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Selected AbstractsIncreased death risk and altered cancer incidence pattern in patients with isolated or combined autoimmune primary adrenocortical insufficiencyCLINICAL ENDOCRINOLOGY, Issue 5 2008Sophie Bensing Summary Objectives, Primary adrenocortical insufficiency is mostly caused by an autoimmune destruction of the adrenal cortex. The disease may appear isolated or as a part of an autoimmune polyendocrine syndrome (APS). APS1 is a rare hereditary disorder with a broad spectrum of clinical manifestations. In APS2, primary adrenocortical insufficiency is often combined with autoimmune thyroid disease and/or type 1 diabetes. We analysed mortality and cancer incidence in primary adrenocortical insufficiency patients during 40 years. Data were compared with the general Swedish population. Design and patients, A population based cohort study including all patients with autoimmune primary adrenocortical insufficiency (3299) admitted to Swedish hospitals 1964,2004. Measurements, Mortality risk was calculated as the standardized mortality ratio (SMR) and cancer incidence as the standardized incidence ratio (SIR). Results, A more than 2-fold increased mortality risk was observed in both women (SMR 2·9, 95% CI 2·7,3·0) and men (SMR 2·5, 95% CI 2·3,2·7). Highest risks were observed in patients diagnosed in childhood. SMR was higher in APS1 patients (SMR 4·6, 95% CI 3·5,6·0) compared with patients with APS2 (SMR 2·1, 95% CI 1·9,2·4). Cancer incidence was increased (SIR 1·3, 95% CI 1·2,1·5). When tumours observed during the first year of follow-up were excluded, only the cancer risk among APS1 patients remained increased. Cause-specific cancer incidence analysis revealed significantly higher incidences of oral cancer, nonmelanoma skin cancer, and male genital system cancer among patients. Breast cancer incidence was lower than in the general population. Conclusions, Our study shows a reduced life expectancy and altered cancer incidence pattern in patients with autoimmune primary adrenocortical insufficiency. [source] Recent advances in the management and prophylaxis of respiratory syncytial virus infectionACTA PAEDIATRICA, Issue 2001A Greenough Respiratory syncytial virus (RSV) infection is an important cause of morbidity, particularly in prematurely born infants who have had chronic lung disease. Current therapy is essentially supportive. Overall, the results of randomized trials do not support the use of bronchodilators, corticosteroids or Ribavirin. Nitric oxide and exogenous surfactant may improve the respiratory status of those infants who require ventilatory support. Nosocomial infection can be reduced by appropriate handwashing. There is no safe and effective vaccine for use in infants. Immunoprophylaxis reduces hospitalization and requirement for intensive care. Palivizumab, a humanized monoclonal antibody, is preferred to RSV immune globulin as the immunoprophylactic agent. Immunoprophylaxis should be reserved for infants at highest risk of severe respiratory syncytial virus infection, if this strategy is to be used most cost-effectively. [source] Dental injuries resulting from tracheal intubation , a retrospective studyDENTAL TRAUMATOLOGY, Issue 1 2009Jobst Vogel Thus, this retrospective study was conducted including the data of 115,151 patients. All patients involved had been exposed to general anesthesia between 1995 and 2005. The resulting tooth injuries were assessed according to the following parameters: age, kind of hospital conducting treatment, intubation difficulties, pre-existing tooth damage, type and localization of tooth, type of tooth damage, and the number of teeth injured. At least 170 teeth were injured in 130 patients, while patients 50 years of age and older were especially affected. In contrast to older patients where in the majority of cases the periodontium (lateral dislocation) was injured, in younger patients dental hard tissue (crown fracture) was more likely to be affected. It was calculated that patients from the cardiothoracic surgery clinic were showing the highest risk of tooth damage. In more than three-fourth of all cases the anterior teeth of the maxilla, especially the maxillary central incisors, were affected. Pre-existing dental pathology like caries, marginal periodontitis and tooth restorations were often distinguishable prior to operation. Mouthguards in connection with tracheal intubation are not generally recommended as preventive device, due to the already limited amount of space available. Instead, pre-existing risk factors should be thoroughly explored before the induction of intubation narcosis. [source] Latex allergy: diagnosis and managementDERMATOLOGIC THERAPY, Issue 4 2004James S. Taylor ABSTRACT:, Latex allergy is an IgE-mediated immediate hypersensitivity response to natural rubber latex (NRL) protein with a variety of clinical signs ranging from contact urticaria, angioedema, asthma, and anaphylaxis. Major allergens include dipped latex products such as gloves and balloons. In highest risk for NRL allergy are patients with spina bifida, but health care workers and others who wear latex gloves are also at risk. NRL allergic patients may also react to fruits/foods, especially banana, kiwi, and avocado. Diagnosis is made by a positive latex RAST and/or skin prick test or challenge test to NRL. Allergen avoidance and substitution and the use of latex-safe devices including synthetic gloves (vinyl, synthetic polyisoprene, neoprene, nitrile, block polymers, or polyurethane) are essential for the affected patient. Accommodation in the workplace may include the use of powder-free, low-allergen NRL gloves or synthetic gloves. These preventive measures have significantly reduced the prevalence of reported reactions to NRL. Hyposensitization is not yet feasible. [source] Candidate genes and the behavioral phenotype in 22q11.2 deletion syndromeDEVELOPMENTAL DISABILITIES RESEARCH REVIEW, Issue 1 2008Sarah E. Prasad Abstract There is an overwhelming evidence that children and adults with 22q11.2 deletion syndrome (22q11.2DS) have a characteristic behavioral phenotype. In particular, there is a growing body of evidence that indicates an unequivocal association between 22q11.2DS and schizophrenia, especially in adulthood. Deletion of 22q11.2 is the third highest risk for the development of schizophrenia, with only a greater risk conferred by being the child of two parents with schizophrenia or the monozygotic co-twin of an affected individual. Both linkage and association studies of people with schizophrenia have implicated several susceptibility genes, of which three are in the 22q11.2 region; catechol- o -methyltransferase (COMT), proline dehydrogenase (PRODH), and Gnb1L. In