; however, evidence was also found that the HADS depression subscale may not be a unidimensional measure of depression in this clinical group.

Question: Can the Hospital Anxiety and Depression Scale be used in patients with schizophrenia?

Caution should be used when using the HADS depression subscale in this clinical group. The direction of future research in this area is indicated, in particular comparison of HADS anxiety and depression measures to determine further the validity or otherwise of these subscale domains.

Answer the question based on the following context: Analgesia is a recommended practice for pain treatment in prehospital emergency medicine, but all experts note suboptimal pain relief or oligoanalgesia. The increase in the Care Workload (CW) and the Medical Treatment Duration (MTD) linked to analgesia are two explanatory factors, and they are representative of the unavailability of a prehospital team. The unavailability of a team is an opportunity cost which is probably the most important cost within the framework of prehospital emergency. The aim of this study was to analyse the influence of analgesia use on the availability of prehospital emergency teams. This study was a prospective, multicentre cohort study conducted in 10 French Mobile Emergency and Resuscitation Services (MERS) between September 2001 and June 2003. A case-control study was performed including 568 case patients who received analgesia matched with controls based on diagnosis and severity. The pairs were compared for MTD and CW. No significant difference between cases and controls was found concerning MTD (P = 0.134). Conversely, a difference was found for CW (P<10(-4)), with a mean value of 53.7 Project Recherche Nursing (PRN) points for the cases and 45.8 PRN points for the controls.

Question: Prehospital pain treatment: an economic productivity factor in emergency medicine?

This study shows that analgesia generates an additional CW without increasing the MTD, and does not hinder the MERS teams' availability. This economic result should improve adherence to these clinical practice guidelines. Thus, analgesia appears to be a factor of productivity in the current context of economic pressures in terms of the funding of the healthcare system.

Answer the question based on the following context: Depressive disorders generate severe personal burden and high economic costs. Cost-utility analyses of the different therapeutical options are crucial to policy-makers and clinicians. Previous cost-utility studies, comparing selective serotonin reuptake inhibitors and tricyclic antidepressants, have used modelling techniques or have not included indirect costs in the economic analyses. To determine the cost-utility of fluoxetine compared with imipramine for treating depressive disorders in primary care. A 6-month randomized prospective naturalistic study comparing fluoxetine with imipramine was conducted in three primary care centres in Spain. One hundred and three patients requiring antidepressant treatment for a DSM-IV depressive disorder were included in the study. Patients were randomized either to fluoxetine (53 patients) or to imipramine (50 patients) treatment. Patients were treated with antidepressants according to their general practitioner's usual clinical practice. Outcome measures were the quality of life tariff of the European Quality of Life Questionnaire: EuroQoL-5D (five domains), direct costs, indirect costs and total costs. Subjects were evaluated at the beginning of treatment and after 1, 3 and 6 months. Incremental cost-utility ratios (ICUR) were obtained. To address uncertainty in the ICUR's sampling distribution, non-parametric bootstrapping was carried out. Taking into account adjusted total costs and incremental quality of life gained, imipramine dominated fluoxetine with 81.5% of the bootstrap replications in the dominance quadrant.

Question: Fluoxetine and imipramine: are there differences in cost-utility for depression in primary care?

Imipramine seems to be a better cost-utility antidepressant option for treating depressive disorders in primary care.

Answer the question based on the following context: Our recent ERPs study suggested inhibition deficits in addition to cortical arousal in insomnia sufferers (INS) relative to good sleepers (GS). The aim of the present study was to investigate the relation between objective sleep parameters and the amplitudes and latencies of ERPs components N1 and P2 in a multi-assessment protocol. Participants, 15 INS and 16 GS, underwent four consecutive nights of polysomnography recordings (N1 to N4). ERPs in the evening and upon awakening were recorded on N3 and N4, with the addition of sleep-onset recordings on N4. Auditory stimuli consisted of 'standard' and 'deviant' tones. Objective sleep measures were computed on each night [sleep efficiency (SE), wake after sleep onset (WASO), total sleep time (TST) and sleep-onset latency (SOL)]. The amplitude and latency of N1 and P2 components were assessed for each recorded session on each night and related to measures of sleep of the same nights (N3 and N4). Pearson's correlations between the amplitude and latency of N1 and P2 and objective sleep measures revealed that arousal levels in the evening, before going to bed seem to have an impact on subsequent sleep quality. Furthermore, the sleep quality of the previous night also appeared to have an impact on morning (daily) arousal levels.

Question: Is quality of sleep related to the N1 and P2 ERPs in chronic psychophysiological insomnia sufferers?

These results suggest that hyperactivation and inhibition deficits present in insomnia sufferers are directly associated with a poorer sleep quality. This highlights once again that when information processing and/or performance is assessed, the sleep quality of the night preceding the evaluation shall be documented.

Answer the question based on the following context: A retrospective cross sectional study was conducted among 136 consecutive patients with osteoporosis at Ninewells Hospital, Dundee, UK, between 1998-2002. 20.5% of female patients in this study were identified with previously unrecognised contributors to the low bone mineral density. In women, at a Z score cut-off of -1, the sensitivity of detecting a secondary cause for osteoporosis is 87.5% with a positive predictive value of 29.2%.

Question: Search for secondary osteoporosis: are Z scores useful predictors?

In women, a Z score of -1 would identify a majority of patients with a secondary cause for low bone mineral density and identifies patients who would especially benefit from a thorough history and clinical examination.

Answer the question based on the following context: To assess the accuracy of residents' record review, using trained abstractors as a gold standard comparison. In 2005, the authors asked 74 residents to review their own charts (n = 392) after they received brief instruction on both how to locate data on the medical record and how to use a data abstraction form. Trained abstractors then re-reviewed these charts to assess performance of preventive health care measures in medicine (smoking screening, smoking cessation advice, mammography, colon cancer screening, lipid screening, and pneumonia vaccination) and pediatrics (parent smoking screening, parent smoking cessation advice, car seat safety, car restraint use, eye alignment, and immunizations up to date). The authors then quantified agreement between the two record reviews and assessed the sensitivity and specificity of the residents versus the trained abstractors. Overall resident-measured performance was similar (within 5%) to that of the trained abstractor for five of six measures in medicine and four of six in pediatrics. For the various measures, sensitivity of resident-measured performance ranged from 100% to 15% and specificity from 100% to 33% compared with the trained abstractors. Relative to the trained abstractor record review, residents did not overestimate their performance. Most residents' (81%) relative performance rankings did not change when the basis for the ranking was resident measured versus trained abstractor measured.

Question: Can residents accurately abstract their own charts?

Residents' self-abstraction can be an alternative to costly trained abstractors. Appropriate use of these data should be carefully considered, acknowledging the limitations.

Answer the question based on the following context: The microsurgical pseudocapsule can be found in the transition zone between an adenoma and the surrounding normal pituitary tissue. We investigated the precise histology of the pseudocapsule. Furthermore, we evaluated the remission rate, the changes in pituitary function, and the recurrence rate after intensive resection of the pseudocapsule. In 616 patients with pituitary adenomas (Hardy Types I-III) over a period of 14 years, we introduced intensive resection of the microsurgical pseudocapsule to achieve complete tumor removal. A combined pituitary function test and radiological study were performed on the patients before surgery, 1 year after surgery, and at subsequent 1.5-year intervals 2 to 13 years postoperatively. Microsurgical pseudocapsules were identified in 343 (55.7%) of 616 patients, and the distinct microsurgical pseudocapsules were observed in 180 (52.5%) of these patients. In the remaining 163 patients, the microsurgical pseudocapsules were incompletely developed. Tumor cluster infiltration was present in the pseudocapsule in 71 (43.6%) of these patients. Aggressive resection of the microsurgical pseudocapsule was more often required in larger tumors than in smaller ones. The presence of a pseudocapsule was slightly more frequent in prolactin-secreting tumors (70.9%) than in growth hormone-secreting (55.0%) and adrenocorticotropic hormone-secreting (40.0%) tumors. In the 243 patients of the total resection group who underwent combined pituitary function tests more than 2 times after surgery, the surgical remission rate was 99.1% in clinically nonfunctional tumors, 88% in growth hormone-secreting, 70.6% in prolactin-secreting, and 100% in adrenocorticotropic hormone-secreting tumors. The surgical remission rate was 86.2% in the presence of a pseudocapsule and 94.3% in the absence of a pseudocapsule. Preoperative hypopituitarism improved in 140 patients (57.6%), persisted in 47 patients (19.3%), and was aggravated in 33 patients (13.6%). There was no statistical difference in improvement or deterioration of pituitary function according to the existence or absence of the pseudocapsule. The tumor recurrence rate was 0.8% in the total resection group and was 42.1% in the subtotal resection group.

Question: Tumor tissue identification in the pseudocapsule of pituitary adenoma: should the pseudocapsule be removed for total resection of pituitary adenoma?

