shukoor65/lab-rag-model huggingface dataset:
Consequences of queuing for care at a public hospital emergency department OBJECTIVE: To determine whether the length of a queue at a public hospital emergency department was associated with increased likelihood of patients' leaving without being seen by a physician and whether leaving adversely affected patients' health or affected their subsequent use of health care services. DESIGN: Observational cohort. Patients were surveyed during 1 week in July 1990 and received a follow-up survey 7 to 14 days later. The responses of patients who left without being seen by a physician were compared with those who were seen by a physician. SETTING: Emergency department at San Francisco (Calif) General Hospital. PATIENTS: All English-, Spanish-, and Cantonese-speaking adults waiting for emergency care were eligible. Of 882 eligible individuals, 700 agreed to participate; 85% of enrolled subjects saw a physician and 15% left without being seen. Demographic characteristics of patients who were and who were not seen were not significantly different. MAIN OUTCOME MEASURES: Emergency department waiting time and changes in patients' self-reported health. RESULTS: Patients were more likely to leave as waiting times increased. At follow-up, patients who left without being seen were twice as likely as those who were seen to report that their pain or the seriousness of their problem was worse. Only 4% of patients who left required subsequent hospitalization, but 27% returned to an emergency department. CONCLUSION: Many patients can appropriately decide whether their problem is truly urgent and make alternative plans in the face of long waits, but the health of some patients may be jeopardized by long queues for emergency care.
Four years of North American registry home parenteral nutrition outcome data and their implications for patient management. The OASIS Registry started annual collection of longitudinal data on patients on home parenteral nutrition (HPN) in 1984. This report describes outcome profiles on 1594 HPN patients in seven disease categories. Analysis showed clinical outcome was principally a reflection of the underlying diagnosis. Patients with Crohn's disease, ischemic bowel disease, motility disorders, radiation enteritis, and congenital bowel dysfunction all had a fairly long-term clinical outcome, whereas those with active cancer and acquired immunodeficiency syndrome (AIDS) had a short-term outcome. The long-term group had a 3-year survival rate of 65 to 80%, they averaged 2.6 complications requiring hospitalization per year, and 49% experienced complete rehabilitation. The short-term group had a mean survival of 6 months; they averaged 4.6 complications per year and about 15% experienced complete rehabilitation. The registry data also indicated HPN was used for 19,700 patients in 1987 with therapy growth averaging about 8% per year. This growth was chiefly from new cancer patients. The number of new patients with long-term disorders in whom HPN was initiated appeared rather constant. We conclude that these clinical outcome assessments justify HPN for long-term patients, but the utility and appropriateness of HPN for the cancer and AIDS patients remains uncertain and requires further study. Medical, social, and fiscal aspects of HPN management in long-term and short-term patients appear to involve quite separate considerations.
Can decision analysis help in the management of giant hemangioma of the liver? [editorial] We explore the trade-off between the risk and expected benefits from resection of giant liver hemangioma (GLH), one larger than 4 cm in diameter. We searched the English-language literature for studies of the postoperative mortality after resection of GLH and of the outcome of expectantly treated patients. The results of the data synthesis showed an operative mortality of 1.5% (90% confidence intervals, 0.1-3.0%) and an early surgical morbidity of up to 13%. Mortality among the 37 reported cases with ruptured GLH was 78%. There were no cases of spontaneous or traumatic rupture of unresected GLH during a follow-up of a total of 282 patient years. The main source of ambiguity regarding the management of GLH is the uncertain risk of its rupture. Rough estimates of this risk based on published data suggest that surgical resection is not justified in asymptomatic GLH. Yet, although rare, rupture of GLH does occur with disastrous consequences. Future research may attempt to define patient subsets whose GLHs are at higher risk of rupture, and in whom preventive resection may improve survival.