addition, variation in Gnb1L is associated with the presence of psychosis in males with 22q11.2DS. In mouse models of 22q11.2DS, haploinsufficiency of Tbx1 and Gnb1L is associated with reduced prepulse inhibition, a schizophrenia endophenotype. The study of 22q11.2DS provides an attractive model to increase our understanding of the development and pathogenesis of schizophrenia and other psychiatric disorders in 22q11.2DS and in wider population. © 2008 Wiley-Liss, Inc. Dev Disabil Res Rev 2008;14:26,34. [source] Type 2 diabetes and cardiovascular disease in polycystic ovary syndrome: what are the risks and can they be reduced?DIABETIC MEDICINE, Issue 5 2010J. Tomlinson Diabet. Med. 27, 498,515 (2010) Abstract Polycystic ovary syndrome (PCOS) is a risk factor for Type 2 diabetes mellitus (T2DM) and cardiovascular disease (CVD), but these risks are poorly defined. This study aimed to evaluate the evidence for these risks and whether screening and risk reduction are feasible. Medline reviews and data quality analysis were used using standard tools. Results showed that (i) polycystic ovary syndrome is a risk factor forT2DM but the magnitude of risk is uncertain, (ii) fasting plasma glucose is an inadequate screening test forT2DM in this population and the oral glucose tolerance test is superior, (iii) the identification of women with PCOS for diabetes screening is constrained by current diagnostic criteria for PCOS; however, women with oligomenorrhoea and those with diagnosed PCOS and obesity or a family history of T2DM are at highest risk, (iv) risk factors for T2DM are improved by weight loss interventions and by metformin. However, no studies have determined whether T2DM incidence is reduced, (v) polycystic ovary syndrome is associated with cardiovascular disease (CVD) risk factors but data on CVD incidence are weak, (vi) risk factors for CVD are improved by the same interventions and statins and (vi) no studies have evaluated whether CVD incidence is reduced. While PCOS has important metabolic associations, and short-term interventions reduce risk factors for T2DM and CVD, data on prevalence and incidence of T2DM and particularly CVD are poor. There is a need for a clear definition of PCOS, for diabetes screening protocols and for long-term studies to determine whether risks can be reduced. [source] Near patient blood ketone measurements and their utility in predicting diabetic ketoacidosisDIABETIC MEDICINE, Issue 2 2005S. Harris Abstract Aim To assess the utility of near patient blood ketone measurements in predicting diabetic ketoacidosis (DKA) among a group of hyperglycaemic unwell patients presenting to a hospital emergency department. Methods Near patient blood ,-hydroxybutyrate (,-OHB) testing has recently been introduced as a new tool in our hospital Accident and Emergency department (A&E) for patients with a finger-prick glucose of > 11 mmol/l. We reviewed the records of the first 50 patients to have a ,-OHB measurement to establish if they developed DKA or received treatment with intravenous insulin within 48 h of presentation. We then compared the diagnostic power of ,-OHB measurements with other clinical, physiological and biochemical markers of DKA. Results Nine patients had DKA, eight had a compensated metabolic acidosis secondary to raised serum ketones, and 33 had no evidence of DKA during the following 48 h. The median (range) ,-OHB levels in each group were 6.0 (3.1,6.0) mmol/l, 3.4 (1.2,5.7) mmol/l, and 0.1 (0.0,1.2) mmol/l, respectively. A ,-OHB level of , 3.0 mmol/l had a sensitivity of 100% and specificity of 88% for DKA. All those with ,-OHB level > 3.0 mmol/l required treatment with intravenous insulin. Conclusion Measuring ,-OHB when a hyperglycaemic patient is identified could offer a simple method of identifying at an early stage those patients at highest risk of DKA (,-OHB > 3.0 mmol/l), and redirecting the search for a diagnosis in others (,-OHB < 1.0 mmol/l). [source] Prevention of Type 2 diabetes mellitus.DIABETIC MEDICINE, Issue 5 2004A review of the evidence, its application in a UK setting Abstract Type 2 Diabetes mellitus (T2DM) is a complex metabolic, multifactorial disease, which affects the quality, quantity and style of life. People with T2DM have a life expectancy that can be shortened by as much as 15 years, with up to 75% dying of macrovascular complications. To reduce the impact of T2DM in the 21st century, we need an approach that not only optimally treats the person with established diabetes but also prevents diabetes from occurring in the first place. The best evidence for prevention of diabetes is for interventions that target individuals at highest risk. Targeting patients who have impaired glucose tolerance with lifestyle changes including physical activity and dietary factors has been shown to be effective in the Chinese, North American and Finnish populations. In order for such lifestyle interventions to be successful in other populations, they need to be culturally sensitive, individualized and sustained. Some pharmacological agents including metformin and acarbose have also been shown to be effective, although the profile of those who respond is different. There continues to be a need to develop and evaluate interventions that target communities and populations at risk in a UK setting. Diabet. Med. (2004) [source] Atypical antipsychotics and weightgain , a systematic reviewACTA PSYCHIATRICA SCANDINAVICA, Issue 6 2000D. M. Taylor Objective: To review systematically data relating to weight changes with atypical antipsychotics. Method: We conducted a Medline search on October 29 1999 and covered the period 1980,99. All recovered papers were examined for further relevant reports. In addition, we wrote to pharmaceutical manufacturers and 10 practising clinicians to ask them to provide other relevant reports known to them. Results: Eighty reports mentioning change in body weight were retrieved. Data relating to weight changes were of variable quality. Weight changes were indicated by a variety of measures. The majority of reports related to short-term changes. Conclusion: All atypical drugs, with the exception of ziprasidone, have been associated with weight increases. Clozapine seems to have the highest risk of weight gain, followed by olanzapine and quetiapine. There is probably a lower risk with risperidone, sertindole and zotepine and a still lower risk with amisulpride. Ziprasidone appears not to be associated with weight gain. In the absence of more compelling data, these rankings must be considered approximate and preliminary. Longer, more robust trials are needed. [source] Effects of Valproate on Acylcarnitines in Children with Epilepsy Using ESI-MS/MSEPILEPSIA, Issue 1 2007Tamara Werner Summary:,Purpose: To determine the