We have shown that tumor tissue is frequently present within the pseudocapsule, suggesting that any tumor remnant in the pseudocapsule could be a source of recurrence and an obstacle to achieving complete remission. These results indicate that intensive resection of the pseudocapsule could result in a higher remission rate without deteriorating pituitary function.

Answer the question based on the following context: Biobanks may play a pivotal role in lung cancer patients' management, research, and health policy. The Nancy "Centre of Biologic Resources" analyzed the evolving profiles of operated lung cancer patients and their management over 20 years. A total of 1259 consecutive patients operated upon from 1988 till 2007 were included. Survival rates were statistically compared before and after 1997. The parameters associated with a significant improvement of survival were determined. After 1997, lung cancer was diagnosed at an earlier stage. For Squamous Cell Lung Cancer (SQCLC), stages IA increased from 5.4 to 19.5% and for Adenocarcinoma (ADC), stage IA increased from 9.9 to 24.7%. More women with stage I ADC were operated upon after 1997 (p = 0.01). More patients with Large Cell Lung Cancer were diagnosed recently. Recent patients received more adjuvant or neo-adjuvant chemotherapy (p<0.001) and less radiotherapy (stage p = 0.019, stage p<0.001). A longer overall patients' survival was observed after 1997 (chi test for SQLC and ADC independently p<or = 0.002). Among SQCLC long survivors, those at stage I-II, below 50 years, were more numerous. A longer survival was associated with early stage in ADC patients. Stage was the single constant factor for overall outcome.

Question: Do evolving practices improve survival in operated lung cancer patients?

Overall and stage-adjusted survival of operated lung cancer patients has been improved in the last decade due mainly to earlier diagnosis. The generalized use of computed tomography scan, chemotherapy, and a collegial management improved patients' survival.

Answer the question based on the following context: Colorectal cancer (CRC) screening with colonoscopy was introduced into the National Cancer Prevention Program in Germany in 2002. As compliance for screening is low (around 3% per year), colon capsule endoscopy (CCE) could be an alternative approach. In this study, feasibility and performance of CCE were evaluated in comparison with colonoscopy in ambulatory patients with special attention to a short colon transit time. CCE was prospectively tested in ambulatory patients enrolled for colonoscopy who presented for screening or with positive fecal occult blood test. Study subjects underwent colon preparation and ingested the capsule in the morning. Colonoscopy was performed after excretion of the capsule. Colonoscopy and CCE were performed by independent physicians who were blinded to the results. In total, 38 patients were included. One patient was excluded because the capsule remained in the stomach during the entire period of examination. Another patient had limited time and the procedure had to be stopped when the capsule was still in the transverse colon. We therefore report the results of 36 patients (30 men and 6 women; mean age 56 years, range 23-73 years) who successfully completed CCE and the conventional colonoscopy examination. The capsule was excreted within 6 h in 84% of the patients (median transit time 4.5 h). If oral sodium phosphate was excluded from the preparation, the colon transit time increased to a median of 8.25 h. In total, 7 of 11 small polyps (<6 mm) detected by colonoscopy were identified by CCE. One small polyp detected by CCE was not identified by colonoscopy. In this series, no large polyps were found. One CRC was detected by both methods. The mean rates of colon cleanliness (range from 1=excellent to 4=poor) in the cecum (2.1), transverse colon (1.6), and in the descending colon (1.5) were significantly better than in the rectosigmoid colon (2.6), and the overall mean rate during colonoscopy was significantly better than during CCE. No adverse effects occurred.

Question: Is PillCam COLON capsule endoscopy ready for colorectal cancer screening?

CCE appears to be a promising new modality for colonic evaluation and may increase compliance with CRC screening. To achieve a short colon transit time, sodium phosphate seems to be a necessary adjunct during preparation. The short transit time is a prerequisite to abandon the delay mode of the capsule. With an undelayed PillCam COLON capsule, a "pan-enteric" examination of the gastrointestinal tract would be possible. Further studies are needed to improve the cleanliness, especially in the rectum and to evaluate the method as a potential screening tool.

Answer the question based on the following context: Among benign thyroid nodules, nodular hyperplasia (NH) is the most common and represents a "leave me alone" lesion with no requirement for further treatment, while follicular adenoma (FA) is a lesion that should potentially be removed due to the difficulty of differentiation from a carcinoma on a biopsy alone. To evaluate whether there are specific ultrasound (US) findings for an NH to distinguish it from an FA. Pathologically proven cases of benign thyroid nodules (95 cases: 53 NH, 42 FA) were reviewed retrospectively. The number of associated nodules, the nodule size, internal content, shape, margin, echogenicity, presence of peripheral halo, and calcification were analyzed using grayscale ultrasonography. NHs were predominantly solid in 40 cases (75.5%) and predominantly cystic in 13 cases (24.5%), while FAs were predominantly solid in all cases (n=42, 100%) (P<0.001). A spongiform appearance was present exclusively in NH (9/53, 17.0%). For NH, 83.0% of the lesions (44/53) showed an isoechoic pattern. For FA, the lesions showed a variable echoic pattern, including a marked hypoechoic pattern (5/42, 11.9%), a hypoechoic pattern (22/42, 52.4%), and an isoechoic pattern (15/42, 35.7%) (P<0.001). The nodule size, shape, margin, presence of peripheral halo, and calcification did not show any difference between FA and NH.

Question: Are there any specific ultrasound findings of nodular hyperplasia ("leave me alone" lesion) to differentiate it from follicular adenoma?

The ratio of solid to cystic content, spongiform appearance, and echogenicity is a combination of US findings that may be helpful in distinguishing an NH from an FA, and may thereby help to avoid unnecessary fine-needle aspirations for "leave me alone" lesions.

Answer the question based on the following context: In Australia just over half of all women of reproductive age have experienced an unplanned pregnancy, many of which could have been avoided by use of emergency contraception. A dedicated emergency contraceptive pill (ECP) pack became available on prescription in Australia in 2002, and over the counter in 2004. To determine if availability of a dedicated over the counter ECP pack in Australia increased knowledge and use of emergency contraception (EC). Women attending three free-standing abortion clinics in Sydney answered an anonymous questionnaire on their knowledge and use of the ECP. Group 1 (208 women) was recruited prior to a dedicated ECP pack being available, group 2 (308) after it was available on prescription, and group 3 (202) after it became available over the counter. Women who had heard about EC were significantly younger (p<0.005). The mean age of women who had never heard about EC was 29.8 years compared to 26.3 for women who had heard about EC. More women expressed awareness of the ECP after it became available over the counter. Women in group 2 attained a higher educational level than women in the other groups (p<0.005). There was a significant trend to increased use of the ECP in women of higher educational level (p<0.005). The use of EC did not increase significantly with improved availability and access.

Question: Does readily available emergency contraception increase women's awareness and use?

Among women seeking termination of pregnancy wider availability of the ECP has increased women's awareness of EC but not use.

Answer the question based on the following context: Prevention and early detection are key elements for the reduction of stomach cancer mortality. To apply pertinent measures effectively, high-risk groups need to be identified. With this aim, we assessed stomach cancer mortality among migrants from the Former Soviet Union (FSU), a high-risk area, to Germany and Israel. We calculated standardized mortality ratios (SMRs) comparing stomach cancer mortality in two retrospective migrant cohorts from the FSU to Germany (n=34,393) and Israel (n=589,388) to that in the FSU and the host country. The study period ranges from 1990 to 2005 in Germany and from 1990 to 2003 in Israel. Vital status and cause of death were retrieved from municipal and state registries. To assess secular mortality trends, we calculated annual age-standardized mortality rates in the cohorts, the FSU, and the two host countries and conducted Poisson regression modeling. SMRs (95% confidence intervals) for men in the German migrant cohort were 0.51 (0.36-0.70) compared with the FSU population and 1.44 (1.04-1.99) compared with the German population, respectively. For women, SMRs were 0.73 (0.49-1.03) compared with the FSU population and 1.40 (0.98-1.99) compared with the German population. SMRs for men in the Israeli migrant cohort were 0.49 (0.45-0.53) compared with the FSU population and 1.79 (1.65-1.94) compared with the Israeli population. SMRs for women in the Israeli cohort were 0.65 (0.59-0.72) compared with the FSU population and 1.82 (1.66-1.99) compared with the Israeli population. Poisson modeling showed a secular decrease in all populations with a time lag of 4-5 years between migrants and 'natives' in Germany and converging rates between migrants and the general population in Israel.

Question: Stomach cancer mortality in two large cohorts of migrants from the Former Soviet Union to Israel and Germany: are there implications for prevention?

Stomach cancer mortality in migrants from the FSU remains elevated after migration to Germany and Israel but is much lower than in the FSU. Due to a secular decline, it can be expected that mortality among migrants from the FSU reaches within a few years levels similar to those of the host countries today. Therefore, migrant-specific prevention and early detection measures cannot be recommended. Detailed risk factor profiles, however, need to be obtained through further studies.

