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Evaluate recurrence-free survival (RFS) and short-term morbidity in patients with early cervical cancer who undergo bilateral pelvic lymphadenectomy (BPLND) versus bilateral sentinel lymph node biopsy only (BSLNB) at primary surgery. All patients with pathologically confirmed node negative stage IA/IB cervical cancer managed with BPLND or BSLNB were identified in the University of Toronto's prospective cervical cancer database from May 1984-June 2015. Groups were compared with Wilcoxon rank-sum, Chi-square, and Fisher's exact tests. Predictors of RFS were identified with Cox proportional hazard models. Kaplan-Meier survival curves were compared. Statistical significance was p<0.05. 1188 node negative patients were identified, BPLND-1078; BSLNB-110. There was no difference between BPLND and BSLNB in 2 and 5year RFS (95% vs 97% and 92% vs 93% respectively), tumor size, histology, invasion depth, intra-operative complications or short-term morbidity. BPLND was associated with increased surgical time (2.8 vs 2.0h, p<0.001), blood loss (500mL vs 100mL, p<0.001), transfusion (23% vs 0%, p<0.001) and post-operative infection (11% vs 0%, p=0.001). Age, surgery date, stage, LVSI, and radicality of surgery differed between groups. Controlling for age, stage, LVSI, invasion depth and histology, there was no significant difference in RFS between groups. Only invasion depth, LVSI and histology were predictors of RFS.

A negative BSLNB is not associated with a difference in RFS compared to a negative BPLND. Short-term morbidity may be reduced, however due to the long study period, changes in demographics and surgery may contribute to differences noted.

Can sentinel lymph node biopsy replace pelvic lymphadenectomy for early cervical cancer?

Eosinophilic esophagitis is a disease associated with dysphagia and has a seasonal variation in incidence. The primary aim of this study was to search for a potential seasonal variation in the incidence of esophageal foreign bodies or food impaction. In addition, after exclusion of structural or accidental causes, the authors sought to explore if such a variation would differ between patients with or without atopic disorders. Case series with chart review. NÄL Medical Centre Hospital, a secondary referral hospital. A total of 314 consecutive cases of esophageal bolus impaction from 2004 through 2009 were included and analyzed regarding seasonal variation in incidence. The analysis was repeated after exclusion of cases with sharp items, cancer, or atresia and again separately after subdividing this group according to presence of atopy. The overall incidence of esophageal bolus impaction was significantly higher during summer and fall than during the corresponding winter and spring period. In cases with atopic disorders and soft foods or meat bolus obstruction (n = 90), the incidence during the fall was significantly higher than that during the winter, and the incidence during the summer and fall was significantly higher than the corresponding incidence during the winter and spring. This variation was not present in patients without any signs or symptoms of atopy.

There was a significant seasonal variation in the incidence of acute esophageal bolus impaction. This variation was pronounced in patients with a coexisting atopic diathesis but was nonsignificant in patients without atopy.

The incidence of esophageal bolus impaction: is there a seasonal variation?

While there is evidence of an increased incidence of sinusitis in patients with allergic rhinitis, it is unclear whether an allergic process occurs in the sinus tissues per se. The purpose of this study was to determine whether inhaled pollen reaches the sinus mucosa. Tc99m labeled ragweed pollen was inhaled by five non-atopic adults. Imaging studies of the sinuses were performed with a tomographic rotating gamma camera. To determine the sensitivity of the technique, the nose and the maxillary sinuses of cadaver heads were painted with varying amounts of Tc99m and then similarly scanned. Scans of the cadaver heads showed clear resolution between the nasal cavity and the maxillary sinus. It was determined that 20 microci was the smallest amount of Tc99m that could be resolved to be in the sinuses. Scans of subjects showed intense activity in the nasal cavity but none in the paranasal sinuses despite the delivery of a supraphysiologic dose of Tc99m ragweed pollen.

Inhaled ragweed pollen does not appear to enter the paranasal sinuses. It is unlikely that an inhaled antigen-IgE antibody reaction occurs in the sinus mucosa.

Does inhaled pollen enter the sinus cavities?

To study the clinical characteristics and susceptibility to antimicrobial agents of Streptococcus pneumoniae invasive infection in our neonatal unit. Data from newborns with Streptococcus pneumoniae invasive infection in the last 12 years were retrospectively collected. Eight cases of invasive infection were identified. Gestational age ranged from 30 to 38 weeks (median: 34 weeks) and birth weight ranged from 1,680g to 4,460g (median: 2,480g). Risk factors related to infection were identified in 7 patients. Although infection manifested as shock in 4 patients and meningitis in 1, evolution was favorable in all patients. Penicillin resistance was found in 3 patients.

Streptococcus pneumoniae produces serious disease in neonates. Because of the increasing prevalence of penicillin-resistant pneumococci, the relationship between the percentage of mothers colonized with pneumococci and neonatal infection should be determined to develop new prevention and treatment strategies in newborn infants.

Pneumococci: a new microorganism in the newborn?

It remains uncertain whether angiotensin converting enzyme (ACE) inhibitors benefit all heart failure patients or just those with renin-angiotensin-aldosterone system (RAAS) activation. To determine whether the response to an ACE inhibitor, assessed by urine sodium excretion, was different in patients with low renin versus those with high renin. Plasma renin activity (PRA) was measured in 38 patients with stable chronic heart failure (21 male, 17 female; mean (SD) age 71 (6) years, range 59-82 years) on chronic diuretic treatment alone. They were divided into three groups: low (PRA</= 1.5 ng/ml/h, n = 11); normal (1.5<PRA<5, n = 14); and high (PRA>5, n = 13). The effect of ACE inhibition was then assessed on diuretic induced natriuresis with respect to renin status. There were no significant differences in age and sex distribution between the groups. Plasma angiotensin II and aldosterone increased serially from low to high renin groups, while 24 h urinary sodium concentrations fell from low to high renin groups (low PRA, 96.7 (39.5); normal PRA, 90.4 (26.7); high PRA, 66. 3 (18.9) mmol/l; p = 0.033), despite a higher diuretic dose in the high renin group. This blunted natriuretic effect of loop diuretics was caused by RAAS activation, which could partly be reversed by ACE inhibition. ACE inhibitors increased natriuresis by 22% in the high renin group (p = 0.029), but had no effect in the normal and low renin groups. Within the low renin group, five of the 11 patients had persistently low renin levels despite ACE inhibition. There was a non-significant reduction in natriuresis (-9.6%, p = 0.335) following ACE inhibition in this subgroup of patients.

About one third of heart failure patients in our study had low renin status and a non-activated RAAS, despite diuretic treatment. ACE inhibitors did not alter natriuresis significantly in this subgroup of patients, and enhanced natriuresis only in patients with high renin. There is thus tentative support for renin profiling in targeting ACE inhibitors to the most deserving, by showing that short term sodium retention does not occur in low renin patients if ACE inhibitors are withdrawn.

Is there a role for renin profiling in selecting chronic heart failure patients for ACE inhibitor treatment?

Urgent or emergent status is often associated with increased risk among cardiac operations. The objective of this study was to analyze outcomes and cost differences in patients undergoing elective versus urgent or emergent mitral valve replacement (MVR) and repair operations. From 2003 to 2008, 1,477 patients underwent isolated, primary mitral valve (MV) operations at 11 different centers in the Commonwealth of Virginia. Patients were stratified into four groups: elective MVR (n = 419), elective MV repair (n = 674), urgent or emergent MVR (n = 261) and urgent or emergent MV repair (n = 123). Preoperative risk, operative features, outcomes, and total costs were evaluated. Mitral valve replacement patients had more risk factors, including advanced age. Female sex and severe mitral regurgitation were more common among MV repairs. Mitral valve replacement incurred higher operative mortality (5.2% versus 1.2%; p<0.001), more major complications (20.6% versus 6.5%; p<0.001), longer postoperative (10.8 days versus 6.2 days; p<0.001) and intensive care unit (117.7 hours versus 51.4 hours; p<0.001) duration, and greater total costs ($45,166 versus $26,229; p<0.001) compared with MV repair operations. Postoperative length of stay was longer for elective MVR patients compared with elective MV repair patients (p<0.001) as well as for urgent or emergent MVR patients compared with urgent or emergent MV repair patients (p = 0.001). Total hospital costs were also higher for both elective MVR (p<0.001) and urgent or emergent MVR (p<0.001) compared with elective MV repair and urgent or emergent MV repair. Risk-adjusted operative mortality (odds ratio, 11.4; p<0.001) and major complication rates (odds ratio, 7.6; p<0.001) were highest for urgent or emergent MVR.

Mitral valve repair is associated with lower morbidity, mortality, and total costs compared with MVR. For urgent or emergent operations, the improved outcomes with mitral repair versus replacement are even more profound.

Does urgent or emergent status influence choice in mitral valve operations?

An El Ganzouri risk index test (EGRI) score of seven and the ability to achieve difficult laryngeal exposure with the GlideScope® may represent a highly predictive decisional threshold. Hence, we hypothesized that a new difficult airways algorithm that is EGRI- and GlideScope®-based may enable tracheal intubation in every patient. Thirteen staff practitioners trained in videolaryngoscopic intubation followed the algorithm from 2008 through 2010. Elective and emergency neurosurgical patients assessed as having an EGRI score of seven and higher underwent flexible fiberoptic bronchoscopy (FFB) intubation while conscious. Those with a score of six and lower were intubated with the GlideScope®, excluding patients with morbid obesity or pharyngo-laryngeal or neck tumors. A decision to perform alternative procedures, difficult laryngeal exposure [Cormack and Lehane (CL) grades III-IV], difficult ventilation and failure to intubate were recorded. The decisional rule was applied in 6,276 patients and resulted in six FFB intubations in conscious patients. The overall incidence of CL grade III-IV views was 0.2%. Difficult videolaryngoscopy was found in 14 patients (0.14%) with a score of 6 and lower. Post-hoc examinations of FFB intubations revealed five difficult laryngeal exposures. The positive predictive value was 85.7%, while the negative predictive value was 99.9%. The incidence of difficult ventilation and difficult laryngeal exposure was 0.03%. Two patients with neck tumors were assigned to alternative procedures.

Adherence to the decisional process of the algorithm and to GlideScope® videolaryngoscopy achieved successful tracheal intubation in our cohort of patients.

A new difficult airway management algorithm based upon the El Ganzouri Risk Index and GlideScope® videolaryngoscope. A new look for intubation?

To evaluate the possible role of an hemostatic matrix on hemostasis, perioperative outcomes and complications in patients who underwent laparoscopic partial nephrectomy (LPN). Patients charts were analyzed retrospectively and their demographic characteristics, operative parameters and follow-up results were recorded. Patients were divided into two groups, according to those who used an hemostatic matrix as Group 1 (n = 41) and those who did not used as Group 2 (n = 44). Demographic characteristics of patients, tumor features, operation time, clamping of the renal vessels, ischemia time, suturing of the collecting system, perioperative hemorrhage and complications were evaluated. Histopathological results, surgical margin status, creatinine level and recurrence at the 3rd month of follow up were analyzed. Statistical analyses were performed with SPSS 17.0 and significance was set at p value of<0.05. The mean RENAL nephrometry score was 5.9 ± 2.0 and the mean tumor size was 35 ± 12 mm. All patients had a single tumor and 44 of them had a tumor in the right kidney. The renal artery was clamped in 79 cases and the mean ischemia time was 20.1 ± 7 minutes. The mean tumor size and the mean RENAL nephrometry score was statistically higher in Group 1 (p: 0.016 and p<0.001, respectively). Pelvicaliceal repair was more common in Group 1 due to deeper extension of tumors in this group (p: 0.038). In Group 1, less hemorrhage and blood transfusion requirement, with shorter ischemia and operation time was detected.

The outcomes of the recent study showed that adjunctive use of an hemostatic matrix improves hemostasis and decreases hemorrhagic complications during LPN. Further prospective studies are required to assess the potential role of an hemostatic matrix in LPN.

Bleeding during laparoscopic partial nephrectomy: Can a hemostatic matrix help to improve hemostasis?

Pouch formation after failed gastric banding bears a risk of anastomotic leakage, bleeding or ischemic damage due to an impaired vascular supply or demanding preparation in the scarry tissue. We evaluated the clinical outcome in patients following Roux-en-Y gastric bypass (RYBP) with and without gastric pouch reconstruction after removal of adjustable gastric bands. This study comprised 24 morbidly obese patients undergoing RYBP as their final bariatric procedure. Group 1 consisted of eight patients after band migration or pouch dilatation. An esophago-jejunal anastomosis was performed. Group 2 comprised 16 patients with esophageal motility disorders or pouch dilation after banding. A regular-sized pouch was created. Clinical parameters, such as weight loss, complications and a satiety score were assessed. Serum values of ghrelin and gastrin were measured. All but one procedure (Group 2) could be performed by laparoscopy. Mortality rate was 0%. One patient of Group 1 developed a liver abscess that required percutaneous drainage and one patient of Group 2 developed stenosis at the gastrojejunostomy that necessitated endoscopic balloon-dilation. All patients significantly reduced body weight (p<0.01 compared to preoperative values) during a median follow-up of 37.5 and 31.5 months, respectively. Two out of 16 (12.5%) patients of Group 2 showed pathologic postoperative DeMeester scores. Esophageal body peristalsis did not reveal statistically significant differences between the two groups. Parameters of satiety assessment did not differ between the two groups as did serum values of gastrin and ghrelin.

RYBP in patients experiencing adjustable gastric band failure is technically demanding. Esophago-jejunostomy avoids preparation in scarred tissue whereas routine pouch formation may increase the risk for complications. Adapted procedural strategy is recommended based on intraoperative decision making.

Is a pouch compulsory in Roux-en-Y gastric bypass after failed adjustable gastric banding?

Evidence on physical activity (PA) and transitions out of full-time employment in middle-to-older age is mainly cross-sectional and focused upon retirement. The purpose was to examine trajectories in PA before and after transitions out of full-time employment. Data were obtained for 5,754 people in full-time employment aged 50-75 from the US Health and Retirement Survey. Logistic regression was used to examine trajectories in twice-weekly participation in light, moderate and vigorous PA among those transitioning to part-time work, semi-retirement, full retirement, or economic inactivity due to disability, in comparison to those remaining in full-time employment. Twice weekly participation in vigorous and light physical activity changed little for those who remained in full-time employment, while moderate physical activity decreased between baseline and follow-up (OR 0.95, 95 % CI 0.91, 0.99). Differences in physical activity according to transitional categories at follow-up were evident. Baseline differences in physical activity across all intensities were greatest among participants transitioning from full-time to part-time employment compared to those who remained in full-time employment throughout the study period (vigorous OR 1.41 95 % CI 1.23, 1.61; moderate OR 1.28 95 % CI 1.12, 1.46; light OR 1.29 95 % CI 1.12, 1.49). Those transitioning to unemployment were already among the least physically active at baseline, irrespective of intensity (albeit, with 95 % CIs spanning unity). Those transitioning to full-time retirement were also among the least active (e.g. vigorous OR 0.71 95 % CI 0.61, 0.81; moderate OR 0.80 95 % CI 0.71, 0.90). Declines in physical activity were reported for those transitioning to economic inactivity due to a disability (vigorous OR 0.29 95 % CI 0.14, 0.64; moderate OR 0.56 95 % CI 0.33, 0.95; light OR 0.34 95 % CI 0.19, 0.63). Physical activity increased regardless of intensity among participants transitioning to semi-retirement (p > 0.05) and full retirement (e.g. vigorous OR 1.28 95 % CI 1.09, 1.51; moderate OR 1.24 95 % CI 1.07, 1.43). Light physical activity increased for those transitioning to unemployment (OR 1.40 95 % CI 1.02, 1.93), though less change was evident in moderate or vigorous physical activity.

The amount and intensity of PA varies by the type of transition out of full-time employment among people in middle-to-older age.

Does retirement mean more physical activity?

To determine whether pan diameter influences carbon monoxide (CO) concentration during heating of water to boiling point with a camping stove. The hypothesis was that increasing pan diameter increases CO concentration because of greater flame dispersal and a larger flame. This was a randomized, prospective study. A Coleman Dual Fuel 533 stove was used to heat pans of water to boiling point, with CO concentration monitored every 30 seconds for 5 minutes. The stove was inside a partially ventilated 200-L cardboard box model that was inside an environmental chamber at -6 degrees C. Water temperature, water volume, and flame characteristics were all standardized. Ten trials were performed for each of 2 pan diameters (base diameters of 165 mm [small] and 220 mm [large]). There was a significant difference (P = .002) between the pans for CO levels at each measurement interval from 60 seconds onward. These differences were markedly larger after 90 seconds, with a mean difference of 185 ppm (95% CI 115, 276 ppm) for all the results from 120 seconds onwards.

This study has shown that there is significantly higher CO production with a large-diameter pan compared with a small-diameter pan. These findings were evident by using a camping stove to heat water to boiling point when a maximum blue flame was present throughout. Thus, in enclosed environments it is recommended that small-diameter pans be used in an attempt to prevent high CO levels.

Does pan diameter influence carbon monoxide levels during heating of water to boiling point with a camping stove?

Relatives of patients with early onset colorectal cancer, a feature of hereditary non-polyposis colorectal cancer (HNPCC), are at increased risk of colorectal cancer. To investigate risk in relatives of patients with multiple primary cancers, another feature of HNPCC. Details were obtained on patients from one region who had developed colorectal cancer and a separate primary from the HNPCC tumour spectrum (colorectal, stomach, urinary, ovary, endometrial). Overall, 157 patients had second primaries occurring between 1990 and 1995 and 128 completed family histories were obtained by structured interview (study group). A comparison group of 444 patients with a single colorectal cancer were similarly interviewed. Fifteen families (13%) from the study group were suggestive of HNPCC compared with three (0.7%, p<0.0001) from the comparison group. Overall risk of colorectal cancer in close relatives of the study group was 3.4 times the general population rate compared with 1.8 times for the comparison group. Bowel cancer risk was even higher for relatives of bowel/ovary and bowel/endometrial subgroups, but was similar to the comparison group for the bowel/bowel subgroup. Finally, extracolonic HNPCC associated cancers were seen twice as frequently as expected in the general population in relatives of the study group.