influence of valproate (VPA) treatment on acylcarnitines in children with epilepsy. Methods: Determination of acylcarnitines (including free carnitine and acylcarnitines from C2 to C18) in dried blood spot specimens using tandem-mass spectrometry. Longitudinal study of changes in acylcarnitines in children under VPA treatment without pretreatment (group 1) or with pretreatment with other antiepileptic drugs (group 2) before the start of VPA treatment at an early and a late treatment interval (12,66, 90,260 days after the beginning of treatment, respectively). Cross-sectional comparison of these two VPA groups and of a group receiving carbamazepine monotherapy (group 3) with controls. Results: Acylcarnitines in epileptic patients before VPA therapy did not differ from control values. In group 1, decreases of C0 (,26%), C2 (,12%), C16 (,31%), C18 (,41%), Ctotal (,10%), increases of C5OH (+31%), C8 (+33%) in the early treatment interval, and decreases of C16 (,21%), C18 (,42%), and increases of C2 (+26%), C5OH (+44%) in the late treatment interval were significant. In group 2, both in the longitudinal and the cross-sectional study, only a decrease of C18 (,41%, ,43%, respectively) in the late treatment interval was found. In group 3, no significant changes have been observed. Conclusions: We could prove changes in acylcarnitine subspecies, which were associated with VPA treatment in children with epilepsy. The treatment interval with the most marked changes coincides with the interval of highest risk for VPA-induced hepatotoxicity. The observed specific acylcarnitine pattern might point to the impaired intermediary metabolism that is responsible for VPA-induced hepatotoxicity. [source] An Epidemiologic Study of Closed Emergency Department Malpractice Claims in a National Database of Physician Malpractice InsurersACADEMIC EMERGENCY MEDICINE, Issue 5 2010Terrence W. Brown MD Abstract Objectives:, The objective was to perform an epidemiologic study of emergency department (ED) medical malpractice claims using data maintained by the Physician Insurers Association of America (PIAA), a trade association whose participating malpractice insurance carriers collectively insure over 60% of practicing physicians in the United States. Methods:, All closed malpractice claims in the PIAA database between 1985 and 2007, where an event in an ED was alleged to have caused injury to a patient 18 years of age or older, were retrospectively reviewed. Study outcomes were the frequency of claims and average indemnity payments associated with specific errors identified by the malpractice insurer, as well as associated health conditions, primary specialty groups, and injury severity. Indemnity payments include money paid to claimants as a result of settlement or court adjudication, and this financial obligation to compensate a claimant constitutes the insured's financial liability. These payments do not include the expenses associated with resolving a claim, such as attorneys' fees. The study examined claims by adjudicatory outcome, associated financial liability, and expenses of litigation. Adjudicatory outcome refers to the legal disposition of a claim as it makes its way into and through the court system and includes resolution of claims by formal verdict as well as by settlement. The study also investigated how the number of claims, average indemnity payments, paid-to-close ratios (the percentage of closed claims that resolved with a payment to the plaintiff), and litigation expenses have trended over the 23-year study period. Results:, The authors identified 11,529 claims arising from an event originating in an ED, representing over $664 million in total liability over the 23-year study period. Emergency physicians (EPs) were the primary defendants in 19% of ED claims. The largest sources of error, as identified by the individual malpractice insurer, included errors in diagnosis (37%), followed by improper performance of a procedure (17%). In 18% of claims, no error could be identified by the insurer. Acute myocardial infarction (AMI; 5%), fractures (6%), and appendicitis (2%) were the health conditions associated with the highest number of claims. Over two-thirds of claims (70%) closed without payment to the claimant. Most claims that paid out did so through settlement (29%). Only 7% of claims were resolved by verdict, and 85% of those were in favor of the clinician. Over time, the average indemnity payments and expenses of litigation, adjusted for inflation, more than doubled, while both the total number of claims and number of paid claims decreased. Conclusions:, Emergency physicians were the primary defendants in a relatively small proportion of ED claims. The disease processes associated with the highest numbers of claims included AMI, appendicitis, and fractures. The largest share of overall indemnity was attributed to errors in the diagnostic process. The financial liability of medical malpractice in the ED is substantial, yet the vast majority of claims resolve in favor of the clinician. Efforts to mitigate risk in the ED should include the diverse clinical specialties who work in this complex environment, with attention to those health conditions and potential errors with the highest risk. ACADEMIC EMERGENCY MEDICINE 2010; 17:553,560 © 2010 by the Society for Academic Emergency Medicine [source] Invasive fungal infections in patients with acute myeloid leukemia and in those submitted to allogeneic hemopoietic stem cell transplant: who is at highest risk?EUROPEAN JOURNAL OF HAEMATOLOGY, Issue 3 2008Morena Caira No abstract is available for this article. [source] Screening for fetal alcohol syndrome: is it feasible and necessary?ADDICTION BIOLOGY, Issue 2 2000Larry Burd The potential to utilize screening strategies to improve the identification and outcome of persons with fetal alcohol syndrome (FAS) is reviewed. FAS is a condition where screening and surveillance activities would be appropriate. Development of FAS screening and surveillance programs is encouraged because the disorder is expensive. People with FAS have poor outcomes as adults with less than 10% living independently. Several useful tools and models are available. Screening would improve ascertainment and prevalence estimates. Early identification could improve access to services and long term outcome, secondary disabilities and, by extension, excess disability in affected children could be decreased. Lastly, mothers who are at the highest risk to have additional children with FAS could be identified and offered treatment. While both screening and surveillance activities are discussed, the principle focus of this article is a review of the screening process. Two screening tools and several screening methodologies for FAS