Answer the question based on the following context: Anastomotic leaks represent the most common severe postoperative complications after esophagectomy. In this study standard inflammatory laboratory parameters [leukocytes, C-reactive protein (CRP)] were evaluated as indicators for anastomotic leakage after esophagectomy. Between 1 / 1997 and 12 / 2006 a total of 558 patients with esophageal cancer underwent an Ivor-Lewis esophagectomy. Among these patients, all those (n = 50, 8.9 %) suffering from an anastomotic leak were matched to 50 patients without anastomotic leakage. Leukocytes, CRP level and clinical parameters (body temperature, cardiac / respiratory problems, wound secretion) were retrospectively analysed at short-term intervals in both groups. Patients with anastomotic leaks showed significant continuously increased CRP levels and leukocyte counts from the second or, respectively, 5 (th) postoperative day onwards compared to patients without anastomotic leaks. Using a stepwise regression, an 80 % sensitivity for leakage detection has been calculated by a cut-off value for CRP set at 13.5 mg / dL from day 2 onwards or, respectively, for leukocytes at 10.5 Gpt / L from day 8 onwards. Concomitantly, patients with anastomotic leaks suffered significantly more from respiratory problems and abdominal pain.

Question: Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection?

CRP appears to be a reliable and predictable indicator for anastomotic leakage after esophagectomy and should, therefore, be routinely used as a screening marker to provide a reason for extended diagnosis.

Answer the question based on the following context: To assess the distribution of respiration and cardiac motion-induced field fluctuations in the breast and to evaluate the implications of such fluctuations for proton resonance frequency shift (PRFS) MR thermometry in the breast. Gradient echo MR field maps were made to study the effect of regular respiration, maximum capacity respiration, and cardiac motion on the stability of the local magnetic field in four healthy female volunteers. Field fluctuations (in parts-per-million [ppm]) were averaged over a region of interest covering both breasts. The average field fluctuation due to regular respiration was 0.13 ppm, due to maximum capacity respiration 0.16 ppm and<0.03 ppm due to cardiac motion. These fluctuations can be misinterpreted as temperature changes of 13, 16, and 3 degrees C when PRFS-based MR thermometry is used during thermal treatment of breast cancer.

Question: Do respiration and cardiac motion induce magnetic field fluctuations in the breast and are there implications for MR thermometry?

Respiration causes significant field fluctuations in the breast. If MR thermometry were to be safely used in clinical practice, these fluctuations should be taken into account and should probably be corrected for.

Answer the question based on the following context: The goal of asthma therapy is to achieve an optimal level of disease control, but the relationship between asthma control, impact of comorbid rhinitis and health related quality of life (HRQoL) in real life remains unexplored. The aims of this real life study were to evaluate asthma control, the impact of asthma (with and without rhinitis) on HRQoL, the relationship between asthma control and HRQoL, and the role of rhinitis on asthma control and HRQoL. 122 asthma patients completed the Asthma Control Test, Rhinitis Symptoms score (T5SS) and RHINASTHMA. Asthma control was unsatisfactory (44.27% of uncontrolled patients), as well as HRQoL. Controlled patients controlled showed significantly lower scores in all the RHINASTHMA domains compared to uncontrolled. Irrespective of their level of control, patients with rhinitis symptoms showed worse HRQoL in Upper Airways (UA) (P<0.0001), Lower Airways (LA) (P<0.001), and Global Summary (GS) (P<0.0001). In patients with symptomatic rhinitis, RHINASTHMA were lower in controlled asthma patients (UA P = 0.002; LA P<0.0001; RAI P<0.01; GS P<0.0001). Asthma control was associated with lower T5SS score (P = 0.034).

Question: Does asthma control correlate with quality of life related to upper and lower airways?

Asthma control in real life is unsatisfactory. Rhinitis and asthma influence each other in terms of control and HRQoL. The control of rhinitis in asthma patients can lead to an optimization of HRQoL related to the upper airways, while this phenomenon is not so evident in asthma. These results suggest to strengthen the ARIA recommendation that asthma patients must be evaluated for rhinitis and vice versa.

Answer the question based on the following context: The benefits of physical activity for promoting health and preventing illness are well known, and gender and regional disparities in physical activity have been reported. Although the number of women who perform physical activity has increased, many still do not meet the recommended levels to gain health benefits. A cross-sectional descriptive study was conducted using a structured questionnaire. A convenience sample of 245 women living in a rural area of Korea was recruited during 2004. Self-efficacy, benefits, barriers and sociodemographics were examined in relation to three levels of physical activity: inactive, insufficiently active and active. Descriptive statistics and multinomial logistic regression were used for data analysis. Perceived self-efficacy, benefits and barriers were statistically significant determinants only when the insufficiently active group was compared with the inactive group. Sociodemographic factors related to work and family roles statistically significantly explained the physical activity levels of rural women.

Question: Do the determinants of physical activity change by physical activity level?

Nursing interventions to increase self-efficacy and benefits, or decrease perceived barriers could be effective for initiating physical activity for inactive women, whereas the same may not apply for insufficiently active women. Insufficiently active women may have false confidence that their physical activity will help them gain health benefits. Reducing the burdens of work and family roles of rural women might improve their physical activity levels.

Answer the question based on the following context: The objective of the study was to describe episiotomy rates in the United States following recommended changes in clinical practice. The National Hospital Discharge Survey, a federal data set sampling inpatient hospitals, was used to obtain data based on International Classification of Diseases, Clinical Modification, 9th revision, diagnosis and procedure codes from 1979 to 2004. Age-adjusted rates of term, singleton, vertex, live-born spontaneous vaginal delivery, operative vaginal delivery, cesarean delivery, episiotomy, and anal sphincter laceration were calculated. Census data for 1990 for women 15-44 years of age was used for age adjustment. Regression analysis was used to evaluate trends in episiotomy. The rate of episiotomy with all vaginal deliveries decreased from 60.9% in 1979 to 24.5% in 2004. Anal sphincter laceration with spontaneous vaginal delivery declined from 5% in 1979 to 3.5% in 2004. Rates of anal sphincter laceration with operative delivery increased from 7.7% in 1979 to 15.3% in 2004. The age-adjusted rate of operative vaginal delivery declined from 8.7 in 1979 to 4.6 in 2004, whereas cesarean delivery rates increased from 8.3 in 1979 to 17.2 per 1000 women in 2004.

Question: Episiotomy in the United States: has anything changed?

Routine episiotomy has declined since liberal usage has been discouraged. Anal sphincter laceration rates with spontaneous vaginal delivery have decreased, likely reflecting the decreased usage of episiotomy. The decline in operative vaginal delivery corresponds to a sharp increase in cesarean delivery, which may indicate that practitioners are favoring cesarean delivery for difficult births.

Answer the question based on the following context: Symptomatic choledocholithiasis can be treated during pregnancy. Conceptus doses ranged from 0.1 mGy to 3 mGy in previous studies. The objectives of the current study were to investigate whether the conceptus dose may exceed the threshold of 10 mGy in the case of a pregnant patient undergoing ERCP, and to provide data for the accurate assessment of a conceptus dose. Monte Carlo methodology and mathematical anthropomorphic phantoms were used to determine normalized conceptus dose data. Phantoms simulated pregnant patients of different body sizes and gestational stages. Monte Carlo simulations were performed to estimate the efficiency of external shielding. University hospital. Twenty-four consecutive patients. All patients underwent therapeutic ERCP. Exposure parameters and dose-area product were recorded during the procedures. The total dose-area product recorded during ERCP procedures ranged between 62 x 10(3) and 491 x 10(3) mGy . cm(2). Monte Carlo normalized conceptus dose data are presented as a function of kV(p), total filtration, gestational stage, and body mass index. The conceptus dose may exceed 10 mGy when the total dose-area product surpasses 130 mGy . cm(2). Variations of conceptus location and size from the average.

Question: Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial?

Conceptus dose from ERCP may occasionally exceed 10 mGy, the dose above which the analytical dose calculation is recommended. The use of external shielding is unnecessary because the associated dose reduction is negligible. The normalized dose data may be used for the accurate estimation of conceptus dose from an ERCP procedure performed on a pregnant patient, regardless of body size, gestational stage, operating parameters, and equipment used.