This study highlights the importance of taking a family history in patients with multiple primary cancers and indicates the risk of malignancy in their relatives.

Are relatives of patients with multiple HNPCC spectrum tumours at increased risk of cancer?

To describe the prevalence of Helicobacter pylori infection in patients with reflux esophagitis, and compare it with that in patients with normal endoscopy. Fifty-five patients with endoscopic peptic esophagitis and 55 symptomatic patients with normal endoscopy were studied. Age and sex distribution were similar in both groups. At endoscopy biopsy specimens were taken from gastric antrum and body (H&E, Gram stain and culture). H. pylori was found in 74.5% (95% CI = 62-84%) of patients with reflux esophagitis, and in 76.4% (CI = 64-86%) of cases with normal endoscopy (a non-significant difference). In patients with esophagitis and H. pylori infection normal histologic antral mucosa was observed in 7.3% of cases (CI = 2.5-19.4%). In patients with normal endoscopy the corresponding figure was 4.8% (CI = 1.3-15.8%) (a non-significant difference). At gastric body from infected patients the percentages of patients with normal histologic mucosa was 29.3% (n = 12) and 23.8% (n = 10), in both groups respectively.

The prevalence of H. pylori infection in patients with reflux esophagitis was 74.5%, and no difference was observed when comparing with infection rate in patients with normal endoscopy (76.4%). Therefore, a non-significant association was found between this esophageal disorder and H. pylori infection.

Is there any association between Helicobacter pylori infection and peptic esophagitis?

Bladder catheterization (BC) is a commonly performed, painful procedure in the pediatric emergency department (ED). A survey demonstrated that analgesia is infrequently used for several brief painful procedures, including BC, in pediatric patients. In this study, we evaluated the use of 2% lidocaine gel to alleviate the pain associated with BC in young children (<2 years) in the ED. We conducted a randomized, double-blind, placebo-controlled trial comparing pain scores during bladder catheterization with 2% lidocaine gel versus nonanesthetic lubricant. We used a previously validated scale for measuring brief procedure-related pain in preverbal children (Face Legs Arms Cry Consolability Pain Scale [FLACC]). A total of 115 patients were recruited; 56 patients were randomized to the control group, and 59 were randomized to the lidocaine group. Lubricant was applied to both the genital mucosa and the catheter. Pain measurements were recorded at 3 time intervals: before insertion of the catheter, during catheterization, and after catheterization. Interobserver reliability had been previously established in an observational pilot study. The difference in mean FLACC scores between the control (7.55 +/- 2.56) and study groups (7.37 +/- 2.87) during catheterization was not statistically significant. The change in FLACC from time 1 (preprocedure) to time 2 (during procedure) was statistically significant in both groups, suggesting that bladder catheterization is a painful procedure.

Altering the standard practice of use of nonanesthetic lubricant with 2% lidocaine gel as lubricant during bladder catheterization in young children may not be helpful in alleviating the pain associated with the procedure.

Does lidocaine gel alleviate the pain of bladder catheterization in young children?

Since little is known as to whether sex differences affect the clinical presentation of pediatric BP-I disorder, it is an area of high clinical, scientific and public health relevance. Subjects are 239 BP-I probands (65 female probands, 174 male probands) and their 726 first-degree relatives, and 136 non-bipolar, non-ADHD control probands (37 female probands, 99 male probands) and their 411 first-degree relatives matched for age and sex. We modeled the psychiatric and cognitive outcomes as a function of BP-I status, sex, and the BP-I status-gender interaction. BP-I disorder was equally familial in both sexes. With the exception of duration of mania (shorter in females) and number of depressive episodes (more in females), there were no other meaningful differences between the sexes in clinical correlates of BP-I disorder. With the exception of a significant sex effect for panic disorder and a trend for substance use disorders (p=0.05) with female probands being at a higher risk than male probands, patterns of comorbidity were similar between the sexes. Despite the similarities, boys with BP-I disorder received more intensive and costly academic services than girls with the same disorder. Since we studied children referred to a family study of bipolar disorder, our findings may not generalize to clinic settings.

We found more similarities than differences between the sexes in the personal and familial correlates of BP-I disorder. Clinicians should consider bipolar disorder in the differential diagnosis of both boys and girls afflicted with symptoms suggestive of this disorder.

Does sex moderate the clinical correlates of pediatric bipolar-I disorder?

Allergic eosinophilic esophagitis (AEE) is thought to be an allergic reaction that is characterized by inflammation caused by predominant accumulation of eosinophils in esophageal mucosa (>or =15 eosinophils per high power field). To examine the seasonal distribution of newly diagnosed AEE children. Retrospective analysis of all patients diagnosed with AEE at our institution over a nearly 6-year period (December 1998 to October 2004). Two hundred thirty-four children (mean age 7.3 y, median age 7.0 y, age range 0.2 to 19.5 y) were diagnosed with AEE during the study period. Significantly fewer patients were diagnosed with AEE in Winter as compared with Spring, Summer, and Fall. Although all the patients had severe eosinophilic esophagitis, the intensity of esophageal eosinophilia was less in Winter than in Summer or Fall, but not Spring, seasons.

A seasonal variation was noted with Winter, a season of low outdoor allergens, having the fewest number of newly diagnosed AEE patients.

Is there a seasonal variation in the incidence or intensity of allergic eosinophilic esophagitis in newly diagnosed children?

Some respiratory units routinely administer supplemental oxygen to all patients during flexible bronchoscopy, but other units give oxygen only to those who desaturate (arterial oxygen saturation [SaO(2)],<90%). We performed a study to examine both the requirement for supplemental oxygen and the effect of IV midazolam therapy on oxygenation during flexible bronchoscopy for patients with a known FEV(1). Data on the SaO(2) of patients during flexible bronchoscopy were collected prospectively for all procedures performed in our respiratory unit for the period 1992 to 1997. There were 1,051 flexible bronchoscopy procedures performed in which the patient had a known FEV(1) and was not receiving supplemental oxygen before the procedure. Supplemental oxygen was commenced during or immediately after the procedure in 151 cases (14.4%), while a further 101 cases (9.6%) had momentary desaturation (ie,<20 s) not requiring oxygen therapy. The lower the FEV(1), the greater the risk of significant desaturation and the need for supplemental oxygen (p<0.0001) [supplemental O(2) therapy was administered in 35% of cases if FEV(1)<1.0 L, in 14% of cases if FEV(1) was 1.0 to 1.5 L, and in 7% of cases if FEV(1)>1.5 L]. The use of low-to-moderate doses of midazolam as sedation did not affect the probability of the occurrence of significant desaturation (p = 0.204).

This study supports guidelines that suggest that all patients should be monitored by pulse oximetry during flexible bronchoscopy. Desaturation may occur at any FEV(1) level even without sedation. The majority of our patients did not require routine oxygen supplementation, especially the group with an FEV(1) above 1 L.

Do all patients require supplemental oxygen during flexible bronchoscopy?

To determine the frequency of coincident diagnoses of pregnancy and pelvic inflammatory disease (PID) in adolescents seeking care at a large urban children's hospital. All inpatient medical records for the period from January 1, 1984 through December 31, 1993 were searched for dual diagnoses of pregnancy and PID (presumed secondary to endometritis, salpingitis, or both). During this period, there were 1205 patients admitted for PID, 67 of whom were also pregnant. Ten of these 67 admissions were eliminated from this study because of incomplete or missing records, errors in diagnosis, or lack of proper examinations. The charts of the remaining 57 subjects were reviewed for demographics, physical findings, and laboratory studies. For the purposes of this study, a diagnosis of suspected PID was defined as lower abdominal tenderness, cervical motion tenderness, and adnexal tenderness ("major criteria"), as well as either a positive cervical specimen for Neisseria gonorrhoeae or Chlamydia trachomatis or adnexal fullness ("minor criteria"). The mean age of the 57 subjects was 16.8 years, and the mean gestational age was 6.7 weeks. Twenty-four (42.1%) of the subjects met the criteria for a concurrent diagnosis of PID and pregnancy; 13 had physical findings and a positive cervical specimen for either N. gonorrhoeae or C. trachomatis, and 11 subjects had the minor criteria of adnexal fullness. Twenty-six (45.6%) of the 57 subjects were primigravida, 35 (61.4%) had a history of a sexually transmitted disease, and 18 (31.6%) had been previously admitted to a hospital for PID.

This study found that PID and pregnancy can coexist in adolescents. Therefore, physicians who treat adolescents must consider the possibility of PID in pregnant adolescents presenting with abdominal pain.

The coincident diagnosis of pelvic inflammatory disease and pregnancy: are they compatible?

To assess the effects of joint consultation on referral behaviour of general practitioners (GPs) in a prospective cohort study. All patients with rheumatological complaints that 17 participating GPs, from the area of the University Hospital Maastricht, wanted to refer during a two year inclusion period (n=166) were eligible for inclusion. These patients were either referred to the outpatient clinic, or presented at a joint consultation held every six weeks at the practice of the GP, where groups of three GPs presented their patients to a visiting, consulting rheumatologist. The number of patients referred by each GP a year at the end of the trial, comparing participating and non-participating GPs, was the main outcome measure. During two years of inclusion, the 17 participating GPs presented 166 patients. The number of patients referred by each GP a year decreased for the participating GPs by 62% at the end of the whole study. By contrast, non-participating GPs maintained the same rate of referral. The range of diagnoses remained proportionally the same throughout the study, with the exception of fibromyalgia. The referral rate of this diagnosis decreased significantly (p=0.001).

Joint consultation seems to be a good strategy in influencing the referral behaviour of GPs in the area of rheumatology. The decrease in referral is substantial and can subsequently lead to a reduction of waiting lists.

Joint consultation of general practitioner and rheumatologist: does it matter?

Anatomic anal sphincter defects can involve the internal anal sphincter (IAS), the external anal sphincter (EAS), or both muscles. Surgical repair of anteriorly located EAS defects consists of overlapping suture of the EAS or EAS imbrication; IAS imbrication can be added regardless of whether there is IAS injury. The aim of this study was to assess the functional outcome of anal sphincter repair in patients intraoperatively diagnosed with combined EAS/IAS defects compared to patients with isolated EAS defects. The medical records of patients who underwent anal sphincter repair between 1988 and 2000 and had follow-up of at least 3 months were retrospectively assessed. Fecal incontinence was assessed using the Cleveland Clinic Florida incontinence score wherein 0 equals perfect continence and 20 is associated with complete incontinence. Postoperative scores of 0-10 were interpreted as success whereas scores of 11-20 indicated failure. A total of 131 women were included in this study, including 38 with combined EAS/IAS defects (Group I) and 93 with isolated EAS defects (Group II). Thirty-three patients (87%) in Group I had imbrication of a deficient IAS, compared to 83 patients (89%) in Group II. All patients had either overlapping EAS repair (n=121) or EAS imbrication (n=10). Mean follow-up was 30.9 months (range, 3-131 months). There were no statistically significant differences between the two groups relative to age (48.3 vs. 53.0 years; p=0.14), preoperative incontinence score (16.1 vs. 16.7; p=0.38), extent of pudendal nerve terminal motor latency pathology (left, 11.1% vs. 8%; p=0.58; right, 8.6% vs. 15.1%; p=0.84), extent of pathology at electromyography (54.8% vs. 60.1%; p=0.43), and length of follow-up (26.9 vs. 32.5 months; p=0.31). The success rates of sphincter repair were 68.4% for Group I versus 55.9% for Group II (p=NS). Both groups were well matched for incidence of IAS imbrication as well as age, follow-up interval, and physiologic parameters. The success rates of anal sphincter repair were not statistically significant between the two groups.

A pre-existing IAS defect does not preclude successful sphincteroplasty as compared to repair of an isolated EAS defect. Thus, patients with combined anal sphincter defects should not be considered as poor candidates for sphincter repair.

Do internal anal sphincter defects decrease the success rate of anal sphincter repair?

Opportunistic infections (OIs) are a dreaded adverse effect of immunosuppressive therapy, leading to the use of opportunistic infection prophylaxis (OIP) in many immunosuppressed conditions. However, guidelines for OIP in pemphigus are lacking. Our objective was to evaluate the approach of leading pemphigus experts towards OIP. We conducted an online survey of OIP trends. The survey was completed by 33 experts. Prior to initiation of immunosuppressive therapy, 75% routinely screened for hepatitis viruses, and at least half screened for HIV or tuberculosis. Most experts (76%) prescribed OIP but to <10% of their patients, and the most frequent drugs of choice were sulfamethoxazole/trimethoprim and acyclovir. Most experts agreed that treatment with three or more immunosuppressive agents or a previous history of OIs would lead to the use of OIP that was then discontinued with cessation of immunosuppression. The arguments against OIP were the lack of evidence for its necessity and concern about side effects or emergence of resistant pathogens. The surveyed experts treated patients with severe disease in a tertiary care setting, which may have led to an overestimation of the use of OIP. Infectious disease specialists were not included.

Substantial disparities exist in approaches to OIP for patients with pemphigus, including the decision to treat, type of treatment, and risk stratification among pemphigus experts.

Is There a Role for Opportunistic Infection Prophylaxis in Pemphigus?

A meta-analysis of randomized trials studying the effect of nonsteroidal anti-inflammatory drugs (NSAIDs) on blood pressure. Eight databases were searched, yielding 38 randomized, placebo-controlled trials and 12 randomized but not placebo-controlled trials (comparing two or more NSAIDs). Pooled mean treatment effects were computed in each trial for blood pressure, weight, creatinine clearance, plasma renin activity, and daily urinary excretion of sodium and prostaglandins. Meta-analyses of these variables were done for all randomized, controlled trials; for all randomized, uncontrolled trials; and for several subgroups. When pooled, NSAIDs elevated supine mean blood pressure by 5.0 mm Hg (95% CI, 1.2 to 8.7 mm Hg) but had no effect on variables other than blood pressure. Nonsteroidal anti-inflammatory drugs antagonized the antihypertensive effect of beta-blockers (blood pressure elevation, 6.2 mm Hg; CI, 1.1 to 11.4 mm Hg) more than did vasodilators and diuretics. Among NSAIDs, piroxicam produced the most marked elevation in blood pressure (6.2 mm Hg; CI, 0.8 to 11.5 mm Hg), whereas sulindac and aspirin had the least hypertensive effect.

Nonsteroidal anti-inflammatory drugs may elevate blood pressure and antagonize the blood pressure-lowering effect of antihypertensive medication to an extent that may potentially increase hypertension-related morbidity. Although certain NSAIDs and antihypertensive agents could be more likely to produce these effects, the underlying mechanisms require further study.

Do nonsteroidal anti-inflammatory drugs affect blood pressure?

The purpose of this study was to examine whether fetal outcome in twin pregnancies is dependent on zygosity or chorionicity. This was a prospective observational study comprised of women with twin pregnancies who attended the fetal medicine unit at St Michael's Hospital, Bristol, Ireland, during the years 1998 to 2000 and who were delivered in hospitals in south west England. After delivery, zygosity was determined with umbilical cord blood with the use of microsatellite markers that were amplified by polymerase chain reaction. Placentae were examined histologically for chorionic type. The perinatal outcomes of 3 groups of monozygotic monochorionic, monozygotic dichorionic, and dizygotic pregnancies were compared with the use of the Mann-Whitney U test and the Fisher's exact test. All 92 dizygotic and 15 monozygotic dichorionic pregnancies resulted in live births. In 7 of the 39 cases in the monozygotic monochorionic group, either both twins were not live born or delivery occurred<24 weeks of gestation. The gestational age at delivery and birth weight were significantly lower, and there were a greater number of cases with birth weight discordancy of>25% in the monochorionic pregnancies compared with the other 2 groups (P<.05). There were no significant differences in any of the study parameters between the monozygotic dichorionic and dizygotic groups.

Fetal outcome in twin pregnancies is related to chorionicity rather than zygosity.

Is zygosity or chorionicity the main determinant of fetal outcome in twin pregnancies?

The Nordic countries, profiled as welfare states, are shown to have comparatively large relative socio-economic differences in mortality and comparatively high intergenerational mobility. The aim of this study was to analyse the role of risk indicator-associated social mobility (from childhood through to adulthood) in socio-economic mortality differences among Swedish men aged 35-50 years. We used data on risk indicators for adult mortality (risk use of alcohol, smoking, low emotional control, psychiatric diagnosis, medication for nervous problems, contact with police and child care, experience of unemployment, low body height, low education) collected at compulsory conscription for military training among Swedish men at aged 18-20, fathers' socio-economic status at subjects' ages 9-11 years, data on subjects' socio-economic status at ages 34-36 years, and follow-up data on mortality during 1986-1999 (at ages 35-50 years). Persons in manual occupations in 1985 showed an elevated relative risk (RR) of mortality compared with stable non-manual employees regardless of the social position of their father (RR 1.75 among stable manual workers, and RR 1.74 among the downwardly mobile). In multivariate analyses, taking into account the risk indicators first operating in late adolescence, the increased mortality risk among stable manual workers and also among the downwardly mobile diminished considerably (RR 1.32 and 1.39, respectively).

These results suggest that a substantial part of the socio-economic differences in mortality among middle-aged men had their origin in childhood circumstances. Risk indicator-associated social mobility was found to contribute substantially to an increase in the relative difference in mortality between male manual workers and non-manual employees.

Can large relative mortality differences between socio-economic groups among Swedish men be explained by risk indicator-associated social mobility?