are available. Since no test will be appropriate in all settings, screening tests need to be selected depending on the setting and population of interest. Screening for FAS should be conducted in a variety of settings and in populations of both high and moderate risk. The results would also provide important data to influence public policy development and resource allocation. Appropriate evaluation of the efficacy, efficiency and effectiveness of FAS screening tools and methodologies would be important before utilization in screening programs. [source] Nonobese population in a developing country has a high prevalence of nonalcoholic fatty liver and significant liver disease,,HEPATOLOGY, Issue 5 2010Kausik Das There is a paucity of community-based epidemiological data on nonalcoholic fatty liver (NAFL) among nonaffluent populations in developing countries. Available studies are radiological and/or biochemical and lack histological assessment, limiting their strength. We conducted a prospective epidemiological study comprising a 1:3 subsample of all adult (>18 years) inhabitants of a rural administrative unit of West Bengal, India. Subjects positive for hepatitis B virus and/or hepatitis C virus infection and consuming any amount of alcohol were excluded. Diagnosis of NAFL was by dual radiological screening protocol consisting of ultrasonographic and computed tomographic examination of the liver. Transient elastographic examination and liver biopsy were performed in a subset to identify significant liver disease. The risk factors of having NAFL were analyzed. A total of 1,911 individuals were analyzed, 7% of whom were overweight and 11% of whom had abdominal obesity. The prevalence of NAFL, NAFL with elevated alanine aminotransferase, and cryptogenic cirrhosis was 8.7%, 2.3%, and 0.2%, respectively. Seventy-five percent of NAFL subjects had a body mass index (BMI) <25 kg/m2, and 54% were neither overweight nor had abdominal obesity. The subjects with the highest risk of having NAFL were those with a BMI >25 kg/m2 (odds ratio 4.3, 95% confidence interval 1.6-11.5). Abdominal obesity, dysglycemia (fasting plasma glucose >100 mg/dL or elevated homeostatic model assessment of insulin resistance), and higher income were the other risk factors. Even having a normal BMI (18.5-24.9 kg/m2) was associated with a 2-fold increased risk of NAFL versus those with a BMI <18.5 kg/m2. Conclusion: There is a significant prevalence of NAFL and potentially significant liver disease, including cryptogenic cirrhosis, in this predominantly nonobese, nonaffluent population in a developing country. NAFL will be a major determinant of future liver disease burden in countries of the developing world. (HEPATOLOGY 2010) [source] Closely linked cis -acting modifier of expansion of the CGG repeat in high risk FMR1 haplotypes,HUMAN MUTATION, Issue 12 2007S. Ennis Abstract In its expanded form, the fragile X triplet repeat at Xq27.3 gives rise to the most common form of inherited mental retardation, fragile X syndrome. This high population frequency persists despite strong selective pressure against mutation-bearing chromosomes. Males carrying the full mutation rarely reproduce and females heterozygous for the premutation allele are at risk of premature ovarian failure. Our diagnostic facility and previous research have provided a large databank of X chromosomes that have been tested for the FRAXA allele. Using this resource, we have conducted a detailed genetic association study of the FRAXA region to determine any cis -acting factors that predispose to expansion of the CGG triplet repeat. We have genotyped SNP variants across a 650-kb tract centered on FRAXA in a sample of 877 expanded and normal X chromosomes. These chromosomes were selected to be representative of the haplotypic diversity encountered in our population. We found expansion status to be strongly associated with a ,50-kb region proximal to the fragile site. Subsequent detailed analyses of this region revealed no specific genetic determinants for the whole population. However, stratification of chromosomes by risk subgroups enabled us to identify a common SNP variant which cosegregates with the subset of D group haplotypes at highest risk of expansion (,=17.84, p=0.00002). We have verified that this SNP acts as a marker of repeat expansion in three independent samples. Hum Mutat 28(12), 1216,1224, 2007. © 2007 Wiley-Liss, Inc. [source] Management and prevention of postoperative Crohn's diseaseINFLAMMATORY BOWEL DISEASES, Issue 10 2009Miguel Regueiro MD Abstract Postoperative Crohn's disease (CD) recurrence is a common occurrence after intestinal resection. Currently, the optimal management of patients who have undergone surgical resection is unknown and treatment remains subjective. Clinicians in conjunction with patients must balance the risks of recurrence against the potential risks associated with treatment. For those at very low risk of recurrence, no therapy may be needed; however, for patients at moderate risk immunomodulators should be considered. For those at highest risk of recurrence, biologic therapy, specifically antitumor necrosis factor agents, have emerged as appropriate treatment. Any postoperative management strategy should include a colonoscopy 6,12 months after surgery to identify recurrence. This review discusses current evidence for various pharmacologic approaches in the prevention of postoperative recurrence and provides guidance for clarifying patient risk. (Inflamm Bowel Dis 2009) [source] Gonadal dysfunction in male cancer patients before cytotoxic treatmentINTERNATIONAL JOURNAL OF ANDROLOGY, Issue 1 2010Niels J. Van Casteren Summary Male patients diagnosed with cancer are often referred for semen cryopreservation before gonadotoxic treatment but often have low semen quality. The aim of this study was to evaluate which type of cancer affects gonadal function and proposes a risk factor for low pre-treatment semen quality. Between January 1983 and August 2006, 764 male cancer patients were referred for semen cryopreservation prior to chemotherapy and radiotherapy. We compared semen characteristics and reproductive hormones between different groups of cancer patients. In addition, we evaluated the role of tumour markers in patients with testicular germ-cell tumours (TGCT) on fertility. Abnormal semen parameters were found in 489 men (64%) before cancer treatment. Patients with TGCT and extragonadal germ-cell tumours had significantly lower sperm concentrations and inhibin B levels than all other patient groups. No semen could be banked in 93 patients (12.2%). Eight hundred and thirty-nine of 927 (90%) produced semen samples were adequate for cryopreservation. Inhibin B in all groups showed to be the best predictor of