Answer the question based on the following context: To determine the diagnostic performance of minimally invasive autopsy (MIA) for detection of causes of death and to investigate the feasibility of MIA as an alternative to conventional autopsy (CA) in the clinical setting. The institutional review board approved the MIA procedure and study, and informed consent was obtained for all deceased patients from relatives. Thirty deceased patients (19 men, 11 women; age range, 46-79 years), for whom family permission for CA on medical grounds had already been obtained, underwent additional evaluation with MIA prior to CA. MIA consisted of whole-body 16-section computed tomography (CT) and 1.5-T magnetic resonance (MR) imaging, followed by ultrasonography-guided 12-gauge needle biopsy of heart, both lungs, liver, both kidneys, and spleen. Percentage agreement between MIA and CA on cause of death was evaluated. Sensitivity and corresponding 95% confidence intervals (CIs) of MIA for detection of overall (major plus minor) findings, with CA as the reference standard, were calculated. Specificity was calculated for overall findings. Sensitivity analysis was performed to explore the effect of the clustered nature of the data. In 23 patients (77%), MIA and CA were in agreement on the cause of death. Sensitivity of MIA for detection of overall findings and detection of major findings was 93% (95% CI: 90%, 96%) and 94% (95% CI: 87%, 97%), respectively. Specificity was 99% (95% CI: 98%, 99%) for detection of overall findings. MIA failed to demonstrate acute myocardial infarction as the cause of death in four patients. Sensitivity analysis indicated a negligible correlation between observations within each patient. CT was superior to MR for detection of pneumothorax and calcifications. MR was superior to CT for detection of brain abnormalities and pulmonary embolus. With biopsy only, detection of disease in 55 organs was possible, which included 27 major findings.

Question: Minimally invasive autopsy: an alternative to conventional autopsy?

MIA is a feasible procedure with high diagnostic performance for detection of common causes of death such as pneumonia and sepsis; MIA failed to demonstrate cardiac diseases, such as acute myocardial infarction and endocarditis, as underlying cause of death.

Answer the question based on the following context: Obesity is associated with increased metabolic and cardiovascular risk. The ectopic fat hypothesis suggests that subcutaneous fat may be protective, but this theory has yet to be fully explored. Participants from the Framingham Heart Study (n = 3,001, 48.5% women) were stratified by visceral adipose tissue (VAT) into sex-specific tertiles. Within these tertiles, age-adjusted abdominal subcutaneous adipose tissue (SAT) tertiles were examined in relation to cardiometabolic risk factors. In the lowest VAT tertile, risk factor prevalence was low, although systolic blood pressure in women and rates of high triglycerides, impaired fasting glucose, hypertension, and the metabolic syndrome in men increased with increasing SAT tertile (all P<0.04). In contrast, in the top VAT tertile, lower triglycerides were observed in men with increasing SAT (64.4% high triglycerides in SAT tertile 1 vs. 52.7% in SAT tertile 3, P = 0.03). Similar observations were made for women, although results were not statistically significant (50.6% high triglycerides in SAT tertile 1 vs. 41.0% in tertile 3, P = 0.10). Results in the highest VAT tertile were notable for a lack of increase in the prevalence of low HDL in men and women and in rates of impaired fasting glucose in men with increasing subcutaneous fat, despite sizable differences in BMI across SAT tertiles (27.1 to 36.3 kg/m(2)[women]; 28.1 to 35.7 kg/m(2)[men]).

Question: Abdominal subcutaneous adipose tissue: a protective fat depot?

Although adiposity increases the absolute risk of metabolic and cardiovascular disease, abdominal subcutaneous fat is not associated with a linear increase in the prevalence of all risk factors among the obese, most notably, high triglycerides.

Answer the question based on the following context: Adjunctive use of glycoprotein IIb/IIIa inhibitors (GPI) is associated with favorable outcomes following percutaneous coronary intervention (PCI). Guidelines for use of GPI have been published by various national societies including National Institute of Clinical Excellence (NICE), United Kingdom. The latter has not been updated since publication. The impact of contemporary trials such as ISAR-REACT (which showed no benefit of abciximab and 600 mg of clopidogrel compared with 600 mg of clopidogrel alone, in elective patients) on adherence to NICE guidelines is unknown. We audited use of GPI against NICE guidelines following publication in May 2002. Data were collected from 1,685 patients between September and November in years 2002, 2003, 2004, and 2007. In 2002 and 2003, only 10.2% and 11.8%, respectively, of patients were noncompliant to NICE guidelines. Over time, there was an increase in patients not given GPI despite meeting NICE criteria. After publication of ISAR-REACT, the comparative figures for noncompliance in 2004 and 2007 were 40.0% and 44.5%. A similar pattern was seen in patients with diabetes; in 2002 and 2003 noncompliance was 16.7% and 11.1%, respectively, and in 2004 and 2007 noncompliance was 38.0% and 44.7%, respectively. Qualitatively, similar findings were recorded in patients with NSTE-ACS. The overall noncompliance to NICE guidelines increased from 11.0% to 42.1% (P<0.0001) after the ISAR-REACT study.

Question: Guidelines to practice gap in the use of glycoprotein IIb/IIIa inhibitors: from ISAR-REACT to overreact?

We found a decline in compliance to NICE guidelines on GPI usage during PCI. This was likely influenced by contemporary trials demonstrating little or no benefit of GPI in patients undergoing elective PCI who are adequately pretreated with clopidogrel. Our findings suggest the need for a mechanism whereby regular updates to guidelines can be disseminated following new trial evidence.

Answer the question based on the following context: Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration. List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships. Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small.

Question: Do list size and remuneration affect GPs' decisions about how they provide consultations?

Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.

Answer the question based on the following context: Advanced training in hepato-pancreato-biliary (HPB) surgery is available at select centers. No approved fellowships have yet been established. To determine the level of training in HPB surgery during general surgery residency and to assess the need for additional training. All general surgical residency programs in the United States were surveyed. Resident Review Committee (RRC) and International Hepato-Pancreato-Biliary Association (IHPBA) requirements were compared to Accreditation Council of Graduate Medical Education (ACGME) data. Eighty of 250 general surgical residency programs (32%) responded to the survey. Eighty percent felt their graduating residents had sufficient HPB training. The average number of pancreatic cases per graduating resident was 10.2 +/- 7.3. The average number of hepatic resections was 8.6 +/- 5.1, and for complex biliary cases, 5.3 +/- 1.3.

Question: Hepato-pancreato-biliary training in general surgery residency: is it enough for the real world?

A significant portion of HPB surgery is performed at transplant centers or by HPB surgeons. Guidelines must be established to assure adequate training. When HPB surgery is the main focus of the future practice, residents should seek additional training.

Answer the question based on the following context: Laparoscopic colectomy has become the standard of care for elective resections; however, there are few data regarding laparoscopy in the emergency setting. By using a database with prospectively collected data, we identified 94 patients who underwent an emergency colectomy between August 2005 and July 2008. Laparoscopic surgeries were performed in 42 patients and were compared with 25 patients who were suitable for laparoscopy but received open colectomy. The groups had similar demographics with no differences in age, sex, or surgical indications. Blood loss was lower (118 vs 205 mL; P<0.01) and the postoperative stay was shorter (8 vs 11 d; P = 0.02) in the laparoscopic patients, and perioperative mortality rates were similar between the 2 groups (1 vs 3; P = 0.29).

Question: Emergency laparoscopic colectomy: does it measure up to open?

With increasing experience, laparoscopic colectomy is a feasible option in certain emergency situations and is associated with shorter hospital stay, less morbidity, and similar mortality to that of open surgery.

Answer the question based on the following context: The optimal extent of thyroidectomy for papillary thyroid cancer (PTC)<1 cm is controversial. Our aim was to identify the rate and factors predictive of contralateral PTC in these patients. We examined 228 patients with PTC who underwent either completion or total thyroidectomy and analyzed the predictive value of tumor size, histology, margin status, capsular invasion, extrathyroid extension, multifocality, and node metastases. We observed no differences in the rate of contralateral disease in patients with primary PTC>or =1 cm compared with those having disease<1 cm, 30% versus 24%, respectively (P = .43). Multifocality was the only factor predictive of contralateral PTC in patients with tumors<1 cm (P = .02). Patients with tumors<.5 cm also had a comparable rate of contralateral disease (27%).

Question: Contralateral papillary thyroid cancer: does size matter?

The presence of contralateral PTC appears to be unrelated to the size of the primary tumor. Furthermore, in patients with PTC<1 cm, multifocality is a risk factor for PTC in the contralateral lobe.

Answer the question based on the following context: Because of the growing numbers of members worldwide in the sect of Jehovah's Witnesses, the refusal of blood and blood products due to religious reasons is increasingly encountered in clinical practice. As an alternative to blood transfusion, Jehovah's Witnesses accept blood-free volume substitution, and they sometimes accept the intraoperative reinfusion of autologous blood via a so-called cell saver. The aim of this study was to examine whether the refusal of blood transfusion affects the surgical indications for neurosurgery and whether morbidity and mortality rates are higher after neurosurgical interventions in Jehovah's Witnesses. The pre-, intra-, and postoperative hemoglobin and hematocrit values as well as coagulation parameters of a group of Jehovah's Witnesses (n = 103) were compared with those of a valid control group. The total intraoperative blood loss during spinal and intracranial surgery in Jehovah's Witnesses was often less than in controls, which suggests a less traumatic surgical procedure. Hemodynamically relevant blood loss occurred in two spinal and four intracranial interventions. The patients were managed without receiving blood transfusions or blood products, although increased time in the intensive care unit and increased convalescence days were necessary. Mean surgical times were 17.5 minutes longer for spinal interventions and 36.7 minutes longer for intracranial interventions than for patients in the control group. This may be attributed to a more careful and thus slower surgical technique and to longer and more extensive hemostasis. The length of hospitalization was 15% longer for Jehovah's Witnesses than for controls.