Evidence of a selective increase in cardiac sympathetic activity in patients with sustained ventricular arrhythmias BACKGROUND. Although enhanced efferent cardiac sympathetic nervous activity has been proposed as an important factor in the genesis of ventricular arrhythmias and sudden cardiac death, direct clinical evidence has been lacking. METHODS. We measured the rates of total and cardiac norepinephrine spillover into the plasma, which reflect respectively overall and cardiac sympathetic nervous activity, in 12 patients who had recovered from a spontaneous, sustained episode of ventricular tachycardia or ventricular fibrillation outside the hospital 4 to 48 days earlier. The results were compared with those from three age-matched reference groups without a history of ventricular arrhythmias: 12 patients with coronary artery disease, 6 patients with chest pain but normal coronary arteries, and 12 healthy, normal subjects. RESULTS. The patients who had had ventricular arrhythmias had reduced left ventricular ejection fractions, as compared with the patients with coronary artery disease or chest pain (mean [+/- SE], 46 +/- 3 percent vs. 58 +/- 4 percent and 69 +/- 5 percent, respectively; P less than 0.003). The rates of total norepinephrine spillover into the plasma were similar in the three reference groups, but 80 percent higher in the patients with ventricular arrhythmias (P less than 0.005). The rate of cardiac norepinephrine spillover was 450 percent higher in these patients (176 +/- 39 pmol per minute, as compared with 32 +/- 8 pmol per minute in the normal subjects; P less than 0.001), a disproportionate increase relative to the increase in total spillover, which indicated selective activation of the cardiac sympathetic outflow. This increase in cardiac norepinephrine spillover was probably caused by a reduction in left ventricular function. CONCLUSIONS. These results suggest that in some patients major ventricular arrhythmias are associated with and perhaps caused by sustained and selective cardiac sympathetic activation. We speculate that depressed ventricular function was present before the ventricular arrhythmia occurred, and that this resulted in reflex cardiac sympathetic activation, which in turn contributed to the genesis of the arrhythmia.
Sebaceous carcinoma: an unusual cause of a rapidly enlarging rhinophyma. We describe a patient who developed sebaceous carcinoma within a long-standing rhinophyma with rapid enlargement of the lesion. We believe the development of this tumour was a random occurrence but the possibility of tumour development should be considered in any rhinophyma showing a rapid increase in size.
End-stage avascular necrosis of bone in renal transplant patients. The natural history. We report the results of conservative treatment of stage III and stage IV avascular necrosis of bone (AVN) affecting the hip or knee in renal transplant patients. Twenty-nine patients were followed for a mean period of five years. Conservative management was successful in controlling symptoms in 40% of those with AVN of the hip and in 70% of those with AVN of the knee. Knowledge of the natural history of AVN is important because of the long survival times after renal transplantation.
Epicardial and endocardial mapping of ventricular tachycardia in patients with myocardial infarction. Is the origin of the tachycardia always subendocardially localized? BACKGROUND. Left ventricular endocardial reentry is the conventional concept underlying surgery for ventricular tachycardia (VT). We assessed the incidences of patterns showing complete reentry circuits at either the subendocardial or subepicardial level and of patterns in which left ventricular endocardial mapping could only in part account for a reentrant mechanism. METHODS AND RESULTS. We retrospectively analyzed epicardial and left ventricular endocardial isochronal maps of 47 VTs induced in 28 patients with chronic myocardial infarction (inferior, 14 patients; anteroseptal, 14 patients). Electrograms were recorded intraoperatively from 128 sites with epicardial sock and transatrial left ventricular endocardial balloon electrode arrays. Given the methodology used in this study, the mapping characteristics of the tachycardias suggested five types of activation patterns: 1) complete (90% or more of VT cycle length) subendocardial reentry circuits in seven VTs (15%) and seven patients (25%), 2) complete subepicardial reentry circuits in four VTs (9%) and four patients (14%), 3) incompletely mapped circuits with a left ventricular endocardial breakthrough preceding the epicardial breakthrough in 25 VTs (53%) and 21 patients (75%), 4) incompletely mapped circuits with a left ventricular epicardial breakthrough preceding the endocardial breakthrough in three VTs (6%) and three patients (11%), and 5) a right ventricular epicardial breakthrough preceding the left ventricular endocardial breakthrough in eight VTs (17%) and seven patients (25%). After surgery, one type 3 VT and three type 5 VTs were reinducible. Thus, left ventricular endocardial reentry substrates (types 1 and 3) accounted for 68% of VTs, but substrates involving subepicardial (types 2 and 4) and deep septal layers (type 5) accounted for 32% of VTs. CONCLUSIONS: In a substantial number of VTs, a substrate localization that is at variance with the conventional concept can be detected by simultaneous epicardial and endocardial mapping and may require modification of the surgical approach conventionally aimed at endocardial layers.