semen quality. Although pre-treatment raised tumour markers were associated with a decrease in inhibin B and increased follicle stimulating hormone, both predictive for low semen quality; no direct linear association could be found between raised beta-HCG, alfa-fetoprotein and semen quality. Only 1/3 of cancer patients had normal semen parameters prior to cancer treatment. Patients with TGCT and extragonadal GCT have the highest risk for impaired semen quality and gonadal dysfunction at the time of semen cryopreservation. [source] Parental lung cancer as predictor of cancer risks in offspring: Clues about multiple routes of harmful influence?INTERNATIONAL JOURNAL OF CANCER, Issue 3 2006Kari Hemminki Abstract The carcinogenic effects of active smoking have been demonstrated for many sites, but the effects of passive smoking and exposures during pregnancy and breastfeeding are less well documented. We examined whether 0,70-year-old offspring of parents with lung cancer are at a risk of cancer that cannot be explained by their smoking or familial risk. It was assumed that known target sites for tobacco carcinogenesis would be affected, if any. The nationwide Swedish Family-Cancer Database with cancers recorded from 1958 to 2002 was used to calculate age-specific standardized incidence ratios (SIRs). Among offspring of affected mothers, increased risks were observed for upper aerodigestive (SIR 1.45), nasal (2.93), lung (1.71) and bladder (1.52) cancers and for kidney cancer (6.41) in one age group. The risk of bladder cancer was found in younger age groups than that of lung cancer. Cancers at many of these sites, but not the kidney or the bladder, were in excess in offspring of affected fathers. Nasal cancer was even increased when either parent was diagnosed with lung cancer; the highest risk was for nasal adenoid cystic carcinoma (7.73). The data suggest that passive smoking during childhood is associated with an increase risk of nasal cancer. For bladder and kidney cancers, a contribution by tobacco carcinogens is implicated through breastfeeding and in utero exposure. © 2005 Wiley-Liss, Inc. [source] Metabolic side effects of antipsychotic medicationINTERNATIONAL JOURNAL OF CLINICAL PRACTICE, Issue 8 2007A. Tschoner Summary The use of second-generation antipsychotics (SGAs) is associated with metabolic side effects including weight gain, diabetes mellitus and an atherogenic lipid profile. These adverse effects are not only the risk factors for cardiovascular disease, insulin resistance and diabetes mellitus leading to increased morbidity and mortality but may also impair the patient's adherence to treatment. SGAs in particular are associated with significant weight gain with clozapine and olanzapine carrying the highest risk, whereas newer agents, such as risperidone and aripiprazole, are considered to be less prone to cause weight gain. Consequently, a consensus development conference convened issuing recommendations on patient monitoring when treated with SGAs. The metabolic effects of antipsychotic drugs should be of concern when planning a patient's treatment strategy. Baseline screening and regular follow-up monitoring whose intervals should depend on the individual predisposition are advised. Possible therapeutical strategies for the management of drug-induced obesity include therapeutic approaches, such as life style change and pharmaceutical intervention. Drugs with a weight reducing effect become more important because of the lack of compliance with behavioural intervention. Topiramate, histamine-antagonists, dopaminergic- and serotoninergic agents have shown positive results in the management of psychotropic medication induced weight gain. However, further trials are required to support a specific therapeutical approach as well as studies to investigate the underlying mechanisms for future drug development. [source] Effectiveness of nurse-led cardiac clinics in adult patients with a diagnosis of coronary heart diseaseINTERNATIONAL JOURNAL OF EVIDENCE BASED HEALTHCARE, Issue 1 2005Tamara Page RN BN HyperbaricNursCert GradDipNSc(HighDep) MNSc Executive summary Background, Coronary heart disease is the major cause of illness and death in Western countries and this is likely to increase as the average age of the population rises. Consumers with established coronary heart disease are at the highest risk of experiencing further coronary events. Lifestyle measures can contribute significantly to a reduction in cardiovascular mortality in established coronary heart disease. Improved management of cardiac risk factors by providing education and referrals as required has been suggested as one way of maintaining quality care in patients with established coronary heart disease. There is a need to ascertain whether or not nurse-led clinics would be an effective adjunct for patients with coronary heart disease to supplement general practitioner advice and care. Objectives, The objective of this review was to present the best available evidence related to nurse-led cardiac clinics. Inclusion criteria, This review considered any randomised controlled trials that evaluated cardiac nurse-led clinics. In the absence of randomised controlled trials, other research designs such as non-randomised controlled trials and before and after studies were considered for inclusion. Participants were adults (18 years and older) with new or existing coronary heart disease. The interventions of interest to the review included education, assessment, consultation, referral and administrative structures. Outcomes measured included adverse event rates, readmissions, admissions, clinical and cost effectiveness, consumer satisfaction and compliance with therapy. Results, Based on the search terms used, 80 papers were initially identified and reviewed for inclusion; full reports of 24 of these papers were retrieved. There were no papers included that addressed cost effectiveness or adverse events; and none addressed the outcome of referrals. A critical appraisal of the 24 remaining papers identified a total of six randomised controlled trials that met the inclusion criteria. Two studies addressed nurse-led clinics for patients diagnosed with angina, one looked at medication administration and the other looked at educational plans. A further four studies compared secondary preventative care with a nurse-led clinic and general practitioner clinic. One specifically compared usual care versus shared care introduced by nurses for patients awaiting coronary artery bypass grafting. Of the remaining three studies, two have been combined in the results section, as they are an interim report and a final report of the same study. Because of inconsistencies in reporting styles and outcome measurements, meta-analysis