Question: Neurosurgical procedures in Jehovah's Witnesses: an increased risk?

The morbidity and mortality rates for Jehovah's Witnesses undergoing neurosurgery were not higher than those of the control group. Thus, it can be concluded that Jehovah's Witnesses did not have a higher risk when microsurgical techniques and extensive anesthetic monitoring were applied during neurosurgery. Because the surgical success rate for Jehovah's Witnesses corresponded to that of the control group, the increase in costs because of longer treatment times is compensated in the long run by avoiding a lengthier illness, sometimes with more expensive conservative therapy.

Answer the question based on the following context: The size of adrenal tumour plays an important role in the indications for surgical excision of non-functioning adrenal tumours and in selecting the best surgical approach. Computed tomography (CT) has been reported to underestimate the real size of adrenal lesions. The accuracy of magnetic resonance imaging (MRI) in predicting the true tumour size has not been previously investigated. The present retrospective study investigates the accuracy of MRI and CT in the pre-operative determination of true adrenal tumour size. The medical records of 65 patients who underwent adrenalectomy for an adrenal mass were reviewed. The size of adrenal tumours as determined by pre-operative MRI and/or CT was compared with the "true" histopathological size. The impact of histological diagnosis on size estimation was also investigated. The median age at diagnosis was 42 years (range 1-82 years) and more patients were female (60%). Five patients had bilateral adrenalectomy, thus giving rise to 70 adrenal specimens. The histopathological size of adrenal tumours ranged from 0.9 to 26 cm with a mean of 5.96 cm and a median of 4.70 cm. For tumours larger than 3 cm, MRI significantly underestimated the real tumour size by 20% (P<0.001). CT also underestimated the size of such tumours by 18.1% (P<0.003). Adrenal phaeochromocytomas were consistently underestimated by both modalities.

Question: Is MRI more accurate than CT in estimating the real size of adrenal tumours?

MRI and CT significantly underestimated the true size of adrenal tumours larger than 3 cm by 20% and 18%, respectively. Surgeons and endocrinologists should interpret the pre-operative size of adrenal lesions with caution.

Answer the question based on the following context: The multidrug transporters P-glycoprotein (P-gp) and MRP1 are functionally expressed in several subclasses of lymphocytes. HIV-1 protease inhibitors interact with both; consequently the transporters could reduce the local concentration of HIV-1 protease inhibitors and, thus, influence the selection of viral mutants. To study the effect of the expression of P-gp and MRP1 on the transport and accumulation of HIV-1 protease inhibitors in human lymphocytes and to study the effects of specific P-gp and MRP1 inhibitors. The initial rate and the steady-state intracellular accumulation of radiolabelled ritonavir, indinavir, saquinavir and nelfinavir was measured in three human lymphocyte cell lines: control CEM cells, CEM-MDR cells, which express 30-fold more P-gp than CEM cells, and CEM-MRP cells, which express fivefold more MRP1 protein than CEM cells. The effect of specific inhibitors of P-gp (GF 120918) and MRP1 (MK 571) was also examined. Compared with CEM cells, the initial rates of uptake and the steady-state intracellular concentrations of all protease inhibitors are significantly reduced in CEM-MDR cells. The intracellular concentrations of the protease inhibitors are increased upon co-administration with GF 120918, in some cases to levels approaching those in CEM cells. The intracellular concentrations of the protease inhibitors are also significantly reduced in CEM-MRP cells. Co-administration with MK -571 can partially overcome these effects.

Question: P-Glycoprotein and transporter MRP1 reduce HIV protease inhibitor uptake in CD4 cells: potential for accelerated viral drug resistance?

The overexpression of multidrug transporters significantly reduces the accumulation of protease inhibitors at this major site of virus replication, which, potentially, could accelerate the acquisition of viral resistance. Targeted inhibition of P-gp may represent an important strategy by which this problem can be overcome.

Answer the question based on the following context: The perioperative outcome of patients with tetralogy of Fallot (TOF) seems to have improved over the last four decades. To prove this hypothesis, we retrospectively analysed the data of 269 TOF patients operated on between 1975 and 1999 in our institution. Over the years, younger patients (median age 1975 - 1980: 4.5 years, 1995 - 1999: 0.9 years) were operated on with a lower mortality (1975 - 1980: 8.6 %, 1995 - 1999: 2.4 %). Residual defects such as pulmonary stenosis or insufficiency and VSD occurred with a similar frequency over time, whereas rhythm disturbances were significantly reduced (1981 - 1985: 51.2 %, 1995 - 1999: 24.4 %, p = 0.012). Postoperative length of hospital stay was significantly (p<0.05) shorter in the years 1995 - 1999 (11.0 - 11.4 days) than in 1975 - 1980 (16.9 +/- 16.5 days).

Question: Correction of tetralogy of Fallot: does the time period of surgery influence the outcome?

Over time periods, there was a trend towards lower mortality and towards operating on patients in a younger age. The rate of rhythm disturbances and the LOS after surgery proved to be reduced during the last decade. These differences did not turn out to be statistically significant. Therefore, we conclude that the time period of surgery has only little impact on the early outcome of patients after definitive correction of TOF.

Answer the question based on the following context: To investigate the possible myocardial protective effect of isoflurane during aortic cross-clamp and cardioplegic cardiac arrest in patients undergoing conventional coronary artery bypass graft surgery. Prospective, randomized. University medical center. Forty-nine patients undergoing elective coronary artery bypass graft surgery divided into 2 groups: control group (n = 21) and isoflurane group (n = 28). Isoflurane was administered in the pre-cardiopulmonary bypass (CPB) period to the isoflurane group. Hemodynamics and ST- segment variations were monitored in the pre-CPB period and after weaning from CPB in both groups. Incidence of reperfusion arrhythmias after release of aortic cross-clamp was compared. In the isoflurane group, the mean cardiac index after CPB was significantly higher than the pre-CPB value, whereas no difference between the 2 values was found in the control group. The higher cardiac index in the isoflurane group was associated with a lesser degree of ST- segment changes than in the control group. There was no significant difference between the 2 groups in the incidence of reperfusion arrhythmias after release of aortic cross-clamp.

Question: Does isoflurane optimize myocardial protection during cardiopulmonary bypass?

The present report suggests that administration of isoflurane before aortic cross-clamping in patients undergoing coronary artery bypass graft surgery may optimize the myocardial protective effect of cardioplegia. Isoflurane may be particularly advantageous whenever prolonged periods of aortic cross-clamping or inadequate delivery of cardioplegia is expected.

Answer the question based on the following context: Potential lymphatic drainage patterns from cutaneous melanomas of the head and neck are said to be variable and frequently unpredictable. The aim of this article is to correlate the anatomic distribution of pathologically involved lymph nodes with primary melanoma sites and to compare these findings with clinically predicted patterns of metastatic spread. A prospectively documented series of 169 patients with pathologically proven metastatic melanoma was reviewed by analyzing the clinical, operative, and pathologic records. Clinically, it was predicted that melanomas of the anterior scalp, forehead, and face could metastasize to the parotid and neck levels I-III; the coronal scalp, ear, and neck to the parotid and levels I-V; the posterior scalp to occipital nodes and levels II-V; and the lower neck to levels III-V. Minimum follow up was 2 years. There were 141 therapeutic (97 comprehensive, 44 selective) and 28 elective lymphadenectomies (4 comprehensive dissections, 21 selective neck dissections, and 3 cases in which parotidectomy alone was performed). Overall, there were 112 parotidectomies, 44 of which were therapeutic and 68 elective. Pathologically positive nodes involved clinically predicted nodal groups in 156 of 169 cases (92.3%). The incidence of postauricular node involvement was only 1.5% (3 cases). No patient was initially seen with contralateral metastatic disease; however, 5 patients (2.9%) failed in the contralateral neck after therapeutic dissection. In 68% of patients, metastatic disease involved the nearest nodal group, and in 59% only a single node was involved.

Question: Do nodal metastases from cutaneous melanoma of the head and neck follow a clinically predictable pattern?

Cutaneous malignant melanomas of the head and neck metastasized to clinically predicted nodal groups in 92% of patients in this series. Postauricular and contralateral metastatic node involvement was uncommon.