A randomized clinical trial. To compare the effectiveness of a behavioral graded activity program with manual therapy in patients with subacute (4-12 weeks) nonspecific neck pain. Neck pain is a common complaint, for which many conservative therapies are available in primary care. There is strong evidence for manual therapy in combination with exercises. Psychosocial factors are also believed to play a role in chronic pain. The evidence of the effectiveness of a program focused on these factors is still unknown. A randomized clinical trial was conducted, involving 146 patients with subacute nonspecific neck pain. The BGA program can be described as a time-contingent increase in activities from baseline toward predetermined goals. Manual therapy consists of specific spinal mobilization techniques and exercises. Primary outcomes were global perceived effect, the Numerical Rating Scale for pain and the Neck Disability Index. Secondary outcomes were the Tampa Scale for Kinesiophobia, the 4 Dimensional Symptom Questionnaire, and the Pain Coping and Cognition List. Measurements were carried out at baseline and 6, 13, 26, and 52 weeks after randomization. Data are analyzed according to the intention-to-treat principle, using multilevel analysis. The success rates at 52 weeks, based on the GPE were 89.4% for the BGA program and 86.5% for MT. This difference was not statistically significant. For pain and disability, a difference was found in favor of the BGA program; mean difference for pain = 0.99 (95% CI 0.15-1.83) and mean difference for NDI = 2.42 (95% CI 0.52-4.32). All other differences between the interventions in the primary and secondary outcomes were not statistically significant.

Based on this trial it can be concluded that there are only marginal, but not clinically relevant, differences between a BGA program and MT.

Is a behavioral graded activity program more effective than manual therapy in patients with subacute neck pain?

Pancreatic endocrine tumors (PETs) and intraductal papillary mucinous neoplasms (IPMNs) of the pancreas are rare diseases of the pancreas. Cases of association of endocrine and exocrine neoplasms of the pancreas have been reported, corresponding to mixed or amphicrine tumors. The aim of this report is to describe a series of 6 patients with an original association of IPMN and PET of the pancreas. Among 108 and 103 patients operated on in our center between January 1997 and December 2003 for PETs and IPMNs, respectively, we identified 6 patients with both PET and IPMN, diagnosed on pathologic examination with an immunohistochemical study. Preoperative diagnosis was unspecified pancreatic tumor (n = 1), IPMN (n = 2), and association of PET and IPMN (n = 3). IPMN involved the main pancreatic duct in 4 patients and was classified as benign (n = 4), borderline (n = 1), or malignant noninvasive (n = 1). PETs measured 1.1 to 3 cm and were malignant in 1 patient (lymph node invasion). When analyzed by immunohistochemistry, 2 cases expressed glucagon, 1 expressed somatostatin, and 1 expressed insulin.

This study describes a new aspect of endocrine-exocrine pancreatic neoplasm association. The frequency of the association of PET and IPMN is too large to be fortuitous. Further studies are needed to understand its mechanism.

Endocrine tumor and intraductal papillary mucinous neoplasm of the pancreas: a fortuitous association?

FAIRness (Feedback, Activity, Individualisation, Relevance) teaching is a structured program, comprising series of classes in which student work is anonymised and reviewed by the whole class, as well as students receiving private feedback on their written work. The class work emphasises logic, structure and order in history and examination, with a diagnostic and management focus.AIM: The effect of FAIRness teaching methods on the adaptation of medical students entering their first clinical rotations was studied. 18 students in FAIRness placements and 72 students in conventional placements, all in medical/surgical units in the same University teaching hospital were studied. They completed questionnaires relating to effectiveness and quality of clinical teaching. Some students additionally attended focus groups, at the start of placement to discuss their expectations, and after 3 weeks, to discuss their adaptation to the clinical learning environment. All students entering clinical placements had low expectations of their future teaching. Students in standard placements still expressed negative attitudes after 3 weeks, while students on FAIRness placements felt positive. Students in FAIRness placements scored significantly higher on questions related to feedback and review of student work.

FAIRness teaching practices help students to adapt to their first clinical placements.

First impressions count: does FAIRness affect adaptation of clinical clerks in their first clinical placement?

Lumbar spondylosis (LS) is a common spinal degenerative disorder which causes various types of lower urinary tract dysfunction (LUTD). However, it is not certain whether LS may cause urinary retention in elderly women. In a period covering the past 3 years, we retrospectively reviewed: a) urodynamic case records of women with urinary retention (post-void residuals, PVR>100 ml), b) the records of women with LUTD due to LS (cauda equina syndrome and spinal canal narrowing by MRI), and c) uro-neurological features of women who belonged to both a) and b). a) One-hundred women with a mean age of 58 years had urinary retention. The most common underlying disease was multiple system atrophy [19], followed by multiple sclerosis [13]and cervical/thoracic tumours [8]. LS was the fourth most common [5], with the highest age (71 years) of all diseases. b) Nineteen women with LUTD had LS (12, canal narrowing of 50-70%; 7>70 %), with a mean PVR volume of 60 ml. A fourth [5] of them had urinary retention, with severe spinal canal narrowing (all 5>70%). c) Thus, 5 women belonged to both a) and b). In 4 of these women, LUTD followed or occurred together with typical cauda equina syndrome symptoms such as sciatica and saddle anesthesia. However, one elderly woman presented with painless urinary retention, and absent ankle reflexes were the sole neurological abnormality. The urodynamic abnormalities underlying urinary retention included an underactive detrusor in all 5, bladder sensory impairment in 3, an unrelaxing sphincter in 2, a low compliance detrusor in one, neurogenic sphincter motor unit potentials in 2 of 4 studied, and cholinergic supersensitivity of the detrusor in one of 3 studied. Surgical decompression ameliorated urinary retention in 1 of 2 women who had surgery.

In our series, only 5 percent of the women with urinary retention had LS, but LS poses a potential risk for retention, particularly in elderly women with severe spinal canal narrowing. Preganglionic somato-autonomic dysfunctions underlie this condition. It may appear as the sole initial complaint in cases in which no other obvious neurological abnormalities are found.

Is lumbar spondylosis a cause of urinary retention in elderly women?

Distal radius fractures are very common upper limb injuries irrespective of the patient's age. The aim of our study is to evaluate the reliability of the three systems that are often used for their classification (AO - Arbeitsgemeinschaft für Osteosynthesefragen/Association for the Study of Internal Fixation, Fernandez and Universal) and to assess the need for computed tomography (CT) scan to improve inter- and intra-observer agreement. Five orthopaedic surgeons and two hand surgeons classified radiographs and CT scans of 26 patients using the Fernandez, AO and Universal systems. All data were recorded using MS Excel and Kappa statistics were performed to determine inter- and intra-observer agreement and to evaluate the role of CT scan. Fair-to-moderate inter-observer agreement was noted with the use of X-rays for all classification systems. Intra-observer reproducibility did not improve with the addition of CT scans, especially for the senior hand surgeons.

The agreement rates observed in the present study show that currently there is no classification system that is fully reproducible. Adequate experience is required for the assessment and treatment of these injuries. CT scan should be requested only by experienced hand surgeons in order to help guide treatment, as it does not significantly improve inter- and intra-observer agreement for all classification systems.

Does the CT improve inter- and intra-observer agreement for the AO, Fernandez and Universal classification systems for distal radius fractures?

The prevalence of the "bovine" arch in the population is known (8-25%). However, its prevalence in patients with significant carotid atherosclerosis has never been investigated. Altered flow patterns or turbulence that may occur in these patients may play a causative role in the development of atherosclerotic lesions. The primary purpose of this study was to retrospectively compare the prevalence of aortic arch variants in patients with and without significant carotid artery atherosclerosis, as we hypothesize that carotid atherosclerosis may be more prevalent in patients with a bovine arch due to hemodynamic alterations. A secondary objective was to review radiologist reporting of arch anatomy. Single-center, retrospective, case-control study in which 79 patients with hemodynamically significant carotid artery atherosclerosis who underwent computed tomography angiography, magnetic resonance angiography, or unenhanced computed tomography (CT) imaging including the aortic arch were identified. These patients were then compared with 95 randomly selected controls without carotid atherosclerosis that underwent similar imaging during the same time period. Images were independently reviewed by two blinded radiologists, who assessed arch anatomy as normal, bovine, or other variant. The original radiology reports were reviewed for reporting of arch anatomy. In controls, 70% had normal arch anatomy, and 24% had a bovine arch. Among patients with significant carotid disease, these numbers were 70% and 20%, respectively. There was no statistically significant difference between incidence of arch variants in subjects with and without carotid artery atherosclerosis (P=.97). There was good interreader agreement. Among patients with aortic arch anomalies, 20% of the original radiology reports did not mention arch anatomy.

In our experience, percentage of bovine arch anomalies in patients with significant carotid atherosclerosis is not significantly different from those without disease. Clinicians should be aware of the high prevalence of arch anomalies, which can impact endovascular approach and management, and radiologists should be aware of the clinical importance of reporting such variants.

Bovine arch and carotid artery atherosclerosis: are they related?

This cross-sectional survey study examines the link between ADHD medication misuse and a positive screen for adult ADHD symptoms. Surveys from 184 college student volunteers in Northern Virginia are collected and analyzed. A total of 71% of ADHD stimulant misusers screen positive for ADHD symptoms. Misusers are 7 times more likely to be symptomatic for ADHD than those who do not misuse. Also, 87% of misusers indicate that they do so for academic reasons, and 76% believe that the misuse of the ADHD stimulants improve their grades.

ADHD stimulant misuse in college students is found to be strongly linked to having symptoms of adult ADHD. The desire for cognitive performance enhancement in college students may be a form of self-treatment for undiagnosed ADHD. College students need more accessibility to medical diagnosis and treatment of adult ADHD to reduce the incidence of misuse in the future.

Cognitive performance enhancement: misuse or self-treatment?

Questionnaires are usually used for the measurement of patient satisfaction, however, it is increasingly being recognized that the critical incident technique (CIT) also provides valuable insight. Questionnaires of the "Hamburger questionnaire on hospital stay" were distributed to 650 consecutive patients before discharge. Additionally 103 interviews were conducted in which the patients were asked to describe positive and negative incidents during their hospital stay. The results of both methods were then compared. A total of 369 patients returned the questionnaire and 103 patients participated in the interviews. The duration of a single interview was between 5 and 45 min with a mean of 12.7 min+/-10.1 min standard deviation (SD). Cronbach's alpha of the questionnaire was 0.9. A total of 424 incidents were reported, 301 of them were negative compared to 123 positive events. The questionnaires and interviews yielded partly similar and partly different results at category and subcategory levels concerning the areas of weaknesses and strengths in quality performance. The CIT was more concrete but did not give results for all aspects of quality. The CIT, but not the questionnaire, was able to detect 40/56 (71%) of the positive and 33/75 (44%) of the negative reports regarding medical performance and 25/42 (60%) of the positive and 15/51 (29.4%) of the negative reports of the performance of the nurses were revealed by the CIT and not by the questionnaires.

The CIT gives valuable insights into the patient's perspective of strengths and weaknesses in hospital care, which might be overlooked by the questionnaire alone. However, the CIT is probably not suited for routine use because it is very time-consuming.

Patient satisfaction in hospital: critical incident technique or standardised questionnaire?

The current project undertook a province-wide survey and environmental scan of educational opportunities available to future health care providers on the topic of intimate partner violence (IPV) against women. A team of experts identified university and college programs in Ontario, Canada as potential providers of IPV education to students in health care professions at the undergraduate and post-graduate levels. A telephone survey with contacts representing these programs was conducted between October 2005 and March 2006. The survey asked whether IPV-specific education was provided to learners, and if so, how and by whom. In total, 222 eligible programs in dentistry, medicine, nursing and other allied health professions were surveyed, and 95% (212/222) of programs responded. Of these, 57% reported offering some form of IPV-specific education, with undergraduate nursing (83%) and allied health (82%) programs having the highest rates. Fewer than half of undergraduate medical (43%) and dentistry (46%) programs offered IPV content. Postgraduate programs ranged from no IPV content provision (dentistry) to 41% offering content (nursing).

Significant variability exists across program areas regarding the methods for IPV education, its delivery and evaluation. The results of this project highlight that expectations for an active and consistent response by health care professionals to women experiencing the effects of violence may not match the realities of professional preparation.

Are clinicians being prepared to care for abused women?

Adult intussusception is a rare clinical entity in contrast to pediatric intussusception. Varied and non-specific clinical features, delayed presentation, and lack of awareness among attending surgeons to consider it as differential diagnosis complicates the clinical course of the disease. A retrospective study was conducted in a tertiary care teaching hospital in north India. Nine adult patients who presented with intussusception over a period of six years were analyzed. Their clinical profile, management and underlying pathology were studied. Five out of nine patients had acute presentation while remaining four presented with subacute/chronic symptoms. Median duration of presentation was 8 days (range 2-180 days). Clinical diagnosis of intussusception was considered in only one patient. Ultrasonography clinched the diagnosis in all four patients who presented with subacute/chronic symptoms. Ileo-ileal intussusception was present in five patients, with one having associated jejuno-jejunal intussusception. Other four patients had ileo-colic intussusception. Seven of the 9 patients (77%) were found to have associated bowel gangrene. Resection of the bowel segment having intussusception was done in all patients. Five patients had associated benign intestinal pathology while idiopathic intussusception was present in four patients.

The patients presented in the series are distinct from cases reported earlier in literature in term of late presentation, manifesting as acute intestinal obstruction, high frequency of associated intestinal gangrene, and absence of associated intestinal malignancy. Patients presenting with features of intestinal obstruction and abdominal lump should be subjected to urgent imaging studies to examine the possibility of intussusception. The high frequency of bowel gangrene encountered in patients of adult intussusception mandates prompt surgical intervention soon after diagnosis.

Adult intussusception: is associated bowel gangrene common?

While low back pain (LBP) and neck pain (NP) have been extensively studied, knowledge on mid back pain (MBP) is still lacking. Furthermore, pain from these three spinal areas is typically studied or reported separately and in depth understanding of pain from the entire spine and its consequences is still needed. To describe self-reported consequences of pain in the three spinal regions in relation to age and gender. This was a cross-sectional postal survey, comprising 34,902 twin individuals, representative of the general Danish adult population. The variables of interest in relation to consequences of spinal pain were: Care-seeking, reduced physical activity, sick-leave, change in work situation, and disability pension. Almost two-thirds of individuals with spinal pain did not report any consequence. Generally, consequences due to LBP were more frequently reported than those due to NP or MBP. Regardless of area of complaint, care seeking and reduced physical activities were the most commonly reported consequences, followed by sick-leave, change of work, and disability pension. There was a small mid-life peak for care-seeking and a slow general increase in reduced activities with increasing age. Increasing age was not associated with a higher reporting of sick-leave but the duration of the sick-leave increased somewhat with age. Disability pension due to spinal pain was reported exceedingly rare before the age of 50. Typically, women slightly more often than men reported some kind of consequences due to spinal pain.

Most people reporting spinal pain manage without any serious consequences. Low back pain more commonly results in some kind of consequence when compared to NP and MBP. Few age-related trends in consequences were seen with a slight predominance of women reporting consequences.

Consequences of spinal pain: do age and gender matter?

Previous studies have reported that the alignments of the occipital-cervical and subaxial spine were closely interrelated in asymptomatic individuals; however, none have focused on a population with atlantoaxial dislocation. From 2007 to 2011, 298 patients with atlantoaxial dislocation and atlas occipitalization were studied. Angles formed between Occiput-C2 and C2-C7 were measured. The relationship between the alignment of the occipital-cervical junction and the subaxial cervical spine was evaluated. The range of values for the angles measured was as followed: the Occiput-C2 angles were -35.2° to 44.8°, and the C2-C7 angles were -17.4° to 77.8°. Statistically significant negative correlations were observed between the Occiput-C2 and C2-C7 angles.

Anterior dislocations of the atlas are associated with diminished lordosis or even kyphosis of the occipital-cervical junction, and result in compensatory hyperlordosis of the subaxial cervical spine, collectively presenting as a "swan neck" deformity. Atlantoaxial dislocation may influence the global cervical alignment.

Does atlantoaxial dislocation influence the subaxial cervical spine?

As issues of health care cost escalation and parity of payment between primary care and other physicians have become more important, one proposal has been to eliminate consultation codes. Little is known about the current payment accuracy or financial impact of such a change. To assess the impact of consultation code elimination, 2 assessments were conducted. First, from June 1, 2008, to July 1, 2009, 500 consecutive referrals from primary care physicians to other specialists were reviewed and matched with claims for accuracy of coding and billing. Second, to evaluate the financial impact of this change, year 2007 data on outpatient consultations from the Centers for Medicare and Medicaid Services were reviewed. Of the 500 claims reviewed, 466 were appropriate for analysis. Overall, the coding error rate was 32.4%. When the requesting physician ordered a consultation, the error rate was 5.5%; however, with lower paid referral requests, the error rate was 78.0%. Changing ambulatory consultation codes to those for new patient visits would save Medicare $534.5 million per year.

Consultation codes are being billed erroneously at a high rate. Furthermore, the differential cost to Medicare of these codes over those for new patient evaluation and management codes is over half a billion dollars per year. With the growing needs for cost savings as well as encouraging payment parity for cognitive services for primary care physicians, it is time these codes are reevaluated.

Is it time to eliminate consultation codes?