Preherpetic neuralgia. We have encountered six zoster patients whose pain preceded rash by 7 to more than 100 days. Pain was severe, burning, and radicular, and located both in dermatomes different from, as well as in, the area of eventual rash. Two patients ultimately developed disseminated zoster with neurologic complications, one of zoster paresis, and the other, a fatal zoster encephalitis; both had been taking long-term, low-dose steroids. A third case of preherpetic neuralgia developed in a patient with prior metastatic carcinoma, and another case in a patient with an earlier episode of brachial neuritis. The final two cases of preherpetic neuralgia developed in individuals with no underlying disease. An extended period of pain before the onset of zoster rash has gone largely unrecognized.
Clonorchis-associated cholangiocarcinoma: a report of two cases with unusual manifestations. Two cases of Clonorchis-associated cholangiocarcinoma are described along with their cholangiographic features to illustrate the spectrum of pathology ascribed to the injurious effects of the flukes on the bile duct epithelium. This includes adenomatous hyperplasia, extensive fibrosis, and carcinoma. The first case was also complicated by hepatic abscesses, left hepatic lobar atrophy, gastrobiliary and biliarocutaneous fistulae. The second case features an unusually dilated pancreatic duct containing pancreaticoliths that was found later to consist of hyperplastic bile duct epithelium, presumably carried by worm migration in the biliary tree. Liver sections from both patients showed typical features of hepatic clonorchiasis with the cancer. A knowledge of the wide spectrum of clinical presentation of clonorchiasis, particularly cholangiocarcinoma, might aid Western physicians in averting this serious sequela through prompt eradication of the helminthic infection and early recognition and treatment of its complications.
Biliary lithotripsy: correlation between gallbladder contractility before treatment and the success of treatment. We perform biliary lithotripsy without adjuvant chemolitholytic agents, and therefore fragment clearance depends solely on the gallbladder's ability to evacuate its contents. We studied 205 patients to determine if gallbladder contractility before biliary lithotripsy is a predictor of treatment results and rate of fragment clearance. Percentage gallbladder contraction was calculated from the fractional difference in the sonographically measured gallbladder volumes before and after a fatty meal. Seventy-six patients (37%) were free of stones and fragments, and 129 patients (63%) had residual fragments at comparable follow-up intervals. Statistical analysis showed a significant difference in gallbladder contractility before biliary lithotripsy between the fragment-free group and the residual-fragment group (p = .008). Stone burden before treatment showed no significant difference between the groups (p = .074), but the number of stones was significantly less in the fragment-free group (p = .022). In the fragment-free group, a poor correlation (r = .047) was found between the percentage gallbladder contraction and the rate of fragment clearance. These data indicate that contractility of the gallbladder before treatment correlates with overall success of biliary lithotripsy but is not a predictor of the speed of fragment clearance.
Long-term follow-up and prognostic factor analysis in advanced ovarian carcinoma: the Gynecologic Oncology Group experience. Long-term follow-up was obtained on 726 women with advanced ovarian carcinoma (suboptimal stage III and stage IV) who had received primary chemotherapy on two Gynecologic Oncology Group (GOG) protocols between 1976 and 1982. The first study compared melphalan alone versus melphalan plus hexamethylmelamine versus cyclophosphamide plus doxorubicin (CA). The second study evaluated the same CA regimen with or without cisplatin. Eligibility for the two studies was the same. At last contact, 76 patients were alive. In a multivariate analysis, cell type other than clear cell or mucinous, cisplatin-based treatment, good performance status, younger age, lower stage, clinically nonmeasurable disease, smaller residual tumor volume, and absence of ascites were favorable characteristics for overall survival (P less than .05). Second-look laparotomy was negative significantly more often among those with endometrioid tumors; there were no negative second-look laparotomies among those with mucinous or clear cell tumors. There were 30 patients with suboptimal stage III disease who had a negative second-look laparotomy; 18 (60%) have experienced recurrence, and 13 (43%) have died. Although cisplatin treatment was beneficial, new treatments are clearly needed.