could not be performed on all outcomes. However, a narrative summary of each study and comparisons of specific outcomes assessed from within each study has been developed. Although not all outcomes obtained statistical significance, nurse-led clinics were at least as effective as general practitioner clinics for most outcomes. Recommendations, The following recommendations are made: ,The use of nurse-led clinics is recommended for patients with coronary heart disease (Level II). ,Utilise nurse-led clinics to increase clinic attendance and follow-up rates (Level II). ,Nurse-led clinics are recommended for patients who require lifestyle changes to decrease their risk of adverse outcomes associated with coronary heart disease (Level II). [source] Reaching the population with dementia drugs: what are the challenges?INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY, Issue 7 2007Fiona E Matthews Abstract Background Systematic evidence became available in the late 1990s on efficacy of cholinesterase inhibitors (CHEIs) for patients with mild to moderate Alzheimer's disease (AD) and they began to be used sporadically. Since January 2001 UK based guidelines indicated that one of three cholinesterase inhibitors (CHEIs) could be prescribed for these patients. Since then the cost of prescription in England and Wales has risen. There has been little investigation of uptake at the population level. Objective To estimate the population uptake of CHEIs in a population based study of dementia spanning this period. Design Using data from a 10-year follow up and a later 12 year interview of the Medical Research Council Cognitive Function and Ageing Study (MRC CFAS), a UK population based longitudinal cohort study of people originally aged 65 years and above, we investigated who was taking CHEIs during the period 2001,2004. We sought information from respondents taking part in the study what medication they were taking on a regular basis. Results Only 12, of the 219 individuals who received a study diagnosis of dementia were prescribed CHEIs [5%, 95% Confidence Intervals (CI) 3%,9%]) in 2001/2003 and none of the 28 individuals with a study diagnosis of dementia (0%, 95% CI 0,18%) in 2004 were prescribed CHEIs. Uptake was biased towards individuals with more education and higher social class. Conclusions These data suggest that any impact on AD progression at the population level will be negligible as prescription of CHEIs and uptake in the age group at highest risk is so limited. There is little evidence that this has changed over time. Copyright © 2006 John Wiley & Sons, Ltd. [source] Postoperative impact of regular tobacco use, smoking or snuffing, a prospective multi-center studyACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 3 2010M. BRATTWALL Background: The aim was to study the effects of different tobacco administration routes on pain and post-operative nausea and vomiting (PONV), following three common day surgical procedures: cosmetic breast augmentation (CBA), inguinal hernia repair (IHR) and arthroscopic procedures (AS). We have prospectively investigated the effects of regular tobacco use in ambulatory surgery. Methods: The 355 allocated patients were followed during recovery and the first day at home. Results: Thirty-two percent of the patients used tobacco regularly, 33% of CBA, 27% of IHR and 34% of AS. Pain was well controlled in the post-anesthesia care unit at rest; during ambulation, 37% of all patients reported VAS>3. Tobacco use had no impact on early post-operative pain. Post-operative nausea was experienced by 30% of patients during recovery while in hospital. On day 1, 14% experienced nausea. We found a significant reduction of PONV among tobacco users (smoking and/or snuffing). Smoking or snuffing reduced the risk of PONV by nearly 50% in both genders on the day of surgery and at the first day at home. The reduction of PONV was equal, regardless of tobacco administration routes. Conclusion: We found that regular use of tobacco, both by smoking and snuffing, had a significant effect on PONV during the early post-operative period. Non-tobacco users undergoing breast surgery were found to have the highest risk for PONV. We could not see any influence of nicotine use on post-operative pain. Thus, it seems of value to identify regular tobacco use, not only smoking, as a part of the pre-operative risk assessment. [source] Old Age and Outcome After Primary Angioplasty for Acute Myocardial InfarctionJOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 5 2010Menko-Jan De Boer MD OBJECTIVES: To assess the influence of age as an independent factor determining the prognosis and outcome of patients with acute myocardial infarction (AMI) treated using primary percutaneous coronary intervention (PCI). DESIGN: A retrospective analysis from a dedicated database. SETTING: A high-volume interventional cardiology center in the Netherlands. PARTICIPANTS: Four thousand nine hundred thirty-three consecutive patients with AMI. MEASUREMENTS: Baseline characteristics and clinical outcomes after 30 days and 1 year were compared according to age categorized in three groups: younger than 65, 65 to 74, and 75 and older. A more-detailed analysis was performed with six age groups, from younger than 40 to 80 and older. RESULTS: Of the 4,933 consecutive patients with AMI treated with PCI between 1992 and 2004, 643 were aged 75 and older. Multivariate analysis revealed that patients aged 65 to 75 had a greater risk of 1-year mortality than those younger than 65 (adjusted odds ratio (AOR)=1.57, 95% confidence interval (CI)=1.15,2.16) and that those aged 75 and older had a greater risk of 1-year mortality than those younger than 65 (AOR=3.03, 95% CI=2.14,4.29). CONCLUSION: In this retrospective analysis, older age was independently associated with greater mortality after PCI for AMI. Patients aged 65 and older had a higher risk of mortality than younger patients, and those aged 75 and older had the highest risk of mortality. [source] Effects of Conjugated Equine Estrogen on Risk of Fractures and BMD in Postmenopausal Women With Hysterectomy: Results From the Women's Health Initiative Randomized TrialJOURNAL OF BONE AND MINERAL RESEARCH, Issue 6 2006Rebecca D Jackson MD Abstract Further analyses from the Women's Health Initiative estrogen trial shows that CEE reduced fracture risk. The fracture reduction at the hip did not differ appreciably among risk strata. These data do not support overall benefit over risk, even in women at highest risk for fracture. Introduction: The Women's Health Initiative provided evidence that conjugated equine estrogen (CEE) can significantly reduce fracture risk in postmenopausal women. Additional analysis of the effects of CEE on BMD and fracture are