To evaluate the correlation between the levels of anti-mullerian hormone and body mass index between obese and non-obese premenopausal women. Serum anti-mullerian hormone levels of women younger than 45 years admitted to our reproductive endocrinology clinic for investigation of infertility were examined in this cross-sectional study. Body mass indices were lower than 30 kg/m(2) in 222 patients and equal to or higher than 30 kg/m(2) in 37 patients. Levels of antimullerian hormone were analyzed in each group. Blood samples obtained from study subjects were assayed for levels of anti-mullerian hormone, follicle-stimulating hormone, luteinizing hormone, estradiol, prolactin and thyroid stimulating hormone. There was no significant difference in terms of mean age between the two groups. There was no statistically significant difference between these two groups in terms of FSH, LH, estradiol and prolactin levels. Anti-mullerian hormone levels were 3.46 ± 2.79 ng/ml and 3.79 ± 2.93 ng/ml in non-obese and obese participants, respectively. No statistically significant correlation was found between Anti Müllerian Hormone (AMH) levels and BMI levels in either group (P > 0.05).

Body mass index does not have an effect on serum AMH levels in women of reproductive age. Obesity has no association with levels of serum follicle stimulating hormone, luteinizing hormone, estradiol, prolactin and thyroid stimulating hormone. Obesity is unlikely to affect ovarian reserve in the premenopausal age group.

Is there any correlation between amh and obesity in premenopausal women?

Previous research has shown that sicker patients are less satisfied with their healthcare, but specific effects of adverse health outcomes have not been investigated. The present study aimed to assess whether patients who experience adverse outcomes, in hospital or after discharge, differ in their evaluation of quality of care compared with patients without adverse outcomes. In hospital adverse outcomes were prospectively recorded by surgeons and surgical residents as part of routine care. Four weeks after discharge, patients were interviewed by telephone about the occurrence of post-discharge adverse outcomes, and their overall evaluation of quality of hospital care and specific suggestions for improvements in the healthcare provided. Of 2145 surgical patients admitted to the Leiden University Medical Center in 2003, 1876 (88%) agreed to be interviewed. Overall evaluation was less favourable by patients who experienced post-discharge adverse outcomes only (average 19% lower). These patients were also more often dissatisfied (OR 2.02, 95% CI 1.24 to 3.31) than patients without adverse outcomes, and they more often suggested that improvements were needed in medical care (OR 2.07, 1.45 to 2.95) and that patients were discharged too early (OR 3.26, 1.72 to 6.20). The effect of in hospital adverse outcomes alone was not statistically significant. Patients with both in hospital and post-discharge adverse outcomes also found the quality of care to be lower (on average 33% lower) than patients without adverse outcomes.

Post-discharge adverse outcomes negatively influence patients' overall evaluation of quality of care and are perceived as being discharged too early, suggesting that patients need better information at discharge.

Surgical adverse outcomes and patients' evaluation of quality of care: inherent risk or reduced quality of care?

Aiming to reduce the numbers of high risk autopsies, we use a minimally invasive approach. HIV/hepatitis C virus (HCV)-positive coronial referrals, mainly intravenous drug abusers, have full autopsy only if external examination, toxicology and/or postmortem CT scan do not provide the cause of death. In this study, we review and validate this protocol. 62 HIV/HCV-positive subjects were investigated. All had external examination, 59 toxicology and 24 CT. In 42/62, this minimally invasive approach provided a cause of death. Invasive autopsy was required in 20/62, CT/toxicology being inconclusive, giving a potential rather than definite cause of death. Autopsy findings provided the cause of death in 6/20; in the remainder, a negative autopsy allowed more weight to be given to toxicological results previously regarded as inconclusive. In order to validate selection of cases for invasive autopsy using history, external examination and toxicology, a separate group of 57 non-infectious full autopsies were analysed. These were consecutive cases in which there was a history that suggested drug abuse. A review pathologist, provided only with clinical summary, external findings and toxicology, formulated a cause of death. This formulation was compared with the original cause of death, based on full autopsy. The review pathologist correctly identified a drug-related death or requirement for full autopsy in 56/57 cases. In one case, diagnosed as cocaine toxicity by the review pathologist, autopsy additionally revealed subarachnoid haemorrhage and Berry aneurysm.

These findings support the use of minimally invasive techniques in high risk autopsies, which result in a two-thirds reduction in full postmortems.

High risk medicolegal autopsies: is a full postmortem examination necessary?

This study was designed to evaluate the prognostic significance of various prognostic factors affecting recurrence after resection of colorectal hepatic metastases. Records of 54 patients who had hepatic resection between 1986 and 1993 for metastatic liver tumor from colorectal cancer were reviewed. Factors analyzed were those reported to be of prognostic significance in other studies, including gender, primary tumor site, Dukes stage, diagnostic interval, grade, preoperative carcinoembryonic antigen (CEA) level, number of metastases, size of metastases, distribution of metastases, type of resection, resection margin, and estimated blood loss. Average follow-up of surviving patients was 28 (range, 12-89) months. Average survival time from date of hepatic resection was 26 months, with an estimated actuarial survival rate of 25.5 percent at five years. Using the multivariate analysis of factors, gender and preoperative CEA level were shown to be significantly related to overall survival (P = 0.0455 and 0.054, respectively). Cancer of the right side colon had significant correlation with hepatic "recurrence" (P = 0.0071).

Female patients and those with peroperative CEA values higher than 20 ng/ml have a better chance of survival following hepatic resection. Cancer of the right colon has a greater tendency for hepatic recurrence than that of the left colon.

Resection of liver metastases from colorectal cancer: are there any truly significant clinical prognosticators?

To investigate the mechanism of pressure related ventricular arrhythmias by examining them during atrioventricular (AV) block. Complete AV block, where all ventricular beats are ectopic, was induced by AV node ablation and/or by toxic digitalisation, and rhythm changes were studied while arterial blood pressure was repeatedly raised and lowered. 15 anaesthetised mongrel dogs, weight 15-28 kg, were used. AV block was induced in eight by chemical or mechanical ablation of the AV node. In five of these and in seven other dogs, 5.0-7.5 mg digoxin was also given. Following AV block due to ablation, a heart rate increase (or no change) was found in 87.5% of 56 arterial pressure increases produced by elevation of an open arterial blood reservoir or by metaraminol infusion, but in only 21.8% of 55 pressure decreases caused by arterial bleeding (p much less than 0.001). Following AV block due to digitalisation, the equivalent figures were 96% of 50 pressure increases and 27.3% of 55 pressure decreases (p much less than 0.001). While arterial pressure was increased there was moderate acceleration of the escape rhythm, then appearance of premature ventricular beats, then non-sustained and finally sustained ventricular tachycardia. The reverse occurred, with some hysteresis, on decreasing the arterial pressure. In five of the digitalised animals, arterial pressure reduction to nearly zero caused reproducible sudden arrest, with resumption of the ordinary escape rhythm on increasing the pressure again.

The findings suggest the possibility of two kinds of ectopic rhythm in AV block: the "normal" escape rhythm which is only moderately affected by arterial pressure changes; and an "abnormal" faster pressure dependent rhythm which is generated by high arterial pressure and abolished by pressure near zero, as if there were a mechano-electrical association. This abnormal rhythm may prevail completely in digitalis toxicity so that if cardiac arrest occurs, no automaticity can be expected to appear unless arterial pressure is raised.

Response of tertiary centres to pressure changes. Is there a mechano-electrical association?

Feeling stigmatized or having comorbid depression in a PWE may significantly influence epilepsy care and treatment. An important contributory factor to this can be the expressed emotions (EEs) from family, friends, or society. The present study aimed at understanding the influence of EEs, as exhibited by close relatives, on the perception of stigma and comorbid depression experienced by PWEs. Eighty PWEs aged 18 years and above, both genders, visiting neurology OPD in AIIMS Hospital, were recruited. Using the PHQ-09, we subdivided them into Group I (PWEs with comorbid depression) and Group II (PWEs without comorbid depression), followed by administration of Levels of Expressed Emotions Scale and Stigma Scale for Epilepsy, respectively. The comparative analysis, using independent t-test (for categorical data), Pearson's correlation (for continuous data), and multivariate regression analysis, reflected significant influence of EEs on depression and stigma, with more than 20% of the participants reporting comorbid depression, out of which more than 50% further expressed feelings of inferiority or disgrace due to the ways in which family or society discriminated them from healthy persons, thereby highlighting a greater associations of high EEs as opposed to low EEs from key individuals on patients' perception of stigma or feeling of depression.

The result suggested that EEs from a relative might go unnoticed but may significantly overwhelm the patient, thereby making him succumb to depression or feeling stigmatized. The analysis of such a clinical profile and relationship between EEs and perceived stigma/depression may help us understand the pattern of attribution styles adopted by PWEs, thereby utilizing it further for enhancing the efficacy of cognitive-behavioral therapy for facilitating sustained recovery and improved quality of life for PWEs.

Do expressed emotions result in stigma?

We determine the incidence and characteristics of adrenal involvement in localized and advanced renal cell carcinoma, and evaluate the role of adrenalectomy as part of radical nephrectomy. The records of 511 patients undergoing radical nephrectomy with ipsilateral adrenalectomy for renal cell carcinoma at our medical center between 1986 and 1998 were reviewed. Mean patient age was 63.2 years (range 38 to 85), and 78% of the subjects were males and 22% were females. Patients were divided into subgroups of 164 with localized (stage T1-2 tumor, group 1) and 347 with advanced (stage T3-4N01M01, group 2) renal cell carcinoma. Staging of tumors was performed according to the 1997 TNM guidelines. A retrospective review of preoperative computerized tomography (CT) of the abdomen was performed. Radiographic findings were subsequently compared to postoperative histopathological findings to assess the predictive value of tumor characteristics and imaging in determining adrenal metastasis. Of the 511 patients 29 (5.7%) had adrenal involvement. Average size of the adrenal tumor was 3.86 cm. (standard deviation 1.89). Tumor stage correlated with probability of adrenal spread, with T4, T3 and T1-2 tumors accounting for 40%, 7.8% and 0.6% of cases, respectively. Upper pole intrarenal renal cell carcinoma most likely to spread was local extension to the adrenal glands, representing 58.6% of adrenal involvement. In contrast, multifocal, lower pole and mid region renal cell carcinoma tumors metastasized hematogenously, representing 32%, 7% and 4% of adrenal metastasis, respectively. The relationship between intrarenal tumor size (mean 8.9 cm., range 3 to 17) and adrenal involvement (independent of stage) was not statistically significant. Renal vein thrombus involvement was demonstrated in 8 of 12 cases (67%) with left and 2 of 9 (22%) with right adrenal involvement. Preoperative CT demonstrated 99.6% specificity, 99.4% negative predictive value, 89.6% sensitivity and 92.8% positive predictive value for adrenal involvement by renal cell carcinoma.

With a low incidence of 0.6%, adrenal involvement is not likely in patients with localized, early stage renal cell carcinoma and adrenalectomy is unnecessary, particularly when CT is negative. In contrast, the 8.1% incidence of adrenal involvement with advanced renal cell carcinoma supports the need for adrenalectomy. Careful review of preoperative imaging is required to determine the need for adrenalectomy in patients at increased risk with high stage lesions, renal vein thrombus and upper pole or multifocal intrarenal tumors. With a negative predictive value of 99.4%, negative CT should decrease the need for adrenalectomy. In contrast, positive findings are less reliable given the relatively lower positive predictive value of this imaging modality. Although such positive findings may raise suspicion of adrenal involvement, they may not necessarily indicate adrenalectomy given the low incidence, unless renal cell carcinoma with risk factors, such as high stage, upper pole location, multifocality and renal vein thrombus, is present.

Is adrenalectomy a necessary component of radical nephrectomy?

To evaluate whether patients with a higher body mass index (BMI) are at elevated risk of an advanced tumor stage for renal cell carcinoma at diagnosis. A high BMI has recently been proved to be associated with advanced tumor stages for some malignant diseases. From January 1994 to December 2000, 693 operations for renal cell carcinoma were performed in 683 patients at our institution. Ten patients underwent surgery twice for bilateral tumors. Of the 683 patients, 417 were men and 266 women. The mean age at surgery was 62.2 years, and the mean tumor diameter was 5.2 cm. Seventy-eight percent of the patients were asymptomatic at tumor diagnosis. The following parameters were evaluated with regard to a possible correlation to tumor stage and/or tumor diameter: BMI, presence of symptoms, age, sex, hemoglobin, lactate dehydrogenase, erythrocyte sedimentation rate, serum cholesterol, and triglycerides. For statistical analysis, the Spearman rank correlation test was used. The mean BMI was 26.8 +/- 4.4 (range 16.9 to 44.3). Statistical analysis showed a significant positive correlation between advanced T stage and the presence of symptoms (P<0.0001), erythrocyte sedimentation rate (P<0.0001), lactate dehydrogenase (P = 0.0015), and age (P = 0.046), and an inverse correlation with hemoglobin (P<0.0001) and serum cholesterol (P<0.0001). For all other investigated parameters, including BMI, no significant correlation could be proved.

Our data indicate that obese patients are not at greater risk of advanced tumor stages of renal cell carcinoma at the time of diagnosis compared with a population of normal weight.

Do patients with a higher body mass index have a greater risk of advanced-stage renal cell carcinoma?

This study investigated the effect of breastfeeding on cardio respiratory fitness (CRF) in students of Kermanshah, Iran. In this retrospective cohort study, 246 students with the mean ± SD age of 7.28 ± 0.50 years, mean breastfeeding ± SD duration of 8.20 ± 10.26 months, and body mass index (BMI) of 16.96 ± 3.03 kg/m(2) participated. Students had no CVD, liver or kidney diseases. Children were categorized in three groups of over 6 months breast-fed (>6 months group), less than 6 months breast-fed (≤6 months group), and formula group. The physician measured CRF calculating VO2 max; and reported the results as fitness or no fitness. The probable confounders were gender, BMI, fat-free mass, fat mass, mother's BMI, dietary Poly Unsaturated Fatty Acid (PUFA) and folate, beginning time of supplementary nutrition, physical activity, and birth weight. Breastfeeding more than 6 months was positively associated with CRF (p value < 0.001) before and after adjustment for confounders. The risk ratio (RR) of no CRF was 3.22 times more than>6 months group. VO2 max (ml/kg/min) was significantly the highest in>6 months group (p value = 0.001).

Breastfeeding more than 6 months has positive effects on CRF, and the early nutrition may be a predictor for adolescence physical health.

Is exclusive breastfeeding and its duration related to cardio respiratory fitness in childhood?

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

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

Should Transcatheter Aortic Valve Replacement Be Performed in Nonagenarians?

The true impact of postoperative blood pressure (BP) control on development of aortic regurgitation (AR) following continuous-flow left ventricular assist device (CF-LVAD) implantation remains uncertain. This study examines the influence of BP in patients with de novo AR following CF-LVAD implantation. All patients with no or<mild AR who underwent CF-LVAD implantation from July 2006 to July 2012 at our institute and with subsequent device-support of ≥3months (n = 90) were studied. Serial echocardiograms and BP readings were obtained preoperatively, postoperatively at 1, 3 and 6 months, and then at a minimum of 4-monthly intervals. BP readings were compared between patients who developed mild AR (AR group) versus those who did not (non-AR group). Logistic regression analysis was used to define independent predictors of ≥mild AR following CF-LVAD implantation. Median duration of CF-LVAD support was 575 days (range: 98-2433 days). Forty-eight patients (53.3%) developed mild AR over a median duration of 126 days. BP readings (median values, mmHg) between AR and non-AR groups showed statistically significant differences: at 3 months-systolic 99.5 vs 92.5 (P = 0.038), diastolic 81.5 vs 66 (P<0.001), mean 86.5 vs 74 (P<0.001) and at 6 months-diastolic 73 vs 62 (P = 0.044), mean 83 vs 74.5 (P = 0.049), respectively. Systolic BP at 3 months (P = 0.047, 95% CI 0.453-0.994, OR 0.671), aortic valve (AoV) closure (P = 0.01, 95% CI 0.002-0.429, OR 0.029) and duration of support (P = 0.04, 95% CI 1.000-1.009, OR 1.004) were found to be independent predictors of AR following CF-LVAD implantation.

BP readings at 3 months and 6 months showed a statistically significant association with ≥mild AR following CF-LVAD implantation, with systolic blood pressure at 3 months, aortic valve closure and longer support duration being independent predictors. Clinical implications of these data may warrant consideration of aggressive early control of BP to protect against the development/progress of AR following CF-LVAD implantation.

Does postoperative blood pressure influence development of aortic regurgitation following continuous-flow left ventricular assist device implantation?

Recent preclinical basic science studies suggest that patient tumor immunity is altered by general anesthesia (GA), potentially worsening cancer outcomes. A single retrospective review concluded that breast cancer patients receiving paravertebral block and GA had better cancer outcomes compared with patients receiving GA alone. This study has not been validated. We hypothesized that local or regional anesthesia (LRA) would be associated with better cancer outcomes compared with GA. We retrospectively reviewed a prospectively collected database to identify all stage 0-III breast cancer patients undergoing surgery in a single center during a 9-year period ending January 1, 2010. Patients were divided into 2 groups: those who received only LRA and those who received GA. Overall survival (OS), disease-free survival (DFS), and local regional recurrence (LRR) were calculated using the Kaplan-Meier method with log-rank comparison before and after propensity score matching. Median age of the 1107 patients who met study criteria was 64 years (range, 24-97 years). Median and longest follow-up were 5.5 and 12.5 years, respectively. General anesthesia was used for 461 patients (42%), and 646 (58%) received LRA. The point estimates of cumulative OS, DFS, and LRR "free" rates at 5 years for the GA and LRA groups were 85.5% and 87.1%, 94.2% and 96.1%, and 96.3% and 95.8%, respectively. Cox regression showed no significant differences between the 2 groups (GA and LRA) for the 3 outcomes: OS (hazard ratio [HR], 0.81; 95% confidence interval [CI], 0.59-1.10; P = 0.17), DFS (HR, 0.91; 95% CI, 0.55-1.76; P = 0.87), and LRR (HR, 1.73; 95% CI, 0.83-3.63; P = 0.15).