Radiolabeled antibody imaging in the management of colorectal cancer. Results of a multicenter clinical study. Presurgical colorectal cancer patients (n = 116) received single intravenous infusions of 1 mg of CYT-103 (OncoScint CR103), an immunoconjugate of monoclonal antibody B72.3, radiolabeled with 111In. Following gamma camera imaging, 103 patients underwent an operative procedure: 92 had primary or recurrent colorectal carcinoma, 1 patient evaluated for recurrence of colorectal cancer had a second primary malignancy (small cell lung), and 10 patients had no demonstrable evidence of malignancy. 111In-CYT-103 immunoscintigraphic findings were consistent with the pathologic diagnoses for 70% of patients with colorectal cancer and 90% of disease-free patients. Antibody imaging contributed to surgical decision making through the detection of occult disease (12% of patients) and the confirmation of localized, potentially resectable disease without regional or metastatic spread. Seven patients (6%) experienced adverse effects, primarily fevers and itching, and 33% of patients developed antibodies to murine immunoglobulin after administration of 111In-CYT-103. The results of this study suggest that 111In-CYT-103 is a useful diagnostic tool for the presurgical evaluation of colorectal cancer patients.
Management of infected aortoiliac aneurysms. A 30-year retrospective review identified 13 patients treated for infected aneurysms of the abdominal aorta or iliac arteries, for an overall incidence of 0.65%. A constellation of clinical findings led to the correct preoperative diagnosis in 11 (85%) of 13 patients. Treatment methods included resection and in situ replacement grafting in seven patients, resection and extra-anatomic bypass in five patients, and resection-ligation in one patient. Four (31%) of 13 patients died within 30 days of operation, three of whom died of rupture. Overall, good results were achieved in five patients (38%), while poor results were noted in the remaining eight patients (62%). The determinants of outcome were aneurysm location or rupture, the presence of established infection, and the virulence of the infecting organism. In 10 (77%) of the 13 aneurysms, Salmonella species, Bacteroides fragilis, Staphylococcus aureus, and Pseudomonas aeruginosa accounted for all deaths, ruptures, and suprarenal aneurysm infections. These data suggest that patients with primary infections of the abdominal aorta or iliac arteries continue to present with advanced infections or aneurysm rupture that result in a high mortality.
Reduction in the incidence of acute bronchitis by an oral Haemophilus influenzae vaccine in patients with chronic bronchitis in the highlands of Papua New Guinea. Following the administration of a standardized questionnaire, 62 adult patients with chronic bronchitis were enrolled into a double-blind controlled trial of an oral killed Haemophilus influenzae vaccine in the highlands of Papua New Guinea. A 3-day course of vaccine or placebo was given monthly for 3 consecutive months. Participants were monitored weekly over 12 months for acute exacerbations; early morning sputum specimens were collected monthly and during acute exacerbations. Density of colonization by H. influenzae and H. parainfluenzae was determined by standard quantitative and semiquantitative techniques, and the latter method (quadrant score) was used to determine the density of growth of pneumococci. A total of 30 patients received vaccine and 32 placebo. The incidence rate of acute bronchitis in the vaccine group (0.011 episodes/person-weeks) was significantly lower than that in the placebo group (0.021 episodes/person-weeks), but there was no difference between the two groups in the incidence rates of more severe disease. Vaccine efficacy was maximal at times of peak incidence of disease. There was no evidence of a decline in vaccine efficacy for acute bronchitis over the 12-month follow-up period. The number of viable H. influenzae in the sputum declined in both vaccine and placebo groups over the 12-month follow-up period. The average concentration of H. influenzae in the vaccine group fell below that in the placebo group within 1 to 2 months after first immunization and remained so for 12 months, although the difference between the two groups narrowed during the follow-up period.