presented. Materials and Methods: Postmenopausal women 50,79 years of age with hysterectomy were randomized to CEE 0.625 mg daily (n = 5310) or placebo (n = 5429) and followed for an average 7.1 years. Fracture incidence was assessed by semiannual questionnaire and verified by adjudication of radiology reports. BMD was measured in a subset of women (N = 938) at baseline and years 1, 3, and 6. A global index was used to examine whether the balance of risks and benefits differed by baseline fracture risk. Results: CEE reduced the risk of hip (hazard ratio [HR], 0.65; 95% CI, 0.45,0.94), clinical vertebral (HR, 0.64; 95% CI, 0.44,0.93), wrist/lower arm (HR, 0.58; 95% CI, 0.47,0.72), and total fracture (HR, 0.71; 95% CI, 0.64,0.80). This effect did not differ among strata according to age, oophorectomy status, past hormone use, race/ethnicity, fall frequency, physical activity, or fracture history. Total fracture reduction was less in women at the lowest predicted fracture risk in both absolute and relative terms (HR, 0.86; 95% CI, 0.68,1.08). CEE also provided modest but consistent positive effects on BMD. The HRs of the global index for CEE were relatively balanced across tertiles of summary fracture risk (lowest risk: HR, 0.81; 95% CI, 0.62,1.05; mid risk: HR, 1.09; 95% CI, 0.92,1.30; highest risk: HR, 1.04; 95% CI, 0.88,1.23; interaction, p = 0.42). Conclusions: CEE reduces the risk of fracture and increases BMD in hysterectomized postmenopausal women. Even among the women with the highest risk for fractures, when considering the effects of estrogen on other important health outcomes, a summary of the burden of monitored effects does not indicate a significant net benefit. [source] Osteoporosis and Fracture Risk in Women of Different Ethnic GroupsJOURNAL OF BONE AND MINERAL RESEARCH, Issue 2 2005Elizabeth Barrett-Connor MD Abstract Osteoporosis and 1-year fracture risk were studied in 197,848 postmenopausal American women from five ethnic groups. Weight explained differences in BMD, except among blacks, who had the highest BMD. One SD decrease in BMD predicted a 50% increased fracture risk in each group. Despite similar relative risks, absolute fracture rates differed. Introduction: Most information about osteoporosis comes from studies of white women. This study describes the frequency of osteoporosis and the association between BMD and fracture in women from five ethnic groups. Materials and Methods: This study was made up of a cohort of 197,848 community-dwelling postmenopausal women (7784 blacks, 1912 Asians, 6973 Hispanics, and 1708 Native Americans) from the United States, without known osteoporosis or a recent BMD test. Heel, forearm, or finger BMD was measured, and risk factor information was obtained; 82% were followed for 1 year for new fractures. BMD and fracture rates were compared, adjusting for differences in covariates. Results: By age 80, more than one-fifth of women in each ethnic group had peripheral BMD T scores <,2.5. Black women had the highest BMD; Asian women had the lowest. Only the BMD differences for blacks were not explained by differences in weight. After 1 year, 2414 new fractures of the spine, hip, forearm, wrist, or rib were reported. BMD at each site predicted fractures equally well within each ethnic group. After adjusting for BMD, weight, and other covariates, white and Hispanic women had the highest risk for fracture (relative risk ,RR' 1.0 ,referent group' and 0.95, 95% CI, 0.76, 1.20, respectively), followed by Native Americans (RR, 0.87; 95% CI, 0.57, 1.32), blacks (RR, 0.52; 95% CI, 0.38, 0.70), and Asian Americans (RR, 0.32; 95% CI, 0.15, 0.66). In age- and weight-adjusted models, each SD decrease in peripheral BMD predicted a 1.54 times increased risk of fracture in each ethnic group (95% CI, 1.48-1.61). Excluding wrist fractures, the most common fracture, did not materially change associations. Conclusions: Ethnic differences in BMD are strongly influenced by body weight; fracture risk is strongly influenced by BMD in each group. Ethnic differences in absolute fracture risk remain, which may warrant ethnic-specific clinical recommendations. [source] Use of Oral Corticosteroids and Risk of FracturesJOURNAL OF BONE AND MINERAL RESEARCH, Issue 6 2000T. P. Van Staa Abstract Treatment with oral corticosteroids is known to decrease bone density but there are few data on the attendant risk of fracture and on the reversibility of this risk after cessation of therapy. A retrospective cohort study was conducted in a general medical practice setting in the United Kingdom (using data from the General Practice Research Database [GPRD]). For each oral corticosteroid user aged 18 years or older, a control patient was selected randomly, who was matched by age, sex, and medical practice. The study comprised 244,235 oral corticosteroid users and 244,235 controls. The average age was 57.1 years in the oral corticosteroid cohort and 56.9 years in the control cohort. In both cohorts 58.6% were female. The most frequent indication for treatment was respiratory disease (40%). The relative rate of nonvertebral fracture during oral corticosteroid treatment was 1.33 (95% confidence interval [CI], 1.29,1.38), that of hip fracture 1.61 (1.47,1.76), that of forearm fracture 1.09 (1.01,1.17), and that of vertebral fracture 2.60 (2.31,2.92). A dose dependence of fracture risk was observed. With a standardized daily dose of less than 2.5 mg prednisolone, hip fracture risk was 0.99 (0.82,1.20) relative to control, rising to 1.77 (1.55,2.02) at daily doses of 2.5,7.5 mg, and 2.27 (1.94,2.66) at doses of 7.5 mg or greater. For vertebral fracture, the relative rates were 1.55 (1.20,2.01), 2.59 (2.16,3.10), and 5.18 (4.25,6.31), respectively. All fracture risks declined toward baseline rapidly after cessation of oral corticosteroid treatment. These results quantify the increased fracture risk during oral corticosteroid therapy, with greater effects on the hip and spine than forearm. They also suggest a rapid offset of this increased fracture risk on cessation of therapy, which has implications for the use of preventative agents against bone loss in patients at highest risk. [source] Suicidality among Finnish anaesthesiologistsACTA ANAESTHESIOLOGICA SCANDINAVICA, Issue 8 2009P. M. LINDFORS Background: Suicide rates among physicians have constantly been reported to be higher than in the general population and anaesthesiologists appear to lead the suicide statistics among physicians. Methods: A cross-sectional questionnaire study was sent to all working Finnish anaesthesiologists (n=550) investigating their suicidality (ideation and/or planning and/or attempt). The response rate was 60%. Results: One in four had at some time seriously been thinking about suicide. Respondents