Breast cancer OS, DFS, and LRR were not affected by type of anesthesia in our institution. This result differs from that of the only prior published clinical report on this topic and does not provide clinical corroboration of the basic science studies that suggest oncologic benefits to LRA.

Are Cure Rates for Breast Cancer Improved by Local and Regional Anesthesia?

The aim of this study was to examine the impact of metabolic syndrome (MS) on right ventricular (RV) remodeling in different genders. The study included 341 subjects (216 subjects with MS and 125 controls). MS was defined by the presence of ≥ 3 ATP-NCEP-III criteria. All subjects underwent complete two-dimensional echocardiography. RV structure, diastolic, and global function were significantly impaired in MS subjects, in both genders. The multiple regression analysis of MS parameters showed that systolic blood pressure (BP) and waist circumference were independently associated with RV wall thickness in women, whereas the only independent predictor in men was systolic BP. The multivariate logistic regression analysis revealed that increased BP, impaired fasting glucose, and dyslipidemia were a combination of MS risk factors related with RV hypertrophy solely in women. Increased systolic BP, impaired fasting glucose, and abdominal obesity were independently associated with tricuspid E/e' in women, whereas increased systolic BP was the only independent predictor in men. Impaired fasting glucose, abdominal obesity, and dyslipidemia were a combination of MS criteria, which was independently associated with RV diastolic dysfunction only in women.

Different parameters of MS are responsible for RV remodeling in women and men. The metabolic parameters of MS are more important for RV remodeling in women.

Is gender responsible for everything?

There have been three randomised trials investigating docetaxel in combination with androgen deprivation therapy as first-line therapy for hormone-sensitive metastatic and locally advanced/high-risk prostate cancer. The largest of these studies, UK STAMPEDE trial, recently presented in June 2015. The aim of this survey was to evaluate if oncologists' practice has changed as a result of these studies, or if their practice is likely to change in different clinical settings in the future. The British Uro-oncology Group issued a semi-structured online questionnaire to its membership of 160 specialist urological oncologists practising in the UK. Links to the abstracts of GETUG-AFU-15, E3805 CHAARTED and STAMPEDE were attached with the survey for respondents to review before completing the survey. In total, 111 participants completed the survey; 87% stated that STAMPEDE will influence their clinical practice in the future. Almost all (96%) would offer docetaxel with androgen deprivation therapy to men presenting with high volume metastatic prostate cancer. Fewer oncologists would offer this treatment to men with low volume metastatic prostate cancer, locally advanced or relapsed disease. Various patient- and disease-related factors were considered in decision making, as well as resource implications.

This survey reports oncologists' attitudes towards a major change in practice in the standard of care for men with newly diagnosed advanced prostate cancer in the UK. The survey highlighted the complexities surrounding the clinical implementation of the data from these studies, including changes in referral pathways, with the early involvement of oncologists in such patients' care, increases in workloads for oncologists and chemotherapy units and the need for national approval for re-imbursement of these treatments.

Chemotherapy at First Diagnosis of Advanced Prostate Cancer - Revolution or Evolution?

To evaluate the benefit of cochlear implantation in patients with Pendred syndrome. Retrospective study. Tertiary centre. Speech perception was measured using a phonetically balanced word list at a sound pressure level of 65 dB. Post-operative phoneme scores at 12-month for adults and 36-month for children with Pendred syndrome were compared to scores of patients with an enlarged vestibular aqueduct (EVA) and a reference group with an unknown cause of hearing impairment. Quality of life was measured with the Nijmegen Cochlear Implant Questionnaire to evaluate the differences between pre- and post-implantation. The mean post-operative phoneme scores were as follows: in the Pendred group, 91% (n = 16; SD = 10) for children and 78% (n = 7; SD = 14) for adults; in the reference group, 79% (n = 59; SD = 20) for children and 73% (n = 193; SD = 18) for adults; and in the EVA group, 84% (n = 6; SD = 7) for children and 66% (n = 12; SD = 22) for adults. A significant difference in speech perception was found between the children of the Pendred group and the reference group of 11.4% (SE = 5.2; P = 0.031). Between the adults, a difference of 11.2% (SE = 6.7; P = 0.094) was found. The difference between the Pendred group and the EVA group was 5.7%(SE = 4.5; P = 0.22) for children and 9.9% (SE = 8.7; P = 0.28) for adults. A significant improvement post-implantation in four of the six subdomains of the quality of life questionnaire was found: basic sound perception (P = 0.002), advanced sound perception (P = 0.004), speech production (P = 0.018) and activity limitations (P = 0.018). The two not significant subdomains were self-esteem (P = 0.164) and social interaction (P = 0.107).

After cochlear implantation, children with Pendred syndrome performed better than the reference group with respect to speech perception, however, adults performed similar. No significant differences were found between the Pendred and EVA group. Consequently, during pre-operative counselling, the two groups of patients may be considered comparable in terms of expected speech perception performance after cochlear implantation.

Patients with Pendred syndrome: is cochlear implantation beneficial?

Cardiopulmonary exercise testing (CPET) with blood gas analysis may be helpful when there is a discrepancy between clinical findings and physiologic tests at rest. The aim of this study was to examine the added value of CPET compared to the measurement of the diffusing capacity of the lung for carbon monoxide (DLCO) in detecting impaired pulmonary gas exchange in sarcoidosis patients. The clinical records of 160 (age = 41.3 ± 10.0 years; number of females = 63) sarcoidosis patients referred to the former MUMC ild care center were retrospectively reviewed. Patients performed a symptom-limited incremental exercise test with blood gas analysis on a bicycle ergometer. DLCO was measured by the single-breath method. DLCO (mean = 83.2 ± 18.0 %) below 80 % of predicted was demonstrated by 38 % of the sarcoidosis patients in our sample. Of the patients with normal DLCO (n = 99, 61.9 %), the P(A-a)O(2) at maximal exercise [P(A-a)O(2)max] was moderately increased (>2.5 kPa) in 69.7 % and excessively increased (>4.7 kPa) in 18.2 %. Pulmonary gas exchange impairment (PGEI) was more obvious in patients with lower DLCO values. A DLCO value below 60 % of predicted indicated substantial gas exchange impairment. PaO(2) at rest, DLCO, and FVC as a percentage of predicted and radiographic staging predicted 40 % of the PGEI at maximal exercise.

A substantial number of the symptomatic sarcoidosis patients with normal DLCO appeared to have PGEI at maximal exercise, suggesting that normal DLCO at rest is an inappropriate predictor of abnormal pulmonary gas exchange during exercise. CPET appeared to offer added value in detecting impaired gas exchange during exercise in sarcoidosis patients with unexplained disabling symptoms.

Is there an added value of cardiopulmonary exercise testing in sarcoidosis patients?

To determine whether there are important differences in performance between group practices and singlehanded general practitioners and the extent to which any differences are explained by practice characteristics such as deprivation. Cross sectional survey. 206 singlehanded practices and 606 partnerships in Trent region, United Kingdom. Comparison of process and outcome measures derived from routinely collected data on hospital admissions and target payments for singlehanded practices and partnerships. Multivariate analysis was used to adjust for the confounding effects of general practice characteristics-deprivation (Townsend score), percentage of Asian residents, percentage of black residents, proportion of men over 75 years, proportion of women over 75 years, rurality, presence of a female general practitioner, and vocational training status. Differences in achievement of immunisation and cytology targets apparent on univariate analysis were not seen after adjustment for other general practice characteristics. Similarly, significant differences (>15%; P<0.01) for three types of hospital admission seen on univariate analysis were not present after adjustment for other practice characteristics.

This study provides no evidence that singlehanded general practitioners are underperforming clinically. Our results offer insight into the structural difference between the two types of practice and underline the importance of the effect of other practice characteristics on process and outcome measures.

Do single handed practices offer poorer care?

The most common indication for treatment of varicocele is still male subfertility. The aim of this study was to explore the effect of infertility duration on semen parameters and spontaneous pregnancy rate after varicocelectomy. The medical records of 183 infertile patients with clinical varicocele were retrospectively reviewed. The patients were divided into three groups according to the duration of infertility (group I, 1-3 years, group II, 3-6 years and group III,>6 years). Total sperm motility counts (TMCs) before and after varicocelectomy and spontaneous pregnancy rate among these groups were statistically compared. The greatest changes, regarding preoperative and postoperative TMCs and spontaneous pregnancy rate were noticed between group I and III. Preoperative TMCs in group I and III was 15.2 ± 1.2, 7.8 ± 1.4, respectively (p<0.05). Postoperative TMCs in group I and III was 33.7 ± 2.5, 25.2 ± 1.9, respectively (p<0.05). An overall spontaneous pregnancy rate of 34.4% was achieved after inguinal varicocelectomy. The greatest spontaneous pregnancy rate was achieved in Group I (37.3%), and the lowest pregnancy rate in Group III (26.3%) (P<0.05).

Surgical varicocelectomy improves the total sperm motility counts especially in patients who have a TMCS more than 5 million and improves the spontaneous pregnancy rates. The improvement in the spontaneous pregnancy rates after varicocelectomy correlates negatively with the duration of infertility. Therefore, duration of infertility should be considered in treating a patient with a varicocele as a cause of infertility.

Does the duration of infertility affect semen parameters and pregnancy rate after varicocelectomy?

Previous uncontrolled studies have suggested that there is late cognitive decline after coronary artery bypass grafting that may be attributable to use of the cardiopulmonary bypass pump. In this prospective, nonrandomized, longitudinal study, we compared cognitive outcomes after on-pump coronary artery bypass surgery (n = 152) with off-pump bypass surgery patients (n = 75); nonsurgical cardiac comparison subjects (n = 99); and 69 heart-healthy comparison (HHC) subjects. The primary outcome measure was change from baseline to 72 months in the following cognitive domains: verbal memory, visual memory, visuoconstruction, language, motor speed, psychomotor speed, attention, executive function, and a composite global score. There were no consistent differences in 72-month cognitive outcomes among the three groups with coronary artery disease (CAD). The CAD groups had lower baseline performance, and a greater degree of decline compared with HHC. The degree of change was small, with none of the groups having more than 0.5 SD decline. None of the groups was substantially worse at 72 months compared with baseline.

Compared with subjects with no vascular disease risk factors, the CAD patients had lower baseline cognitive performance and greater degrees of decline over 72 months, suggesting that in these patients, vascular disease may have an impact on cognitive performance. We found no significant differences in the long-term cognitive outcomes among patients with various CAD therapies, indicating that management strategy for CAD is not an important determinant of long-term cognitive outcomes.

Do management strategies for coronary artery disease influence 6-year cognitive outcomes?

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.

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.

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

In women, the gonadotrophin response to gonadotrophin-releasing hormone (GnRH) displays a circadian rhythm during the early follicular phase (EFP), with GnRH-stimulated luteinizing hormone (LH) and follicle-stimulating hormone (FSH) release found to be markedly decreased at night. Since the opioidergic inhibition of gonadotrophin secretion is selectively enhanced at night, we reasoned that the circadian changes in the gonadotrophin responsiveness to GnRH might be related to a nocturnal increase of opioidergic activity. Eleven women with normal menstrual cycles were studied in the EFP on four different occasions in random order. Studies were conducted either during the day (0900-1300 h) or at night (2100-0100 h). During these times, GnRH (25 micrograms i.v.) was administered in conjunction with either saline (as control) or naloxone (4 mg i.v.). Frequent blood samples were obtained before and after GnRH stimulation for determination of basal sex steroid and gonadotrophin concentrations by immunoradiometric assays. While oestradiol levels were comparable (P>0.3) at all times, progesterone concentrations were significantly (P<0.01) higher during day than during night hours, with no difference between control and naloxone conditions. Gonadotropin responses to GnRH stimulation were not significantly different between day and night times, nor did they vary between control and naloxone conditions.

Opioidergic blockade imposed by naloxone did not noticeably change GnRH-stimulated gonadotrophin release at any of the study times. We therefore infer that mechanisms other than a nocturnal increase of opioidergic inhibition may account for eventual circadian changes in the gonadotrophin responsiveness of early follicular phase women.

Is opioidergic activity responsible for the circadian variation observed in the gonadotrophin responsiveness of early follicular phase women?

To determine the feasibility of sentinel lymph node mapping in local and in-transit recurrent melanoma. The accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) for identification of occult lymph node metastases is well established in primary melanoma. We hypothesized that LM/SL could be useful to detect regional node metastases in patients with isolated local and in-transit recurrent melanoma (RM). Review of our prospective melanoma database of 1600 LM/SL patients identified 30 patients who underwent LM/SL for RM. Patients with tumor-positive sentinel nodes (SNs) were considered for completion lymph node dissection. Of the 30 patients, 17 were men and 13 were women; their median age was 57 years (range, 29-86 years). Primary lesions were more often on the extremities (40%) than the head and neck (33%) or the trunk (8%). At least 1 SN was identified in each lymph node basin that drained an RM. Of the 14 (47%) patients with tumor-positive SNs, 11 (78%) underwent complete lymph node dissection; 4 had tumor-positive non-SNs. The median disease-free survival after LM/SL was 16 months (range, 1-108 months) when an SN was positive and 36 months (range, 6-132 months) when SNs were negative. At a median follow-up of 20 months (range, 2-48 months), there were no dissected basin recurrences after a tumor-negative SNs.

LM/SL can accurately identify SNs draining an RM, and the high rate of SN metastases and associated poor disease-free survival for patients with tumor-positive SN suggests that LM/SL should be routinely considered in the management of patients with isolated RM.

Is sentinel lymph node mapping indicated for isolated local and in-transit recurrent melanoma?

This aims of this study is to evaluate after laparoscopic exploration or treatment in digestive cancers, the incidence of port site metastases and the incidence of unnecessary laparotomy in advanced disease. 109 patients were included in this study: 91 had localized digestive cancers and 18 had disseminated disease with hepatic and/or peritoneal metastases. All the patients underwent a laparoscopy and a laparoscopic ultra-sonography under general anesthesia prior to a definitive decision on therapeutic management. Depending on the circumstances, histological or cytological biopsies were performed. The puncture sites of the trocar were examined clinically and, if required, by ultrasonography, monthly through out the course of the disease. Chemotherapy was instigated in 60.5 per cent of patients. 35 patients (32.1 per cent) only had one laparoscopic examination with a mean survival of 4.8 months, 22.9 per cent of patients had laparoscopic treatment of their lesion and 44.9 per cent had conventional treatment. Laparoscopic exploration allowed the detection of 52 lesions that had not been identified by conventional imaging techniques and thereby avoided 35 laparotomies (32.1 per cent). Tumor invasion of the peritoneum was present in 46 per cent of cases, most notably in the cases of pancreatico-biliary cancers. The overall mean survival was 32.7 months while it was 9.8 months in cases of palliative treatment. In total, 436 trocars were used. There was one case (0.9 per cent of patient or 0.02 per cent of port) of a metastasis occurring at the site of the trocar following treatment by right-sided, laparoscopic colectomy in a patient with disseminated cancer. Two factors seem to be involved peritoneal spread of the tumor and manipulation of the tumor.

Laparoscopic exploration for digestive cancers is a legitimate technique. It allows the detection of lesions that are not identified by conventional imaging techniques, permits a more accurate assessment of the resectability of a tumor and reduces the number of unnecessary laparotomies. The incidence of metastases at the site of the trocar is low and is closely linked to the presence of disseminated disease and manipulation of the tumor.

Is laparoscopic evaluation of digestive cancers legitimate?

We studied histopathological changes in kidneys with demonstrable ureteropelvic junction obstruction in relation to patient age, differential renal function and urinary tract infection. Renal biopsy was performed in 42 children (44 kidneys) with a mean age of 3 years 6 months who underwent open pyeloplasty due to ureteropelvic junction obstruction. Each specimen was examined for reversible inflammatory cell infiltration and irreversible change, including interstitial fibrosis, arteriolar thickening and glomerular sclerosis. Each pathological finding was scored 0 to 3 in increasing grades of severity, and correlated with patient age, differential renal function and history of urinary tract infection. Of the 44 kidneys 20 (45%) had irreversible change. Correlation study revealed no association between patient age and histological findings, and there was no statistically significant difference in any histopathological category regardless of age. Differential renal function correlated with inflammatory cell infiltration and interstitial fibrosis. There were significantly worse histopathology scores in all categories when differential renal function was less than 30 versus 40% or greater. Interstitial fibrosis was significantly worse in the 30 to 40% group than in the greater than 40% group. The histopathological score of interstitial fibrosis was significantly higher in patients with than without urinary tract infection.

Early correction in infants with ureteropelvic junction obstruction may not be necessary when initial differential renal function is greater than 40%. However, any decrease in differential renal function or recurrent urinary tract infections despite antibiotic prophylaxis warrant surgical correction of obstruction.

Does delayed operation for pediatric ureteropelvic junction obstruction cause histopathological changes?

The ideal method to encourage uptake of clinical guidelines in hospitals is not known. Several strategies have been suggested. This study evaluates the impact of academic detailing and a computerised decision support system (CDSS) on clinicians' prescribing behaviour for patients with community acquired pneumonia (CAP). The management of all patients presenting to the emergency department over three successive time periods was evaluated; the baseline, academic detailing and CDSS periods. The rate of empiric antibiotic prescribing that was concordant with recommendations was studied over time comparing pre and post periods and using an interrupted time series analysis. The odds ratio for concordant therapy in the academic detailing period, after adjustment for age, illness severity and suspicion of aspiration, compared with the baseline period was OR = 2.79 [1.88, 4.14], p<0.01, and for the computerised decision support period compared to the academic detailing period was OR = 1.99 [1.07, 3.69], p = 0.02. During the first months of the computerised decision support period an improvement in the appropriateness of antibiotic prescribing was demonstrated, which was greater than that expected to have occurred with time and academic detailing alone, based on predictions from a binary logistic model.