Answer the question based on the following context: With increasing pressure to use operating room time efficiently, opportunities for residents to learn fiberoptic orotracheal intubation in the operating room have declined. The purpose of this study was to determine whether fiberoptic orotracheal intubation skills learned outside the operating room on a simple model could be transferred into the clinical setting. First-year anesthesiology residents and first- and second-year internal medicine residents were recruited. Subjects were randomized to a didactic-teaching-only group (n = 12) or a model-training group (n = 12). The didactic-teaching group received a detailed lecture from an expert bronchoscopist. The model-training group was guided, by experts, through tasks performed on a simple model designed to refine fiberoptic manipulation skills. After the training session, subjects performed a fiberoptic orotracheal intubation on healthy, consenting, anesthetized, paralyzed female patients undergoing elective surgery with predicted "easy" laryngoscopic intubations. Two blinded anesthesiologists evaluated each subject. After the training session, the model group significantly outperformed the didactic group in the operating room when evaluated with a global rating scale (P<0.01)and checklist (P0.05). Model-trained subjects completed the fiberoptic orotracheal intubation significantly faster than didactic-trained subjects (P<0.01). Model-trained subjects were also more successful at achieving tracheal intubation than the didactic group (P<0.005).

Question: Fiberoptic orotracheal intubation on anesthetized patients: do manipulation skills learned on a simple model transfer into the operating room?

Fiberoptic orotracheal intubation skills training on a simple model is more effective than conventional didactic instruction for transfer to the clinical setting. Incorporating an extraoperative model into the training of fiberoptic orotracheal intubation may greatly reduce the time and pressures that accompany teaching this skill in the operating room.

Answer the question based on the following context: To examine the relationship between nicotine dependence and attitudes, predicted behaviours and support regarding restrictions on smoking. Population-based, computer-assisted, telephone survey of adults in Ontario, Canada using a two-stage stratified sampling design; 1764 interviews were completed (65% response rate) yielding 424 (24%) cigarette smokers, of whom 354 (83%) smoked daily. The Heaviness of Smoking Index was used as a measure of nicotine dependence. Attitudes toward smoking restrictions, predicted compliance with more restrictions, and support for total smoking bans. Attitudes favorable to smoking restrictions tended to decrease with increased nicotine dependence, but the associations were not statistically significant after adjusting for demographic variables. Predicted compliance with more restrictions on smoking decreased with higher levels of dependence, as did support for a total ban on smoking in restaurants, workplaces, bingo halls, and hockey arenas. Support for smoking bans in food courts, family fast food restaurants, and bars and taverns did not vary significantly with level of nicotine dependence.

Question: Is nicotine dependence related to smokers' support for restrictions on smoking?

Level of nicotine dependence is associated with intended behaviors and support for smoking restrictions in some settings. These results have implications for tobacco control programs and policies.

Answer the question based on the following context: We designed this study to elucidate the associated occult spinal lesions in patients with simple dorsal meningocele. The study population was comprised of two groups. Group I comprised newly diagnosed patients with dorsal spinal meningocele, and group II comprised patients who had had surgery for meningocele and presented with progressive neurological deficits. Magnetic resonance imaging (MRI) scans of the whole spinal column were done. The associated spinal cord malformations were also treated at the same operation. There were 14 boys and 8 girls, with an age range from birth to 4 years (mean 3.9 months), in group I. Of 20 patients (90%) with associated spinal lesions, 6 had more than one lesion, excluding hydromyelia. Group II was made up of 6 patients who had been previously operated on for a meningocele and who presented with tethered cord syndrome. These were 4 boys and 2 girls, who ranged in age from 4 to 10 years (mean 6 years). The level of the conus terminalis was lower than L3 in all patients. The other findings on MRI, besides low conus, were as follows: tight filum, split cord malformation, epidermoid, dorsal lipoma and hydromyelia.

Question: Is meningocele really an isolated lesion?

Meningocele frequently camouflages a second, occult, spinal lesion. MRI of the whole spinal column should be performed. An intradural exploration performed with a microneurosurgical technique is needed to detect the fibrous bands that may lead to spinal cord tethering and to release the entrapped nerve roots. The other associated spinal anomalies should be operated on during the same operation.

Answer the question based on the following context: Our goal was to determine whether adult patients with type 2 diabetes who had gross proteinuria or were already taking angiotensin-blocking drugs were screened for microalbuminuria. This was a retrospective cross-sectional study. We included a total of 278 adult patients with type 2 diabetes seen during 1998 and 1999 at the family medicine practices of the Medical University of South Carolina. The outcomes were microalbuminuria testing during either 1998 or 1999 and the initiation of medication if the screening test result was positive. We found that patients who could derive the greatest benefit from testing (ie, those without preexisting proteinuria or who were not receiving an angiotensin-blocking drug) were no more likely to be screened for microalbuminuria than those with existing proteinuria (16% vs 18%, P=.84) or those who were already being treated with an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (16% vs 16%, P=.83). Also, when the microalbuminuria test result was positive, only 40% of the patients were placed on angiotensin-blocking drugs.

Question: Use of microalbuminuria testing in persons with type 2 diabetes: are the right patients being tested?

Physician use of microalbuminuria screening does not follow established guidelines. The test appears to be used for many patients who might not need to be screened, and it is not always used for patients who should be screened. Consideration should be given to other strategies to prevent nephropathy in persons with type 2 diabetes.

Answer the question based on the following context: To assess the clinical efficacy and accuracy of an emergency department based six hour rule-out protocol for myocardial damage. Diagnostic cohort study. Emergency department of an inner city university hospital. 383 consecutive patients aged over 25 years with chest pain of less than 12 hours' duration who were at low to moderate risk of acute myocardial infarction. Serial measurements of creatine kinase MB mass and continuous ST segment monitoring for six hours with 12 leads. Performance of the diagnostic test against a gold standard consisting of either a 48 hour measurement of troponin T concentration or screening for myocardial infarction according to the World Health Organization's criteria. Outcome of the gold standard test was available for 292 patients. On the diagnostic test for the protocol, 53 patients had positive results and 239 patients had negative results. There were 18 false positive results and one false negative result. Sensitivity was 97.2% (95% confidence interval 95.0% to 99.0%), specificity 93.0% (90.0% to 96.0%), the negative predictive value 99.6%, and the positive predictive value 66.0%. The positive likelihood ratio was 13.9 and the negative likelihood ratio 0.03.

Question: Is it possible to exclude a diagnosis of myocardial damage within six hours of admission to an emergency department?

The six hour rule-out protocol for myocardial infarction is accurate and efficacious. It can be used in patients presenting to emergency departments with chest pain indicating a low to moderate risk of myocardial infarction.

Answer the question based on the following context: To assess whether the risk of complications is higher in HIV-1-infected women compared with non-infected women in the two years following insertion of the intrauterine contraceptive device. Prospective cohort study. Six hundred and forty-nine women (156 HIV-1-infected, 493 non-infected) in Nairobi, Kenya who requested an intrauterine contraceptive device and met local eligibility criteria. We gathered information on complications related to the use of the intrauterine contraceptive device, including pelvic inflammatory disease, removals due to infection, pain or bleeding, expulsions, and pregnancies at one, four, and 24 months after insertion by study physicians masked to participants' HIV-1 status. Cox regression was used to estimate hazard ratios. Complications were identified in 94 of 636 women returning for follow up (14.7% of HIV-1-infected, 14.8% of non-infected). The incidence of pelvic inflammatory disease was rare in both infected (2.0%) and non-infected (0.4%) groups. Multivariate analyses suggested no association between HIV-1 infection and increased risk of overall complications (hazard ratio = 1.0; 95% CI 0.6-1.6). Infection-related complications (e.g. any pelvic tenderness, removal for infection or pain) were also similar between groups (10.7% of HIV-1-infected, 8.8% of non-infected; P = 0.50), although there was a non-significant increase in infection-related complications among HIV-1-infected women with use of the intrauterine contraceptive device longer than five months (hazard ratio = 1.8; 95% CI 0.8-4.4). Neither overall nor infection-related complications differed by CD4 (immune) status.

Question: Is the intrauterine device appropriate contraception for HIV-1-infected women?

HIV-1-infected women often have a critical need for safe and effective contraception. The intrauterine contraceptive device may be an appropriate contraceptive method for HIV-1-infected women with ongoing access to medical services.

Answer the question based on the following context: There is increasing evidence that reflux of bile plays a part in the pathogenesis of Barrett's oesophagus. Bile injury to the gastric mucosa results in a "chemical" gastritis in which oedema and intestinal metaplasia are prominent.AIM: To determine if patients with Barrett's oesophagus have more bile related changes in antral mucosa than patients with uncomplicated gastro-oesophageal reflux disease (GORD) or non-ulcer dyspepsia (NUD). Patients were identified by a retrospective search of pathology records and those with a clinically confirmed diagnosis of either Barrett's oesophagus or reflux oesophagitis who had oesophageal and gastric biopsies taken at the same endoscopy and had no evidence of Helicobacter pylori infection entered the study. Control biopsies were taken from H pylori negative NUD patients. Antral biopsies were examined "blind" to clinical group and graded for a series of histological features from which the "reflux gastritis score" (RGS) and "bile reflux index" (BRI) could be calculated. The reproducibility of these histological scores was tested by a second pathologist. There were 100 patients with Barrett's, 61 with GORD, and 50 with NUD. The RGSs did not differ between groups. BRI values in the Barrett's group were significantly higher than those in GORD subjects (p=0.014) which in turn were higher than those in NUD patients (p=0.037). Similarly, the frequency of high BRI values (>14) was significantly greater in the Barrett's group (29/100; 29%) than in the GORD (9/61; 14.8%) or NUD (4/50; 8%) group. However, agreement on BRI values was "poor", indicating limited applicability of this approach.