with poor health (crude odds ratios 11.2 and 95% confidence interval 3.8,33.0), low social support (10.5, 4.0,27.9), and family problems (6.5, 3.4,12.5) had the highest risk of suicidality. The highest risks at work were conflicts with co-workers (4.1, 2.3,7.1) and superiors (2.1, 1.2,3.6), on-call-related stress symptoms (3.9, 1.9,8.3) and low organizational justice (1.9, 1.1,3.2). If a respondent had several risk factors, the risk of suicidality doubled with each cumulating factor. Conclusions: The reported level of suicidal ideation among Finnish anaesthesiologists is worth concern. It should be of utmost importance to screen the risk factors and recognize suicidal physicians in order to help them. Interpersonal relationships, decision-making procedures, and on-call-burden should be focused on when aiming to prevent suicidality among physicians. [source] Predictors of complications in therapeutic plasma exchangeJOURNAL OF CLINICAL APHERESIS, Issue 6 2009Carsten P. Bramlage Abstract Plasma exchange (PE) is used for blood purification to modulate proteins involved in pathological processes. As the number of patients receiving PE treatment and the heterogeneity of the underlying diseases is steadily increasing, we evaluated the most frequent complications and analyzed causes leading to adverse reactions. 883 PE procedures in 113 patients between the years 2000 to 2006 were retrospectively analyzed with respect to complications. Additionally, underlying diseases and settings of PE procedure were analyzed to identify high-risk patients and respective PE settings. A total of 226 adverse reactions were recorded (25.6% of all PE procedures). Most complications were mild (n = 121, 13.7%) or moderate (n = 98, 11.0%). In seven cases (n = 7, 0.7%), severe, life-threatening adverse events were induced by PE either due to severe allergic reactions (n = 4, 0.5%) or to sepsis (n = 3, 0.3%). Patients with neurologic diseases had a significantly higher risk to develop complications compared to those with internal diseases (P = 0.013). This was due to a higher rate of PE associated adverse events (in particular hypotension) and complications associated with vascular access. Among patients from internal medicine those with hemolytic uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP) had the highest risk to develop complications. Patients with neurological diseases compared to those with medical conditions and patients with HUS/TTP compared to those with other diseases had a higher risk to develop complications. However, severe adverse events are rare. Thus, PE seems to be a safe and recommendable procedure. J. Clin. Apheresis, 2009. © 2009 Wiley-Liss, Inc. [source] Current controversies surrounding liver transplantation for hepatocellular carcinomaJOURNAL OF GASTROENTEROLOGY AND HEPATOLOGY, Issue 7 2010Mauricio F Silva Abstract Liver transplantation (LT) for hepatocellular carcinoma (HCC) has progressed rapidly over the last decade from a futile therapy to the first choice therapy for suitable patients. Excellent outcomes of LT for HCC can be largely attributed to the use of the Milan Criteria, which have restricted LT to patients with early stage tumors. These criteria may be conservative, and it is likely that a subset of patients with tumors beyond these criteria can have acceptable outcomes. However, there is currently insufficient data to accept more liberal criteria as a standard of care, and a higher quality evidence base must be achieved to prevent poor utilization of valuable donor liver resources. In the future, it is probable that more sophisticated selection criteria will emerge incorporating aspects of tumor biology beyond tumor size and number. Dropout from the waiting list due to tumor progression remains a clinical challenge particularly in regions with prolonged waiting times. Priority allocation using HCC MELD points is a practical and transparent solution that has successfully reduced waitlist dropout for HCC patients. Further refinements of the HCC MELD point system are required to ensure equity of access to LT for non-HCC patients and prioritization of HCC patients with the highest risk of dropout. Improving the evidence base for pre-LT locoregional therapy to prevent waitlist dropout is an urgent and difficult challenge for the LT community. In the interim transplant clinicians must restrict the use of these therapies to those patients who are most likely to benefit from them. [source] Metabolic syndrome, its preeminent clusters, incident coronary heart disease and all-cause mortality , results of prospective analysis for the Atherosclerosis Risk in Communities studyJOURNAL OF INTERNAL MEDICINE, Issue 1 2007Y. Hong Abstract. Objective., To investigate the prospective association between Metabolic Syndrome (MetS) and coronary heart disease (CHD) and all-cause mortality. Subjects and Design., A bi-racial cohort of 14 699 middle-aged Americans from the Atherosclerosis Risk in Communities study were followed for the development of new CHD and death over a period of 9 years. MetS, using the original ATP-III criteria, was defined as having at least three of the following components: elevated blood pressure (BP), elevated plasma glucose, elevated blood triglyceride (TG), increased waist circumference, and low HDL cholesterol (HDL-c). Incident CHD cases included hospitalized myocardial infarction (MI), fatal CHD, revascularization procedures, and silent MI as detected by EKG. Results., The prevalence of the MetS at baseline was 29%, 30%, 40% and 26% among CHD-free white women, white men, black women, and black men, respectively. There were 1018 incident CHD cases and 1039 deaths. The relative risk (RR) and 95% confidence interval (CI) of incident CHD associated with MetS was 2.46 (1.99, 3.03) for women and 1.86 (1.59, 2.18) for men. Clear dose,response relationship between the number of MetS components and incidence of CHD was found (P for linear trend <0.001). The following three clusters of MetS components posed the highest risk for CHD: (i) the elevated BP and glucose and low HDL-c group [RR = 5.68 (3.44, 9.37)]; (ii) the elevated BP and glucose and TG group [RR = 5.08 (2.96, 8.70)]; and (iii) the elevated BP and TG and low HDL-c group [RR = 3.98 (2.75, 5.77)]. When all five components co-existed, the risk was the highest [RR = 6.24 (4.65, 8.36)]. Similar results with attenuated RR were found for all-cause mortality. Conclusions., Individuals, especially women, with the MetS have significantly higher risk of developing CHD. The riskiest combination is high-BP and glucose clustered with low HDL-c or high TG. These data highlight the importance of targeting MetS in the prevention of CHD and premature death. [source] | |||||||||||||||||||||||||||||||||||||||||||