Deployment of a computerised decision support system was associated with an early improvement in antibiotic prescribing practices which was greater than the changes seen with academic detailing. The sustainability of this intervention requires further evaluation.

Improving antibiotic prescribing for adults with community acquired pneumonia: Does a computerised decision support system achieve more than academic detailing alone?

The aim of this study was to analyze the average and individual blood pressure responses to walking and resistance exercise in patients with peripheral artery disease. Thirteen patients underwent three experimental sessions: walking exercise, resistance exercise, and control. Ambulatory blood pressure, heart rate, and rate pressure product were obtained before and until 24 hours after sessions. The mean cardiovascular values during 24 hours, awake, and sleep periods were similar (P>0.05) after the three experimental sessions. The analysis of individual data revealed that during 24 hours, eight of 13 patients reduced systolic or diastolic blood pressure in ≥4.0 mm Hg in at least one of the exercise session; furthermore, most of these patients presented greater responses after resistance exercise. The clinical characteristics of patients seem to influence the blood pressure responses after exercises. Individual data showed that part of patients presented clinically significant decreases in blood pressure, showing that these patients have acute cardiovascular benefits after performing an acute bout of exercise.

Although, in average, a bout of walking or resistance exercise did not decrease ambulatory blood pressure in peripheral artery disease patients, the individual data revealed that most patients presented clinically relevant blood pressure reductions, especially after resistance exercise.

Individual blood pressure responses to walking and resistance exercise in peripheral artery disease patients: Are the mean values describing what is happening?

Late abdominal irradiation toxicity during childhood included renal damage, hepatic toxicity and secondary diabetes mellitus. We compared the potential of conformal radiotherapy (CRT), helical tomotherapy (HT) and proton beam therapy (PBT) to spare the abdominal organs at risk (pancreas, kidneys and liver- OAR) in children undergoing abdominal irradiation. We selected children with abdominal tumors who received more than 10 Gy to the abdomen. Treatment plans were calculated in order to keep the dose to abdominal OAR as low as possible while maintaining the same planned target volume (PTV) coverage. Dosimetric values were compared using the Wilcoxon signed-rank test. The dose distribution of 20 clinical cases with a median age of 8 years (range 1-14) were calculated with different doses to the PTV: 5 medulloblastomas (36 Gy), 3 left-sided and 2 right-sided nephroblastomas (14.4 Gy to the tumor + 10.8 Gy boost to para-aortic lymphnodes), 1 left-sided and 4 right-sided or midline neuroblastomas (21 Gy) and 5 Hodgkin lymphomas (19.8 Gy to the para-aortic lymphnodes and spleen). HT significantly reduced the mean dose to the whole pancreas (WP), the pancreatic tail (PT) and to the ipsilateral kidney compared to CRT. PBT reduced the mean dose to the WP and PT compared to both CRT and HT especially in midline and right-sided tumors. PBT decreased the mean dose to the ispilateral kidney but also to the contralateral kidney and the liver compared to CRT. Low dose to normal tissue was similar or increased with HT whereas integral dose and the volume of normal tissue receiving at least 5 and 10 Gy were reduced with PBT compared to CRT and HT.

In children undergoing abdominal irradiation therapy, proton beam therapy reduces the dose to abdominal OAR while sparing normal tissue by limiting low dose irradiation.

Can We Spare the Pancreas and Other Abdominal Organs at Risk?

To determine which measures-impaired fasting glucose (IFG), elevated HbA1c, or both-best predict incident diabetes in older adults. From the Health, Aging, and Body Composition study, we selected individuals without diabetes, and we defined IFG (100-125 mg/dL) and elevated HbA1c (5.7-6.4%) per American Diabetes Association guidelines. Incident diabetes was based on self-report, use of antihyperglycemic medicines, or HbA1c ≥6.5% during 7 years of follow-up. Logistic regression analyses were adjusted for age, sex, race, site, BMI, smoking, blood pressure, and physical activity. Discrimination and calibration were assessed for models with IFG and with both IFG and elevated HbA1c. Among 1,690 adults (mean age 76.5, 46% men, 32% black), 183 (10.8%) developed diabetes over 7 years. Adjusted odds ratios of diabetes were 6.2 (95% CI 4.4-8.8) in those with IFG (versus those with fasting plasma glucose [FPG]<100 mg/dL) and 11.3 (7.8-16.4) in those with elevated HbA1c (versus those with HbA1c<5.7%). When FPG and HbA1c were considered together, odds ratios were 3.5 (1.9-6.3) in those with IFG only, 8.0 (4.8-13.2) in those with elevated HbA1c only, and 26.2 (16.3-42.1) in those with both IFG and elevated HbA1c (versus those with normal FPG and HbA1c). Addition of elevated HbA1c to the model with IFG resulted in improved discrimination and calibration.

Older adults with both IFG and elevated HbA1c have a substantially increased odds of developing diabetes over 7 years. Combined screening with FPG and HbA1c may identify older adults at very high risk for diabetes.

Elevated HbA1c and fasting plasma glucose in predicting diabetes incidence among older adults: are two better than one?

Severe burns in children can result in prolonged suffering, disability, disfigurement, and in impaired physical and mental development. Hospitalization rates of children with burns are much higher than for children with other trauma. Therefore, various child burn prevention programs have been implemented, but their efficacy has been evaluated only by assessment of knowledge or satisfaction rather than evaluating actual changes in burn-related hospitalizations. Our objective was to map Israeli child burn prevention programs and to measure their success from the rate of burn-related hospitalizations. A questionnaire-based survey was conducted of organizations participating in injury prevention programs. Official data was obtained on burn-related hospitalizations of children aged 0-4 and 5-14 for 1998 and 2000, and was correlated with the existence or absence of injury prevention programs, and with the population's socio-economic status (SES). In localities with burn prevention programs, there was a reduction in the rate of burn-related hospitalizations of infants, from 1.39 to 1.05 per 1000 infants (p<0.05), in contrast to localities where programs did not exist. The greatest change was in middle and high socio-economic communities. The prevention programs had no similar effects on school-aged children.

Injury prevention programs are effective in reducing burn-related hospitalizations among infants and toddlers, especially from more affluent communities, but not among school-aged children.

Burn prevention programs for children: do they reduce burn-related hospitalizations?

Few studies have examined whether women and men identify the same factors as important in choosing their specialty. We sought to evaluate whether the factors influencing residents' choice of surgical specialty differed by gender. A 32-item Web survey, designed to elucidate which factors motivated residents to seek fellowship training, was sent to 99 graduates of a university general surgery program, all of whom matriculated between 1985 and 2006. A total of 74 (75%) respondents replied (16 women, 58 men). There was a higher proportion of men who pursued fellowship training than women (69% versus 38%, p=0.04), but there was no significant difference in those who were currently in academic practice (men, 46% versus women, 27%, p=0.2). Both genders were equally likely to respond that interest in and intellectual appeal of their field, clinical opportunities in that field, and having an influential mentor during residency were important in choosing their future specialty. But significantly more women listed lifestyle as an important factor in choosing their future careers (69% versus 43%, p=0.03). When respondents' data from the most recent decade were analyzed, there was no difference between genders in completion of fellowship training or in those in academic practice. But lifestyle continued to be more important to women.

Both genders were influenced by many similar factors when deciding to pursue subspecialty training, but women were more likely than men to be influenced by their perception of the lifestyle associated with their career choice. These findings suggest that general surgical residency programs might improve efforts to recruit women by addressing the perception of the lifestyle associated with choosing a surgical career.

Motivation to pursue surgical subspecialty training: is there a gender difference?

Two prospective trials were designed to determine whether there may be a role for inflammatory mediators in human skin erythema at both high and low doses per fraction and for 'out of field' effects. Trial 1. Effects of topical indomethacin (1%) and hydrocortisone (1%) applied before and during radiotherapy were compared for erythema induced by 20 Gy in four fractions (n = 26, 6 MV). Trial 2. Effects of topical hydrocortisone (1 %) applied before and during radiotherapy and no medication were compared for erythema induced by 1, 3, 5 and 7 Gy in five fractions (n = 21, 120 kV). Erythema was measured using reflectance spectrophotometry (RFS) and laser Doppler (LD) on a weekly basis. Trial 1. A bi-phasic reaction time course was suggested in two-thirds of the cases. The first phase did not appear to be influenced by hydrocortisone cream but the second was significantly attenuated. Indomethacin had no effect on either reaction phase. Erythema measured several centimetres outside of the field was reduced by hydrocortisone but not by indomethacin. Trial 2. Trial 2 confirmed the presence of measurable erythema, invisible to the eye, that coincided in its time course to the first phase of erythema noted in trial 1. This reaction was more intense than predicted by the LQ formula and was non-significantly attenuated by topical hydrocortisone. RFS readings proved to be less subject to inter- and intra-patient variations than the LD unit used.

Inflammatory responses may play a role in the mediation of the erythematous response to radiation in human skin. Further studies are warranted.

Do inflammatory processes contribute to radiation induced erythema observed in the skin of humans?

A large proportion of cardiac arrests outside hospital are caused by ventricular fibrillation. Although it is frequently used, the exact role of treatment with adrenaline in these patients remains to be determined.AIM: To describe the proportion of patients with witnessed out-of-hospital cardiac arrest found in ventricular fibrillation who survived and were discharged from hospital in relation to whether they were treated with adrenaline prior to hospital admission. All the patients with out-of-hospital cardiac arrest found in ventricular fibrillation in Göteborg between 1981 and 1992 in whom cardiopulmonary resuscitation (CPR) was initiated by our emergency medical service (EMS). During the observation period, some of the EMS staff were authorized to give medication and some were not. In all, 1360 patients were found in ventricular fibrillation and detailed information was available in 1203 cases (88%). Adrenaline was given in 417 cases (35%). Among patients with sustained ventricular fibrillation, those who received adrenaline experienced the return of spontaneous circulation more frequently (P<0.001) and were hospitalized alive more frequently (P<0.01). However, the rate of discharge from hospital did not differ significantly between the 2 groups. Among patients who converted to asystole or electromechanical dissociation, those who received adrenaline experienced the return of spontaneous circulation more frequently (P<0.001) and were hospitalised alive more frequently (P<0.001). However, the rate of discharge from hospital did not differ significantly between the 2 groups.

On the basis of 2 treatment regimens during a 12-year survey, we explored the usefulness of adrenaline in out-of-hospital ventricular fibrillation. Both patients with sustained ventricular fibrillation and those who converted to asystole or electromechanical dissociation had an initially more favourable outcome if treated with adrenaline. However, the final outcome was not significantly affected. This study does not confirm the hypothesis that adrenaline increases survival among patients with out-of-hospital cardiac arrest who are found in ventricular fibrillation.

Adrenaline in out-of-hospital ventricular fibrillation. Does it make any difference?

Chronic hyperglycaemia stands with diabetes duration as the main predicting factor for the development of nephropathy in insulin dependent diabetes mellitus (IDDM). In contrast, nephropathy in non-insulin-dependent diabetes mellitus (NIDDM) presents with a different natural history and, as well as atherosclerosis, can precede diabetes diagnosis and even the onset of patent hyperglycaemia. The role of lipid abnormalities in this matter remains debated. We studied the prevalence of nephropathy (N+ = urinary albumin excretion rate (UAE)>20 mg/d) in 134 Caucasian NIDDM patients ranked according to alipoprotein E (apoE) genotype (same distribution in 132 controls). Age, diabetes duration and sex ratio did not differ between N+ and N-. A patient with E2E4 (n = 1) was excluded from the analysis. The prevalence of nephropathy was significantly reduced in E2 allele carriers (36%, 8/22) vs 69% (77/111) in E2 non-carriers (P<0.01). Relative risk (RR) of E2 carriers developing nephropathy was 0.52 (95% CI = 0.35-0.80). Both groups were comparable in terms of age (55 +/- 11 vs 57 +/- 11 years), diabetes duration (15 +/- 9 vs 14 +/- 10 years) and prevalence of retinopathy (59 vs 48%). Similar results were observed when patients with diabetes duration longer than 8 years were studied (n = 94).

It has been largely established that low-density lipoprotein (LDL)-cholesterol level in E2 allele carriers (whether diabetic or not) was lower than in E2 non-carriers. The 2-fold increase of nephropathy in E2 non-carriers with NIDDM argues for a role for LDL in the development of human nephropathy in NIDDM patients. This result is in agreement with previous data established both in vitro and in vivo in animal models. These findings support evidence for the pathogenic and morphologic similarities between kidney disease and atherosclerosis in NIDDM patients.

ApoE polymorphism and albuminuria in diabetes mellitus: a role for LDL in the development of nephropathy in NIDDM?

The last decade has seen significant advances in the evaluation of the small bowel. Several endoscopic techniques have been developed in recent years: capsule endoscopy (CE), double-balloon enteroscopy (DBE), and, more recently, the single-balloon enteroscopy (SBE). The aim of this study was to evaluate diagnostic and therapeutic impact, safety, and feasibility of the SBE procedure after a 3-year experience. A total of 73 SBE procedures were performed from July 2006 to July 2009. The starting insertion route (oral or anal) of SBE was chosen according to the estimated location of the suspected lesions based on the clinical presentation and, in 48 patients, on the findings of CE. A total of 70 patients with obscure gastrointestinal bleeding (31), suspected malabsorption syndrome (12), polyposis syndromes (11), suspected Crohn's disease (9), and suspected gastrointestinal tumors (7) were recruited. The SBE was not carried out in four patients because of technical problems. Multiple angiodysplasias were found and treated in 9 patients; Peutz-Jeghers syndrome, familial adenomatous polyposis (FAP), and multiple polypectomies were carried out in 8 patients; endoscopic tattoos were performed in 2 patients due to the large diameter of the polyps; and multiple biopsies was performed in only one patient. SBE diagnosed Crohn's disease in four patients, malabsorption syndromes in two, lymphangiectasia in two, eosinophilic enteritis in one, melanoma in one, and nonspecific inflammation in eight. A total of seven small-bowel tumors were diagnosed (all were tattooed). In 23/70 patients the exam was negative. No major complications occurred.

Single-balloon enteroscopy seems to be safe, useful, and highly effective in the diagnosis and therapy of several small-bowel diseases.

Single-balloon push-and-pull enteroscopy system: does it work?

To investigate the significance of intra-appendiceal air at CT for the evaluation of appendicitis. We retrospectively analyzed 458 patients (216 men, 242 women; age range, 18-91 years) who underwent CT for suspected appendicitis. Two independent readers reviewed the CT. Prevalence, amount, and appearance of intra-appendiceal air were assessed and compared between the patients with and without appendicitis. Performance of CT diagnosis was evaluated in two reading strategies: once ignoring appendiceal air (strategy 1), and the other time considering presence of appendiceal air as indicative of no appendicitis in otherwise indeterminate cases (strategy 2), using receiver operating characteristic (ROC) analysis. Of the 458 patients, 102 had confirmed appendicitis. The prevalence of intra-appendiceal air was significantly different between patients with (13.2%) and without (79.8%) appendicitis (p<0.001). The amount of appendiceal air was significantly lesser in patients having appendicitis as compared with the normal group, for both reader 1 (p = 0.011) and reader 2 (p = 0.002). Stool-like appearance and air-fluid levels were more common in the appendicitis group than in the normal appendix for both readers (p<0.05). Areas under the ROC curves were not significantly different between strategies 1 and 2 in reader 1 (0.971 vs. 0.985, respectively; p = 0.056), but showed a small difference in reader 2 (0.969 vs. 0.986, respectively; p = 0.042).

Although significant differences were seen in the prevalence, amount, and appearance of intra-appendiceal air between patients with and without appendicitis, it has a limited incremental value for the diagnosis of acute appendicitis.

Intra-Appendiceal Air at CT: Is It a Useful or a Confusing Sign for the Diagnosis of Acute Appendicitis?

Several studies have investigated the effects of pay-for-performance (P4P) initiatives. However, little is known about whether patients with multiple chronic conditions (MCC) would benefit from P4P initiatives similarly to patients without MCC. The objective of this study was to compare the effects of the diabetes mellitus pay-for-performance (DM-P4P) program on the quality of diabetic care between type 2 diabetic patients with and without MCC. This study used data from Taiwan's Longitudinal Health Insurance Database 2005. Of this cohort, 52,276 diabetic patients were identified. To address potential selection bias between the intervention and comparison groups, the propensity score matching method was used. Generalized estimating equations were applied to analyze the difference-in-difference model to examine the effect of the intervention, the DM-P4P program. The disease-specific DM-P4P program had positive impacts on process and outcome indicators of health care quality regardless of patients' MCC status. Diabetic patients with MCC experienced a significantly larger decrease in the admission rate of diabetes-related ambulatory care sensitive conditions after the P4P enrollment over time compared with patients without MCC.

The positive impacts on use of diabetes-related services were comparable between diabetic patients with and without MCC. Most importantly, for MCC patients, the disease-specific DM-P4P program had a stronger positive impact on health outcomes. Hence, the commonly observed phenomenon of "cherry picking" in implementing P4P strategies may lead to disparities in the quality of diabetic care between diabetic patients with and without MCC.

Disease-specific Pay-for-Performance Programs: Do the P4P Effects Differ Between Diabetic Patients With and Without Multiple Chronic Conditions?

Human papillomavirus (HPV) vaccine is now approved for use in males in the United States to prevent genital warts. We conducted an experiment to see whether framing HPV vaccination as also preventing cancer in men would increase men's vaccination willingness. We conducted an online survey in January 2009 with a national sample of men ages 18 to 59 years who self-identified as gay/bisexual (n = 312) or heterosexual (n = 296). In the within-subjects experiment, men read four randomly ordered vignettes that described hypothetical vaccines that prevented either genital warts alone, or genital warts and either anal cancer, oral cancer, or penile cancer. We analyzed data using repeated measures ANOVA and tested whether perceived severity or perceived likelihood mediated the effect of disease outcome framing on men's HPV vaccination willingness. Although only 42% of men were willing to receive HPV vaccine when it was framed as preventing genital warts alone, 60% were willing to get it when it was framed as preventing cancer in addition to genital warts (P<0.001). The effect of outcome framing was the same for heterosexual and gay/bisexual men and for the three cancer types examined. Perceived severity of disease partially mediated the association between disease outcome and HPV vaccination willingness.