Question: Bile reflux gastritis and Barrett's oesophagus: further evidence of a role for duodenogastro-oesophageal reflux?

Patients with Barrett's oesophagus have more evidence of bile related gastritis than subjects with uncomplicated GORD or NUD. The presence of bile in the refluxate could be a factor in both the development of "specialised" intestinal metaplasia and malignancy in the oesophagus.

Answer the question based on the following context: Prescott et al. found that the relative risks associated with smoking for respiratory and vascular deaths were higher for women who inhale than for inhaling men, and found no gender differences in relative risks of smoking-related cancers. The purpose of the present study was to assess whether these findings are reproducible, using data from the Renfrew and Paisley study. Age-standardized mortality rate differences and age-adjusted mortality rate ratios (using Cox's proportional hazard model) were calculated for male and female smokers by amount smoked compared with never smokers. These analyses were repeated after excluding non-inhalers. The all-cause mortality rate ratio was higher for men than for women in all categories of amount smoked, although this difference was only statistically significant in the light smokers (1.83 [95% CI : 1.61-2.07] for men and 1.41 [95% CI : 1.28-1.56]for women, P = 0.001). The cause-specific mortality rate ratios tended to be higher for men than for women, and this difference was most substantial for neoplasms (2.57 [95% CI : 2.01-3.29] for male light smokers and 1.35 [95% CI : 1.14-1.61]for female light smokers, P<0.001) and, in particular, for lung cancer (11.10 [95% CI : 5.89-20.92] for male light smokers and 4.73 [95% CI : 2.99-7.50]for female light smokers, P = 0.03). Furthermore, looking at the rate differences the effects of smoking were uniformly greater in men than in women. These results were virtually unchanged after excluding non-inhalers.

Question: Are women more sensitive to smoking than men?

We found similar results to Prescott et al. when all smokers were considered, but could not reproduce their findings when non-inhalers were excluded. Given the fact that we showed greater rate differences in men than in women, we think that it is too early to conclude that women may be more sensitive than men to some of the deleterious effects of smoking.

Answer the question based on the following context: Reconstructive surgery of bladder exstrophy remains a challenge. By using CT of the pelvis, we suggest a new pre- and post-operative investigative procedure to define the AP diameter (APD) as a predictive criterion for continence in this anomaly. Three axial CT slices were selected in nine children with exstrophy who had undergone neonatal reconstructive surgery. The three levels selected were the first sacral plate, the mid acetabular plane and the superior pubic spine. We used combined slices to measure: APD = distance between the first sacral vertebra and the pubic symphysis. Pubic diastasis (PD). Three angles defined on the transverse plane of the first sacral vertebra--iliac wing angle, sacropubic angle and acetabular version. In exstrophy, the angles demonstrate opening of the iliac wings and the pubic ramus, and acetabular retroversion compared to controls. Comparisons between controls, continent and incontinent patients reveal that in continent patients, APD increases with growth and seems to be a predictive criterion for continence, independent of diastasis of the pubic symphysis.

Question: The AP diameter of the pelvis: a new criterion for continence in the exstrophy complex?

We believe that CT of the pelvis with measurements of the APD should be performed in all neonates with bladder exstrophy before reconstructive surgery and for better understanding of the malformation. The APD seems to be predictive and may be a major criterion for continence, independent of PD.

Answer the question based on the following context: Moderation Management (MM) is the only alcohol self-help organization to target nondependent problem drinkers and to allow moderate drinking goals. This study evaluated whether MM drew into assistance an untapped segment of the population with nondependent alcohol problems. It also examined how access to the organization was influenced by the provision of Internet-based resources. A survey was distributed to participants in MM face-to-face and Internet-based self-help groups. MM participants (N = 177, 50.9% male) reported on their demographic characteristics, alcohol consumption, alcohol problems and utilization of professional and peer-run helping resources. MM appears to attract women and young people, especially those who are nondependent problem drinkers. It was also found that a significant minority of members experienced multiple alcohol dependence symptoms and therefore may have been poorly suited to a moderate drinking program.

Question: Can targeting nondependent problem drinkers and providing internet-based services expand access to assistance for alcohol problems?

Tailoring services to nondependent drinkers and offering assistance over the Internet are two valuable methods of broadening the base of treatment for alcohol problems. Although interventions like MM are unlikely to benefit all individuals who access them, they do attract problem drinkers who are otherwise unlikely to use existing alcohol-related services.

Answer the question based on the following context: In the present study, we examined the effects of response priming on the event-related potentials (ERPs) evoked by target stimuli in a go/nogo task. In each trial, subjects were presented a cue and a target stimulus. The cue informed subjects about the following target in that trial, and therefore, also about the kind of response (right-hand response, left-hand response, no overt response) potentially to be given in that trial. The traditional N2 and P3 go/nogo effects were replicated: the ERPs to nogo targets were negative compared to the ERPs evoked by go targets in the N2 latency range at frontal electrode sites, and the nogo P3s were more anteriorly distributed than the go P3s. Comparing the ERPs evoked by nogo targets, we found the P3, but not the N2, to be modulated by response priming.

Question: Response priming in a go/nogo task: do we have to explain the go/nogo N2 effect in terms of response activation instead of inhibition?

These results seem to indicate that the P3, but not the N2, is associated with response inhibition, or with an evaluation/decision process with regard to the expected and/or given response. It could be speculated that the traditional go/nogo N2 effect has to be explained in terms of response activation instead of response inhibition.

Answer the question based on the following context: Thrombopoietin (TPO), the major hormone controlling platelet production, has been measured in thrombocytopenias with discordant results. The aim of our work was to assess the value of the TPO assay for differential diagnosis of thrombocytopenias in a large cohort of patients classified according to the results of their platelet isotopic study. We measured TPO (R&D Systems) in serum of 160 thrombocytopenic patients referred to our department for platelet life span isotopic studies. We classified patients as follows: (a) idiopathic or autoimmune thrombocytopenia group (ITP; patients with increased platelet destruction and shortened platelet life span; n = 67); (b) pure genetic thrombocytopenia group (patients with decreased platelet production, normal platelet life span, and without bone marrow aplasia; n = 55); (c) bone marrow aplasia group (BM; patients with decreased platelet production, normal platelet life span, and bone marrow aplasia; n = 13). In patients with pure genetic thrombocytopenia, TPO (median, 55 ng/L) was not different from TPO in patients with ITP (median, 58 ng/L) or controls (n = 54; median, 51 ng/L). Only in patients with bone marrow aplasia was TPO significantly higher (median, 155 ng/L) and negatively correlated to the platelet count (r(2) = 0.5014).

Question: Is the thrombopoietin assay useful for differential diagnosis of thrombocytopenia?

Although the median serum TPO is increased in thrombocytopenia with decreased platelet production from bone marrow aplasia, it does not differentiate patients with pure genetic thrombocytopenia from those with ITP.

Answer the question based on the following context: To compare the efficacy of one-week versus two-week treatment with lansoprazole, amoxycillin and clarithromycin in inducing healing of Helicobacter pylori-positive duodenal ulcers as well as to investigate the role of several factors, determinant in the ulcer healing process. Seventy-one active duodenal ulcer patients were randomised to receive one- or two-week treatment with lansoprazole (30 mg bid), clarithromycin (500 mg bid) and amoxycillin (1 g bid), not followed by any additional acid suppressive therapy. Ulcer healing and Helicobacter pylori infection were assessed by endoscopy and urea breath test 4 weeks after the end of treatment. Before entering the trial and four weeks after the end of treatment, dyspeptic symptoms were recorded and scored by a validated questionnaire. The potential effects of a number of clinical variables on the ulcer healing process were evaluated by means of univariate and multivariate analyses. Duodenal ulcer was healed in 80.5% patients treated for one week and in 91.4% patients treated for 2 weeks according to intention-to-treat analysis (p=NS). Ulcer healing was more frequent in the Helicobacter pylori cured patients compared to those with persisting infection (90.9% vs 68.5%; p=0.04). Multivariate analysis did not reveal any significant predictor of duodenal ulcer healing.

Question: Prolonging proton pump inhibitor-based anti-Helicobacter pylori treatment from one to two weeks in duodenal ulcer: is it worthwhile?

Two-week treatment with lansoprazole, amoxycillin and clarithromycin, without continuation of antisecretive therapy, is better, although the difference is not statistically significant, than one-week treatment in healing Helicobacter pylori-positive duodenal ulcer disease. The eradication of Helicobacter pylori is the most important factor related to ulcer healing.