Regenerating nodules in hepatic cirrhosis: MR findings with pathologic correlation. To establish clearly the pathologic basis for small low-intensity nodules seen on MR images of the cirrhotic liver, we obtained MR images in 26 patients with cirrhosis in whom partial hepatectomy for hepatoma (15 patients), laparoscopy for cirrhosis (10 patients), or autopsy (one patient) was subsequently performed. Small low-intensity nodules were seen on gradient-echo images with short TEs (10-13 msec) in 13 of the 26 patients. In 12 of these 13 patients, small low-intensity nodules appeared larger and clearer as the TE was prolonged (14-25 msec). On T2-weighted spin-echo images, small low-intensity nodules were seen in 12 of the 13 patients, but not seen as well as on gradient-echo images. Pathologic correlation in these 13 patients revealed that the nodules on the MR images corresponded to iron deposits in regenerating nodules. Small low-intensity nodules were observed only on T2-weighted spin-echo images in two of the remaining 13 patients, in whom microscopic examination of the liver revealed marked inflammatory cell infiltration in the fibrous septa and no iron deposition. We conclude that small low-intensity nodules observed on MR images are caused by iron deposits in regenerating nodules, and that gradient-echo images with short and prolonged TEs are useful to confirm the presence of iron deposits in regenerating nodules.
Suture length to wound length ratio and the integrity of midline and lateral paramedian incisions. A total of 349 patients were randomized to undergo laparotomy through a lateral paramedian incision with layered closure (n = 137), a midline incision with mass closure (n = 104) or a midline incision using layered closure (n = 108), endeavouring to close the latter two incisions with a measured suture length to wound length ratio of greater than 4:1. After 18 months follow-up, no patient in the lateral paramedian group had developed an incisional hernia whereas 7 of 104 patients undergoing a midline incision with mass closure and 7 of 108 patients undergoing a midline incision with layered closure had incisional hernias (P less than 0.01). The mean suture length to wound length ratios for the three groups were 2.6 (range 1.3-6.2), 5.0 (range 3.0-8.7) and 3.7 (range 2.0-6.3) respectively (P less than 0.0001). The lateral paramedian incision remains superior to the midline incision closed with the mass technique and its integrity is independent of the suture length to wound length ratio.
Bilateral coronary ostial stenosis associated with aortitis syndrome. A patient with aortitis syndrome showed severe stenosis of the bilateral coronary ostium. We discuss the coronary angiographic findings and the treatment.
Spontaneous haematomyelia: a necropsy study. Spontaneous haematomyelia (intramedullary spinal haematoma), is an uncommon event. Predisposing conditions have been reported including syringomyelia, pregnancy and delivery, angioma, spinal artery aneurysm, and haemophilia, but only rarely has a pathological evaluation been performed. Two such cases studied at necropsy are reported. In one case, the haematoma was restricted to the cervical spinal cord, while in the second case it extended from the medulla into the lowest thoracic cord segments. In both cases the haematomyelia was fatal. In the first case the clinical course was subacute, but in the other the course was more acute. Careful neuropathological examination showed no apparent cause for the haemorrhages.
Cancer occurrence in a cohort of patients surgically treated for peptic ulcer. A cohort of 4107 patients treated surgically for peptic ulcer between 1955 and 1960 was followed up to determine the incidence of cancer by record linkage to the Danish Cancer Registry. A total of 930 cases of cancer were observed during 76,634 person-years. Relative risks of cancer were computed by comparison with the recorded cancer incidence in the Danish population. During the first five years after surgery the relative risk of gastric cancer was slightly increased (RR = 1.43), but 5-15 years after the operation the risk was lower than expected (RR = 0.55). Thereafter, the relative risk of gastric cancer increased steadily and increased more than twofold after 25 years. Lung cancer occurred more frequently in the cohort members than expected (RR = 1.66), but the relative risk was independent of time since surgery. Malignancies other than gastric cancer and cancers related to tobacco smoking were close to the expected numbers. The results do not support the findings of a recent British study of similar size in which increased risks were reported for cancer at other sites.