Men may be more accepting of HPV vaccine when it is framed as preventing cancer, regardless which of the three most common HPV-related cancers in men is described.

Does framing human papillomavirus vaccine as preventing cancer in men increase vaccine acceptability?

The Affordable Care Act provides health care coverage to an increasing segment of the population at Medicaid reimbursement rates. Health care systems currently offset lower Medicaid reimbursement through higher payers. The ability to "cost shift" will be diminished as the Medicaid population increases. A financial cost and revenue analysis of outpatient laparoscopic cholecystectomy at our institution was performed. Cost was defined as actual expense to the health care institution. Fixed and variable costs were identified to calculate a break-even point. Time spent from check in to dismissal was based on historic averages. When actual costs could not be pinpointed, estimates from industry experts were used. Reimbursement included surgeon and anesthesia professional fees and facility fees. A total of 501 laparoscopic cholecystectomies were performed at the main operating room facility in 2012. Annual fixed costs were $252,637. Variable costs were $1,860/case. Personnel and single-use equipment made the largest contribution to variable costs. Reimbursement for professional and facility fees totaled $2,444/case. The break-even point occurred at 454 cases. Based on historic volume, the break-even point for the calendar year would occur on November 27.

Our analysis demonstrates that laparoscopic cholecystectomy can be performed with a positive margin at Medicaid reimbursement rates with sufficient volume. The minimal margin, however, could substantially limit the ability of lower-volume hospitals to provide these services and negatively impact access to care in this patient population.

Can laparoscopic cholecystectomy be performed with a positive margin at medicaid reimbursement rates?

Recent studies have reported sex differences in recanalization and outcome after intravenous thrombolysis (IVT) in acute ischemic stroke. We analyzed sex differences in outcome in consecutive patients with middle cerebral artery (MCA) M1 or M2 and internal carotid artery (ICA) occlusion treated with intra-arterial thrombolysis (IAT). Recanalization immediately after thrombolysis and outcome after 3 months were assessed. Two hundred five patients (111 men) with MCA and 43 (22 men) with ICA occlusion were identified. Baseline variables did not differ between the sexes except for a higher prevalence of smokers among men in the MCA group (31% vs 12%; P=0.001). Partial or complete recanalization (TIMI flow 2 or 3) of the MCA was observed in 71 (75%) women and 80 (72%) men (P=0.488). In the ICA group, 14 (67%) women and 11 men (50%) showed TIMI 2 or 3 recanalization (P=0.425). Favorable outcome (modified Rankin Scale score 0 to 2) was seen in 57 women (61%) and 63 men (57%) with MCA occlusion (P=0.512) and in 6 women (28%) and 4 men (18%) with ICA occlusion (P=0.656). After multiple-regression analyses, there was still no association between sex and outcome (P=0.763 for MCA and P=0.813 for ICA occlusion) or recanalization (P=0.488 for MCA and P=0.104 for ICA occlusion).

There was no association between sex and recanalization or outcome after IAT. These findings are in contrast to previous studies reporting better recanalization and outcome after IVT in women and might have implications in the selection of patients for IAT or IVT.

Recanalization and outcome after intra-arterial thrombolysis in middle cerebral artery and internal carotid artery occlusion: does sex matter?

Survival of patients on left ventricular assist devices (LVADs) has improved. We examined the differences in risk of adverse outcomes between LVAD-supported and medically managed candidates on the heart transplant waiting list. We analyzed mortality and morbidity in 33,073 heart transplant candidates registered on the United Network for Organ Sharing (UNOS) waiting list between 1999 and 2011. Five groups were selected: patients without LVADs in urgency status 1A, 1B, and 2; patients with pulsatile-flow LVADs; and patients with continuous-flow LVADs. Outcomes in patients requiring biventricular assist devices, total artificial heart, and temporary VADs were also analyzed. Two eras were defined on the basis of the approval date of the first continuous-flow LVAD for bridge to transplantation in the United States (2008). Mortality was lower in the current compared with the first era (2.1%/mo versus 2.9%/mo; P<0.0001). In the first era, mortality of pulsatile-flow LVAD patients was higher than in status 2 (hazard ratio [HR], 2.15; P<0.0001) and similar to that in status 1B patients (HR, 1.04; P=0.61). In the current era, patients with continuous-flow LVADs had mortality similar to that of status 2 (HR, 0.80; P=0.12) and lower mortality compared with status 1A and 1B patients (HR, 0.24 and 0.47; P<0.0001 for both comparisons). However, status upgrade for LVAD-related complications occurred frequently (28%) and increased the mortality risk (HR, 1.75; P=0.001). Mortality was highest in patients with biventricular assist devices (HR, 5.00; P<0.0001) and temporary VADs (HR, 7.72; P<0.0001).

Mortality and morbidity on the heart transplant waiting list have decreased. Candidates supported with contemporary continuous-flow LVADs have favorable waiting list outcomes; however, they worsen significantly once a serious LVAD-related complication occurs. Transplant candidates requiring temporary and biventricular support have the highest risk of adverse outcomes. These results may help to guide optimal allocation of donor hearts.

Morbidity and mortality in heart transplant candidates supported with mechanical circulatory support: is reappraisal of the current United network for organ sharing thoracic organ allocation policy justified?

We retrospectively evaluated the clinical profile and the patterns of outcome among patients who were treated in our center with the diagnosis of aggressive, B-cell, primary endocrine lymphoma. Between May 1980 and December 2011, 450 patients were diagnosed as primary extranodal non-Hodgkin lymphomas. Among them, 18 cases (4%) were primary testicular lymphoma (PTL), 8 cases (2%) were primary thyroid lymphoma (PTHL) and 4 cases (1%) were primary adrenal lymphoma (PAL). The therapeutic approaches employed were variable, including mainly chemotherapy in combination with radiotherapy and surgery. The median OS for the patients with PTL and PAL was 27 and 6 months, respectively. Better outcome was observed in patients with PTHL for whom the median OS has not been reached yet, whereas the PAL group had the worst prognosis.

The discrepancies in the outcome among endocrine lymphomas could be partly attributed to their biologic variability, which might be determined by the initial site involved. We conclude that treatment decisions should be made according to a multi-disciplinary approach to avoid unnecessary surgery. Existing treatment strategies for PTL and PAL fail to provide long-term survival, rendering the application of novel therapeutic approaches essential.

Long-term outcome of primary endocrine non-Hodgkin lymphomas: does the site make the difference?

To determine whether a gap exists between program directors' expectations for performance and residents' actual performance on learning objectives designed to address the Accreditation Council for Graduate Medical Education's (ACGME's) competencies. In 2007-2008, the authors analyzed data on the performance of 40 pediatric residents across all levels of training who were assessed a total of 8,974 times during 2002-2005 on 35 learning objectives developed to address the ACGME patient care competency. Residents "passed" the objectives if assessments met the expected performance standards for each level of training that were set by pediatric program directors in a previous survey. To address concurrent validity, the authors also reviewed faculty evaluations of resident performance using a modified version of the American Board of Internal Medicine competency card. The mean pass rate (percentage of residents meeting or exceeding the predetermined standard) for the 35 learning objectives was 92% for first-year, 84% for second-year, and 72% for third-year residents. Actual performance met expected performance standards for all patient care learning objectives except those for procedural competence and some related to patient management. However, faculty competency card evaluations demonstrated that residents met or exceeded competence in patient care, suggesting that program directors set unrealistic standards for these few items.

Program directors' expectations predicted residents' actual performance for the majority of patient care learning objectives. The authors offer lessons learned to inform the next iteration of performance standards for clinical competence.

Is there a gap between program directors' expectations and residents' performance?

Despite national guidelines for asthma treatment, many children have troublesome symptoms.AIM: To assess the extent to which the use of inappropriate inhaler devices contributes to this problem. Of 14 813 questionnaires distributed to schoolchildren, 6996 (47%) were returned identifying 1444 children using asthma inhalers. Inhalers were categorised as age appropriate or inappropriate according to national guidelines and were compared with those used by 75 patients attending a hospital clinic. A total of 35% of "schools" and 4% of "clinic" children reported using an inappropriate inhaler device. Most were using metered dose inhalers alone. Twenty four per cent of "schools" children<or = 5 years old did not use a spacer. Both children and parents overestimated the child's ability to use their inhaler.

Large numbers of children are given inhalers they cannot use. To improve asthma care we must ensure that prescriptions reflect the age and ability of the child. Recent recommendations by the Department of Health in England and Wales stress the importance of seamless care between primary and secondary services. As the management of childhood asthma is guided primarily by secondary care providers, it is therefore imperative that general paediatricians know the difficulties and issues which are occurring in the community. This will enable them to lead and support necessary change.

Inhaler devices for asthma: do we follow the guidelines?

The type of paraclinoid aneurysm has been used to decide management methods. Our aim was to assess the relation of the types of paraclinoid aneurysms and outcomes after endovascular treatment and the efficiency of present endovascular techniques. A retrospective analysis was performed on patients with saccular paraclinoid aneurysms that had more than 6 months of angiographic follow-up or recurrence within this period after endovascular treatment from January 2009 to December 2010. Paraclinoid aneurysms were classified into two types and then further into four subtypes by a modified classification method. A classification-based microcatheter shaping method was used in the procedure. The significant risk factors of angiographic results were determined through correlation analysis and logistic regression analysis by SPSS 17.0. There were 64 aneurysms in 56 patients; 28 aneurysms belonged to Type I, while 36 were Type II. A total of 12 aneurysms were managed with coil embolization, and 52 with stent-assisted coiling technique. Our classification-based microcatheter shaping method was successful in all cases. Coil protrusion happened in two cases without severe complications. Recurrence were found in 13 (20.3 %) aneurysms followed up at 12.42 ± 3.78 (mean±SD) months after treatment. The correlation between aneurysm types and immediate angiographic result or follow-up angiographic results did not reach statistical significance. Aneurysm types were not the risk factor of recurrence.

The types of paraclinoid aneurysm had not been significant correlated with outcomes of endovascular treatment. Fundus size was the significant risk factor of recurrence after endovascular treatment. A classification-based microcatheter shaping method may be used in endovascular treatment paraclinoid aneurysms. The present endovascular techniques are safe and effective.

Could the types of paraclinoid aneurysm be used as a criterion in choosing endovascular treatment?

Bureau of Labor Statistics figures have shown declines in injury and illness rates over the past 25 years. It is unclear what factors are contributing to that decline. Connecticut injury and illness data was industry-adjusted to account for the shifts in employment by industry sector for the 25-year period from 1976 to 2000. Additional adjustment was made for manufacturing sub-sectors, since declines in manufacturing employment accounted for the largest proportion of the shift in injuries over that period. Approximately 18% of the decline in injury and illness rates was associated with a shift in employment from more hazardous to less hazardous industries. Shifts in manufacturing sub-sectors accounted for an additional 5.7% of the decline.

A significant proportion of the decline in injury and illness rates appears to be due to demographic shifts in industry composition.

Are employment shifts into non-manufacturing industries partially responsible for the decline in occupational injury rates?

To reduce airway injury secondary to high suction pressures, the American Academy of Pediatrics Neonatal Resuscitation Program (NPR) recommends that suction pressures be less than 100 mm Hg. This study was conducted to determine if suction bulbs conform to these recommendations. In this prospective in vitro study, 25 personnel involved in neonatal resuscitation squeezed a new bulb three times for each of six commercially available bulbs using their delivery suite technique. A calibrated, pneumatic transducer measured the pressure of each squeeze. Only one bulb met the NRP guidelines with none of the participants exceeding 100mm Hg (p<0.001).

Only one bulb met the NRP guidelines of generating pressures less than 100 mm Hg. This bulb's large size (3 oz) may preclude its use in premature infants. Individuals involved in resuscitating newborns need to be aware of the pressures generated to avoid injuring the delicate oral airway.

Do bulb syringes conform to neonatal resuscitation guidelines?

Physicians play a role in the current prescription drug-abuse epidemic. Surgeons often prescribe more postoperative narcotic pain medication than patients routinely need. Although narcotics are effective for severe, acute, postoperative pain, few evidence-based guidelines exist regarding the routinely required amount and duration of use post-hospital discharge. Patients in a prospective cohort undergoing posterior spinal fusion for idiopathic scoliosis were asked preoperatively to rate their pain level, the level of pain expected each week postoperatively, and their pain tolerance. Post-discharge pain scores and narcotic use were reported at weekly intervals for 4 weeks postoperatively. Demographic data, preoperative Scoliosis Research Society (SRS)-22 scores, operative details, perioperative data, and self-reported pain levels were analyzed with respect to their association with total medication use and refills received. Disposal plans were also assessed. Seventy-two patients were enrolled, and 85% completed the surveys. The mean patient age was 14.9 years; 69% of the patients were female. The cohort was divided into 3 groups on the basis of total medication usage. The mean number of pills used in the middle (average-use) group was 49 pills. In postoperative week 4, narcotic usage was minimal (a mean of 2.9 pills by the highest-use group). Also by this time point, pain scores had, on average, returned to preoperative levels. Older age, male sex, a higher body mass index, and a higher preoperative pain score were associated with increased narcotic use. Sixty-seven percent of the patients planned to dispose of their unused medication, although only 59% of those patients planned on doing so in a manner recommended by the U.S. Food and Drug Administration.

Postoperative narcotic dosing may be improved by considering patient age, weight, sex, and preoperative pain score. The precise estimation of individual narcotic needs is complex. Patient and family education on the importance and proper method of narcotic disposal is an essential component of minimizing the availability of unused postoperative medication.

Are We Prescribing Our Patients Too Much Pain Medication?

To evaluate the predictive value of the absence of rapid and linear progressive motile spermatozoa "grade A" on the intrauterine insemination success rates. The present retrospective case-control study included 338 couples in their first intrauterine insemination cycles. All intrauterine insemination cycles were preceded by ovarian stimulation with recombinant follicle-stimulating hormone starting on cycle day 3 with a standard protocol. A single intrauterine insemination was performed 36-40 hours after human chorionic gonadotropin administration. Multivariate analysis was performed to define the independent predictors of intrauterine insemination success. The main outcome measure, the clinical pregnancy rate per cycle, was assessed in 3 different categories, according to the total motile sperm count (TMSC). Multivariate logistic regression analysis identified a 2.7 times increased chance of clinical pregnancy in the presence of grade A spermatozoa, after adjustment for female and male age (P = .023, 95% confidence interval 1.149-6.359). The influence of the absence of grade A spermatozoa on the clinical pregnancy rate was significant when the TMSC was 5-10 × 10(6) (0% vs 9.2%, respectively, P = .033).

The absence of grade A spermatozoa decreased the intrauterine insemination success rates in couples with male factor subfertility, especially when the TMSC was<10 × 10(6). In vitro fertilization, instead of intrauterine insemination, might be a more effective treatment option for couples with a TMSC<10 × 10(6) and no grade A spermatozoa.

Absence of rapid and linear progressive motile spermatozoa "grade A" in semen specimens: does it change intrauterine insemination outcomes?

Although the Brief Psychiatric Rating Scale (BPRS) is widely used for evaluating patients with schizophrenia, it has limited value in estimating the clinical weight of individual symptoms. The aim of this study was 4-fold: 1) to investigate the relationship of the BPRS to the Clinical Global Impression-Schizophrenia Scale (CGI-SCH), 2) to express this relationship in mathematical form, 3) to seek significant symptoms, and 4) to consider a possible modified BPRS subscale. We evaluated 150 schizophrenia patients using the BPRS and the CGI-SCH, then examined the scatter plot distribution of the two scales and expressed it in a mathematical equation. Next, backward stepwise regression was performed to select BPRS items that were highly associated with the CGI-SCH. Multivariate regression was conducted to allocate marks to individual items, proportional to their respective magnitude. We assessed the influence of modifications to the BPRS in terms of Pearson's r correlation coefficient and r-squared to evaluate the relationship between the two scales. Utilizing symptom weighting, we assumed a possible BPRS subscale. By plotting the scores for the two scales, a logarithmic curve was obtained. By performing a logarithmic transformation of the BPRS total score, the curve was modified to a linear distribution, described by [CGI-SCH] = 7.1497 × log10[18-item BPRS]- 6.7705 (p<0.001). Pearson's r for the relationship between the scales was 0.7926 and r-squared was 0.7560 (both p<0.001). Applying backward stepwise regression using small sets of items, eight symptoms were positively correlated with the CGI-SCH (p<0.005) and the subset gave Pearson's r of 0.8185 and r-squared of 0.7198. Further selection at the multivariate regression yielded Pearson's r of 0.8315 and r-squared of 0.7036. Then, modification of point allocation provided Pearson's r of 0.8339 and r-squared of 0.7036 (all these p<0.001). A possible modified BPRS subscale, "the modified seven-item BPRS", was designed.

Limited within our data, a logarithmic relationship was assumed between the two scales, and not only individual items of the BPRS but also their weightings were considered important for a linear relationship and improvement of the BPRS for evaluating schizophrenia.

Is there a linear relationship between the Brief Psychiatric Rating Scale and the Clinical Global Impression-Schizophrenia scale?