Answer the question based on the following context: It is still unclear whether recent advancements in colorectal cancer research have led to an improvement in management and prognosis of the disease. Through the data of a specialized colorectal cancer Registry we aimed at analysing pathological staging and 5-year survival of all patients with malignancies of large bowel diagnosed between 1984 and 1997. Main objective was to ascertain whether or not we are making progress in the control of this common neoplasm. During the 14-year period 1984-97, a total of 2,240 colorectal cancer patients were registered, for a crude incidence rate of 64.5 and 55.2/100,000/year in males and females, respectively Tumours were staged with "Tumour, Node, Metastasis" system, corresponding to Dukes' classification, into four main groups. Survival was assessed with Life Table analysis, and statistical significance--between various subgroups--evaluated with Log-Rank Test. Crude incidence rates of colorectal neoplasms showed minor fluctuations during initial period of registration, increasing sharply after 1990 mainly due to localized (stage I and II) lesions and, to a lesser degree, to stage III tumours. Number of advanced (stage IV and unstaged) malignancies remained virtually stable. When results were expressed as percent of total cases, the fraction of localized lesions increased from 39% in the biennium 1984-5 to 51.6% in 1986-97, and the proportion of advanced tumours fell from 39% to 21.6% (p for trend<0.001). As expected, 5-year survival was significantly (p<0.002) more favourable for individuals diagnosed in 1990-91 than for patients registered in 1984-89.

Question: Staging and survival of colorectal cancer: are we making progress?

In Northern Italy, incidence rates of colorectal carcinoma are rising. This trend is associated with a sharp increase of newly detected localized lesions and with a significant improvement of overall 5-year survival. The result may be attributed to several concomitant factors, such as: A] wider use of colonoscopy, B) increased education of patients, C) more attention given to symptoms.

Answer the question based on the following context: The cancer cachexia syndrome occurs in patients with non-small cell lung cancer (NSCLC) and includes elevated resting energy expenditure (REE). This increase in REE leads to weight loss, which in turn confers a poor prognosis. This study was undertaken to determine whether the cancer cachexia syndrome occurs in patients with nonmetastatic NSCLC. In this case-control study, 18 patients with nonmetastatic NSCLC (stages IA to IIIB) were matched to healthy controls on age (+/- 5 years), gender, and body mass index (+/- 3 kg/m2). Only 4 cancer patients had experienced>5% weight loss. Cancer patients and controls were compared on the basis of: (1) unadjusted REE, as measured by indirect calorimetry; (2) REE adjusted for lean body mass, as measured by dual x-ray absorptiometry; (3) REE adjusted for body cell mass, as measured by potassium-40 measurement; and (4) REE adjusted for total body water, as measured by tritiated water dilution. We observed no significant difference in unadjusted REE or in REE adjusted for total body water. However, with separate adjustments for lean body mass and body cell mass, cancer patients manifested an increase in REE: mean difference +/- standard error of the mean: 140+/-35 kcal/day (p = 0.001) and 173+/-65 kcal/day (p = 0.032), respectively. Further adjustment for weight loss yielded similarly significant results.

Question: Do patients with nonmetastatic non-small cell lung cancer demonstrate altered resting energy expenditure?

These results suggest that the cancer cachexia syndrome occurs in patients with nonmetastatic NSCLC and raise the question of whether clinical trials that target cancer cachexia should be initiated before weight loss.

Answer the question based on the following context: The effects of aortopulmonary collaterals (APCs) on the outcome of a Fontan procedure are unclear. We undertook this study to define the incidence and extent of APC flow, identify risk factors for APC flow, and determine if APC flow has a measurable effect on the outcome of a Fontan procedure. The APC flow was directly measured in 32 patients undergoing Fontan procedures from July 1997 to September 2000. The APC flow was measured in the operating room during total cardiopulmonary bypass, and was expressed as a percentage of total bypass pump flow. The APC flow ranged from 9% to 49% of total pump flow (median, 18%). Higher preoperative systemic oxygen saturation, pulmonary artery oxygen saturation, pulmonary to systemic flow ratio, and angiographic APC grade correlated with higher APC flow. There were no operative deaths; there was one Fontan takedown (APC flow = 14%). The APC flow had no significant effects on postoperative Fontan pressure, common atrial pressure, transpulmonary gradient, duration of effusions, or resource utilization after the Fontan procedures.

Question: Aortopulmonary collateral flow in the Fontan patient: does it matter?

In patients undergoing a Fontan procedure, APC flow is omnipresent, although its extent varies widely. Increased APC flow has no significant effect on the outcome of a Fontan procedure. This conclusion applies to patients who are well prepared for a Fontan procedure, but may not extend to patients at higher risk.

Answer the question based on the following context: The feasibility of off-pump coronary artery bypass surgery has been well demonstrated. The purpose of the present study was to assess the safety and efficacy of off-pump coronary artery surgery in patients with left main coronary artery disease. Between January 1997 and December 2000, 174 patients with significant left main coronary artery stenosis underwent coronary artery bypass grafting without a pump. During the same period, 991 patients who also had significant left main coronary artery stenosis underwent coronary artery surgery on a pump. The patients in the two groups were matched in preoperative variables except that those in the off-pump group were slightly older, and more required urgent surgery. Hospital mortality was 2/174 and 21/991 in the off-pump and on-pump groups, respectively (p=0.560). The incidence of perioperative myocardial infarction (1.74 v. 14/991, p=0.712), atrial fibrillation (17/174 v 157/991, p=0.050) and blood transfusion requirement (63/174 v. 476/991, p=0.05) were significantly less in the off-pump group. The intubation time (15+/-3 hours v 22+/-4 hours, p=0.001), blood loss (365+/-61 ml v 582+/-76 ml, p<0.001), intensive care unit stay (23+/-10 hours v. 36+/-11 hours, p<0.001) and hospital stay (6+/-4 days v. 9+/-5 days, p<0.001) were also less in the off-pump group.

Question: Is off-pump coronary artery bypass surgery safe for left main coronary artery stenosis?

Off-pump coronary artery bypass surgery is safe and effective for patients with left main coronary artery disease.

Answer the question based on the following context: Nitric oxide (NO), a potent vasodilator, is presumed to be constitutively released in most mammalian blood vessels. In isolated rat thoracic aorta, however, hemoglobin (Hb), a nitric oxide scavenger, elicited contraction only when the vessels were precontracted with an alpha adrenergic agonist. Does vascular contraction induce endothelial NO release? Thoracic aortic rings from male Sprague-Dawley rats were prepared with or without the endothelium. Vessel rings were contracted with several distinct types of contractile agonists and NO release was probed using a Hb contraction assay in the presence and absence of nitro-l-arginine methyl ester (NAME), a NO synthase inhibitor. In vessel rings precontracted with norepinephrine, potassium chloride, arginine vasopressin, prostaglandin F(2alpha), or serotonin, Hb elicited significant additional contractions. In contrast, Hb failed to elicit significant contractions in vessel rings without the functional endothelium or vessels pretreated with NAME. The Hb mediated additional contraction was not inhibited by calmidazolium, a calmodulin antagonist, and protein kinase inhibitors staurosporine and 2,5-dihydromethylcinnamate. Intercellular gap junction inhibitor 2,3-butanedione monoxime at a low dose (<2 mM) significantly attenuated the NE/Hb mediated contractions but at a high dose (>15 mM) completely prevented both contractions. The contraction coupled NO release may be mediated through a mechanism distinct from the Ca(2+)-calmodulin-dependent endothelial NOS pathway.

Question: Contraction coupled endothelial nitric oxide release: a new paradigm for local vascular control?

In the isolated rat thoracic aorta, endothelial NO release may be coupled to contractile stimulus. This vascular property appears to render a unique local control mechanism independent of baroreflex and other central mechanisms.

Answer the question based on the following context: There is controversy as to whether PTSD can develop following a brain injury with a loss of consciousness. However, no studies have specifically examined the influence of the memories that the individuals may or may not have on the development of symptoms. To consider how amnesia for the traumatic event effects the development and profile of traumatic stress symptoms. Fifteen hundred case records from an Accident and Emergency Unit were screened to identify 371 individuals with traumatic brain injury who were sent questionnaires by post. The 53 subsequent valid responses yielded three groups: those with no memory (n = 14), untraumatic memories (n = 13) and traumatic memories (n = 26) of the index event. The IES-R was used as a screening measure followed by a structured interview (CAPS-DX) to determine caseness and provide details of symptom profile. Groups with no memories or traumatic memories of the index event reported higher levels of psychological distress than the group with untraumatic memories. Ratings of PTSD symptoms were less severe in the no memory groups compared to those with traumatic memories.

Question: Post-traumatic stress disorder symptoms following a head injury: does amnesia for the event influence the development of symptoms?

Psychological distress was associated with having traumatic or no memories of an index event. Amnesia for the event did not protect against PTSD; however, it does appear to protect against the severity and presence of specific intrusive symptoms.