Population-based estimates for the prevalence of smokers receiving advice from a health professional to quit smoking and the prevalence of binge drinkers being talked to about alcohol use are lacking for U.S. adults. This information is useful for clinicians and public health professionals. Data are from the Behavioral Risk Factor Surveillance System, a continuous random-digit-dial telephone survey of U.S. adults. In 1997, 10 states collected data on these health interventions for tobacco and alcohol use. The prevalence of professional advice to quit smoking and about alcohol use was calculated and examined by demographic characteristics. The number of at-risk adults who had a routine checkup in the last year and had not received these interventions was also estimated. By self-report, 70% of smokers were advised to quit, and 23% of binge drinkers were talked to about their alcohol use. Using multivariate logistic regression analyses, we found among smokers that women and older persons were more likely to receive advice; among binge drinkers, health intervention was more likely to occur for men and non-Hispanic blacks. Across the 10 states, approximately 2 million smokers and 2 million binge drinkers with a routine checkup in the past 12 months were not advised to quit smoking or talked to about their alcohol use.

Many opportunities to intervene with smokers and binge drinkers are lost. Efforts to increase physician education and to identify and reduce other barriers may help.

Physician advice about smoking and drinking: are U.S. adults being informed?

To examine the extent to which obstetric providers abide by prenatal practice guidelines published by ACOG. The prenatal records were abstracted for low-risk patients initiating care with randomly selected urban obstetrician-gynecologists, rural obstetrician-gynecologists, urban family physicians, rural family physicians, and urban certified nurse-midwives in Washington state between September 1, 1988 and August 30, 1989. The prenatal care recorded in their medical charts was compared with the ACOG-recommended guidelines. Overall, providers of all five types adhered closely to the published standards. Certified nurse-midwives recorded a standard of practice that most closely matched that recommended by ACOG. Overall, there was less complete adherence in the recording of maternal height, fetal activity after 30 weeks' gestation, and fetal presentation at or after 36 weeks' gestation. Those laboratory tests that ACOG has recommended most recently (serum alpha-fetoprotein and diabetes screening) and those not recommended for routine use were ordered less often on average by providers.

The cross-sectional nature of this study cannot demonstrate definitively that ACOG's guidelines have changed provider prenatal practices. However, these findings demonstrate that providers in varying specialties and geographic locations can adhere to a detailed set of clinical guidelines if they are appropriately disseminated and implemented.

Do providers adhere to ACOG standards?

Infliximab, a monoclonal antibody directed against tumor necrosis factor α (TNFα), is commonly used during flares and on a regular basis to maintain the remission of inflammatory bowel diseases (IBD). It is usually administered in 2-hours infusion and 2 hours of monitoring after as recommended. However, recent reports suggest that infliximab infusions over a shorter period (30 minutes to 1 hour) are well tolerated. We aimed to compare the tolerability of 1-hour and 2-hours infliximab infusions in patients with IBD in our institution. We analyzed data from all patients treated with infliximab between 1999 and September 2010. Infliximab was administered in 1-hour infusion and 1 hour monitoring since 2009. Only the early adverse events were analyzed. Adverse events during infusion were compared between one group of patients who had 1-hour infusion (989 infusions) and the other who had 2-hours infusion (2102 infusions). The incidence of adverse events was 10.6% in the 2-hours infusion group versus 6.3% in the 1-hour infusion group (P=0.36).

These results suggest that the occurrence of infliximab infusion-related adverse events is similar across the two groups, regardless of the infusion cycle. One-hour infusion could then be proposed safely for all patients.

Infliximab infusion time in patients with inflammatory bowel diseases: is longer really safer?

Achieving sample size is imperative to obtaining sufficient power to detect potential effects in health care research, yet many research studies are prone to under-recruitment. Not only does this create problems with power but also it contributes to research extensions, additional costs and delayed results. To combat this problem, one increasingly used technique is database recruitment, a method of searching the electronic medical records system for potential research participants. We discuss the advantages and disadvantages of identifying potential research participants using database recruitment with particular reference to primary care.

Database recruitment is a relatively simple and affordable means to recruit large numbers of patients in a timely manner; however, it is not without limitations.

Database recruitment: a solution to poor recruitment in randomized trials?

Retrospective evaluation of the use of the free PSA index before prostatic biopsies. The authors retrospectively studied the values for total PSA, free PSA, and free PSA index (ratio of free PSA over total PSA expressed as a %) in men with a total PSA between 2 and 10 ng/ml, from a population of 391 men prior to prostatic biopsies. They also isolated a subgroup of patients in whom the free PSA index could have been used as a first-line marker to decide whether or not to perform prostatic biopsies. The mean values for total PSA, free PSA, and free PSA index were compared as a function of the diagnosis, age, and ultrasound prostatic volume. The yields of the various cut-off values for the free PSA index for PSA between 2 and 4 ng/ml, 4 and 10 ng/ml, and 2 and 10 ng/ml with a normal digital rectal examination are reported. Between 2 to 10 ng/ml, at a cut-off value of 30%, 94.1% of cancers would have been detected (sensitivity) and 22% of biopsies would have been avoided, 10 of which would have been useless, i.e. a 30.3% economy of useless biopsies not performed (specificity). At the cut-off value of 15%, less than half of cancers would have been detected (47.1%) and 90.9% of useless biopsies would have been avoided. Biases creating difficulties of interpretation were the assay kits, the reference population, age, storage of sera, and prostatic volume.

The free PSA index would be a useful first-line parameter in only 12.7% of candidates for prostatic biopsies. The cut-off value of 30%, validated for our assay method, would be able to detect the majority of cancers in men aged 50 to 65 years, while avoiding biopsies in the third of men with no detectable cancer.

Is it possible to define a threshold for free PSA index that is useful in the daily practice of urology?

Among patients with breast cancer, obesity has been associated with an increased likelihood of having triple-negative breast cancer (TNBC). This association has been thought to be due to the antiapoptotic effects of obesity-related proteins. However, the effect of obesity on the outcomes in patients with TNBC remains unclear. We hypothesized that obesity would be associated with decreased overall survival and disease-free survival in these patients. A retrospective review of a prospectively maintained database was conducted of patients treated for breast cancer at an academic medical center from March 1998 to September 2011. The body mass index (BMI) of patients with TNBC was calculated at diagnosis. The patients were categorized as normal (BMI < 25 kg/m(2)), overweight (BMI 25-30 kg/m(2)), or obese (BMI > 30 kg/m(2)). The endpoints of overall survival and disease-free survival were analyzed. A total of 183 patients with TNBC were included for analysis. Of the 183 patients, 24 (13.1%) were normal (BMI < 25 kg/m(2)), 42 (23.1%) were overweight (BMI 25-30 kg/m(2)), and 117 (63.7%) were obese (BMI > 30 kg/m(2)). The median follow-up period was 42.5 months. Of the 183 patients, 2 (9.1%) died in the normal group, 10 (23.1%) died in the overweight group, and 25 (21.4%) died in the obese group (P = 0.28). The patients who were overweight or obese had larger tumors (P = 0.02), a higher T stage (P = 0.001), and higher tumor grade (P = 0.01) than the normal BMI patients. By Kaplan-Meier analysis, normal patients had higher overall survival than the overweight or obese patients, but this difference was not statistically significant (P = 0.29). Disease-free survival was also not significantly different (P = 0.91).

Despite an increased frequency of larger tumors, higher T stage, and higher tumor grade, obesity was not associated with decreased overall or disease-free survival in patients with TNBC.

Does obesity have an effect on outcomes in triple-negative breast cancer?

The aim of this trial was to investigate the effect of therapeutic microwave diathermy (MD) on pain, disability, trunk muscle strength, walking performance, mobility, quality of life (QOL), and depression in the patients with chronic low back pain (CLBP). A total of 39 patients were included in this study. The patients were randomized into two groups. Group 1 (n=19) received MD treatment and exercises. Group 2 (n=20) was given only exercises. The pain (visual analog scale), disability (Oswestry Disability Questionnaire and pain disability index), walking performance (6 minute walking test, 6MWT), depression and QOL (Short Form 36) of all participants were evaluated. Patients were assessed before treatment (BT), after treatment (AT), and at a 1-month follow-up (F). The patients with CLBP in each group had significant improvements in pain, disability, muscle strength, endurance, 6MWT, mobility, QOL, and depression AT and F when compared with their initial status. There was no statistically significant difference between the groups regarding the change scores between AT-BT test and F-BT test.

Since a 2,450-MHz MD showed no beneficial effects on clinical parameters, exercise program could be preferable for the treatment of patients with CLBP alone.

Does microwave diathermy have an effect on clinical parameters in chronic low back pain?

Little has been reported about the completeness and accuracy of data in existing Australian clinical information systems. We examined the accuracy of the diagnoses of some chronic diseases in an ED information system (EDIS), a module of the NSW Health electronic medical record (EMR), and the consistency of the reports generated by the EMR. A list of ED attendees and those admitted was generated from the EDIS, using specific (e.g. angina) and possible clinical terms (e.g. chest pain) for the selected chronic diseases. This EDIS list was validated with an audit of discharge summaries, and compared with a list generated, using similar specific and possible Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT), from the underlying EMR database. Of the 33,115 ED attendees, 2559 had diabetes mellitus (DM), cardiovascular disease or asthma/chronic obstructive pulmonary disease; of these 2559, 876 were admitted. Discharge summaries were missing for 12-15% of patients. Only three-quarters or fewer of the diagnoses were confirmed by the discharge summary audit, best for DM and worst for cardiovascular disease. Proportion of agreement between the lists generated from the EDIS and EMR was best for DM and worst for asthma/chronic obstructive pulmonary disease. Possible reasons for this discrepancy are technical, such as use of different extraction terms or system inconsistency; or clinical, such as data entry, decision-making, professional behaviour and organizational performance.

Variations in information quality and consistency of the EDIS/EMR raise concerns about the 'fitness for purpose' of the information for care and planning, information sharing, research and quality assurance.

Health reform: is routinely collected electronic information fit for purpose?

As school dropout is an important public health problem that needs to be addressed, we set out to examine whether and how, beyond the well-known effects of sex, gender beliefs and self-reported masculinity and femininity are related to school dropout. The study used a case-control design, consisting of 330 dropout cases and 330 controls still attending school. The respondents, aged between 18 and 23 years, living in the south-east of the Netherlands, were sent a self-administered questionnaire. Separate logistic regression analyses for the male and female participants were used to explore the relation between dropout and gender, controlling for sociodemographic determinants. As indicated by significant curvilinearity, young women were less likely to drop out when they occupied an intermediate positions on the gender variables. Odds of dropout were elevated among highly masculine women (odds ratio = 2.1, 95% confidence interval: 1.1-4.1), and, as indicated by significant interactions, also among highly masculine men with strong normative masculine beliefs and in feminine men who simultaneously considered themselves low on masculinity.

Beyond sex, gender is important in the explanation of school dropout. To prevent dropout, public health professionals should assess, monitor and intervene on the basis of gender characteristics.

Are Barbie and Ken too cool for school?

Whether menopause-related changes in sex steroids account for midlife weight gain in women or whether weight drives changes in sex steroids remains unanswered. The objective of the study was to characterize the potential reciprocal nature of the associations between sex hormones and their binding protein with waist circumference in midlife women. The study included 1528 women (mean age 46 yr) with 9 yr of follow-up across the menopause transition from the observational Study of Women's Health Across the Nation. Waist circumference, SHBG, testosterone, FSH, and estradiol were measured. Current waist circumference predicted future SHBG, testosterone, and FSH but not vice versa. For each SD higher current waist circumference, at the subsequent visit SHBG was lower by 0.04-0.15 SD, testosterone was higher by 0.08-0.13 SD, and log(2) FSH was lower by 0.15-0.26 SD. Estradiol results were distinct from those above, changing direction across the menopause transition. Estradiol and waist circumference were negatively associated in early menopausal transition stages and positively associated in later transition stages (for each SD higher current waist circumference, future estradiol was lower by 0.15 SD in pre- and early perimenopause and higher by 0.38 SD in late peri- and postmenopause; P for interaction<0.001). In addition, they appeared to be reciprocal, with current waist circumference associated with future estradiol and current estradiol associated with future waist circumference. However, associations in the direction of current waist circumference predicting future estradiol levels were of considerably larger magnitude than the reverse.

These Study of Women's Health Across the Nation data suggest that the predominant temporal sequence is that weight gain leads to changes in sex steroids rather than vice versa.

Do changes in sex steroid hormones precede or follow increases in body weight during the menopause transition?

To determine if rural residence is independently associated with different access to health care services for children eligible for public health insurance. We conducted a mail-return survey of 10,175 families randomly selected from Oregon's food stamp population (46% rural and 54% urban). With a response rate of 31%, we used a raking ratio estimation process to weight results back to the overall food stamp population. We examined associations between rural residence and access to health care (adjusting for child's age, child's race/ethnicity, household income, parental employment, and parental and child's insurance type). A second logistic regression model controlled for child's special health care needs. Compared with urban children (reference = 1.00), rural children were more likely to have unmet medical care needs (odds ratio [OR] 1.48, 95% confidence interval [CI]1.07-2.04), problems getting dental care (OR 1.36, 95% CI 1.03-1.79), and at least one emergency department visit in the past year (OR 1.42, 95% CI 1.10-1.81). After adjusting for special health care needs (more prevalent among rural children), there was no rural-urban difference in unmet medical needs, but physician visits were more likely among rural children. There were no statistically significant differences in unmet prescription needs, delayed urgent care, or having a usual source of care.

These findings suggest that access disparities between rural and urban low-income children persist, even after adjusting for health insurance. Coupled with continued expansions in children's health insurance coverage, targeted policy interventions are needed to ensure the availability of health care services for children in rural areas, especially those with special needs.

Do children in rural areas still have different access to health care?

A randomized clinical has shown the effectiveness of intramuscular electrical stimulation for the treatment of poststroke shoulder pain. Identify predictors of treatment success and assess the impact of the strongest predictor on outcomes. This is a secondary analysis of a multisite randomized clinical trial of intramuscular electrical stimulation for poststroke shoulder pain. The study included 61 chronic stroke survivors with shoulder pain randomized to a 6-week course of intramuscular electrical stimulation (n = 32) versus a hemisling (n = 29). The primary outcome measure was Brief Pain Inventory Question 12. Treatment success was defined as>or = 2-point reduction in this measure at end of treatment and at 3, 6, and 12 months posttreatment. Forward stepwise regression was used to identify factors predictive of treatment success among participants assigned to the electrical stimulation group. The factor most predictive of treatment success was used as an explanatory variable, and the clinical trials data were reanalyzed. Time from stroke onset was most predictive of treatment success. Subjects were divided according to the median value of stroke onset: early (<77 weeks) versus late (>77 weeks). Electrical stimulation was effective in reducing poststroke shoulder pain for the early group (94% vs 7%, P<.001) but not for the late group (31% vs 33%). Repeated-measure analysis of variance revealed significant treatment (P<.001), time from stroke onset (P = .032), and treatment by time from stroke onset interaction (P<.001) effects.

Stroke survivors who are treated early after stroke onset may experience greater benefit from intramuscular electrical stimulation for poststroke shoulder pain. However, the relative importance of time from stroke onset versus duration of pain is not known.

Intramuscular electrical stimulation for shoulder pain in hemiplegia: does time from stroke onset predict treatment success?

Atrial fibrillation (AF) persisting after mitral valve surgery reduces survival due to heart failure and thrombo-embolisms, and impairs quality of life. Arrhythmia surgery for AF shows today very satisfying results and therefore mitral valve surgery with AF surgery appears appealing. This study explores whether combined surgery in view of today's results of mitral valve surgery is indicated. An outcome analysis of the arrhythmia outcome of patients undergoing exclusive mitral valve surgery with or without tricuspid repair was done. Preoperative baseline characteristics including arrhythmia pattern, surgical methods and follow-up findings were reviewed. Postoperative management of AF was not protocolized. Between 1990 and 1993, 162 consecutive patients underwent mitral valve surgery; follow-up was a mean of 3.3+/-1.9 years. In-hospital and late mortality were 1 and 9%, respectively. Sinus rhythm was preserved in 40 of 57 (70%) patients with preoperative sinus rhythm whereas AF persisted in 58 of 68 (85%) of patients with preoperative chronic AF (>1 year present). Sinus rhythm without AF was observed in 10 of 29 (34%) patients with preoperative paroxysmal AF. The 4-year Kaplan-Meier survival did not differ between patients with preoperative sinus rhythm (95.2%), paroxysmal AF (89.2%) and chronic AF (82.9%) but AF persisting after surgery tended to determine survival (P=0.05). Gender, age and right ventricular pressure and tricuspid valve repair were risk factors for postoperative recurrence of AF in patients with sinus rhythm at discharge, relative risk 0.35, 1.06, 1. 04 and 2.9, respectively.

Current mitral valve surgery with or without tricuspid valve repair does not eliminate preoperative paroxysmal or chronic AF. Secondly, because preoperative AF did not determine survival after mitral valve surgery, whereas postoperatively persisting AF was weakly associated with survival, atrial arrhythmia surgery primarily aims to reduce morbidity due to AF. Some characteristics can identify patients with increased propensity for persisting AF after surgery. Randomized studies of AF surgery are needed to identify suitable candidates for combined surgery.

Mitral valve surgery and atrial fibrillation: is atrial fibrillation surgery also needed?

In light of declining numbers of physician-scientists, the goal of this project was to identify strategies to invigorate and attract new talent to clinical research in the field of pediatric neurosciences. To develop a broad perspective, a program of direct questions was addressed to both US and non-US physicians at all stages of career development. Respondents identified numerous promising avenues of research but also indicated obstacles to research progress at all stages of career development including medical students, resident physicians, junior medical faculty, mid-career faculty, and senior faculty. At each career stage, ideas were offered to attract resources for, build prestige for, and motivate commitment for participation in clinical research.

Creative promotion of clinical research at all stages of medical education and career development offers great promise to expand current physician-scientist numbers, and thereby stimulate many exciting advances in medicine.

Basic and translational neonatal neuroscience research: whither goest the future of physician-scientists?