INTERNATIONAL JOURNAL OF DERMATOLOGY, Issue 12 2009
Carlos Galarza MD
Background, Cutaneous acanthamebiasis is a rare infection and few patients have been reported worldwide. Methods, Observational and descriptive study carried out from March 1996 to February 2006 in patients with diagnosis of cutaneous free-living amebic infection caused by Acanthamoeba spp. The patients were diagnosed at the Dos de Mayo National Hospital (Lima-Peru) where skin biopsies, histopathologic studies and cultures were performed. The clinical and epidemiologic characteristics, diagnosis, treatment and evolution were recorded in a survey. Results, Five patients with cutaneous free-living amebic infection caused by Acanthamoeba spp. were identified. Skin lesions were ulceronecrotic (four patients), an infiltrative bluish plaque (one patient), and a periorbital tumor (one patient). Three patients were positive for human immunodeficiency virus (HIV), had only cutaneous involvement, and died of opportunistic infections. The two immunocompetent patients developed Acanthamoeba granulomatous encephalitis and meningoencephalitis that progressed to intracranial hypertension and death. Conclusion, The clinical manifestations of cutaneous free-living amebic infection caused by Acanthamoeba spp. appear to vary according to the underlying immunologic status. [source]

Agreement Between Nosologist and Cardiovascular Health Study Review of Deaths: Implications of Coding Differences

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 1 2009
Diane G. Ives MPH
OBJECTIVES: To compare nosologist coding of underlying cause of death according to the death certificate with adjudicated cause of death for subjects aged 65 and older in the Cardiovascular Health Study (CHS). DESIGN: Observational. SETTING: Four communities: Forsyth County, North Carolina (Wake Forest University); Sacramento County, California (University of California at Davis); Washington County, Maryland (Johns Hopkins University); and Pittsburgh, Pennsylvania (University of Pittsburgh). PARTICIPANTS: Men and women aged 65 and older participating in CHS, a longitudinal study of coronary heart disease and stroke, who died through June 2004. MEASUREMENTS: The CHS centrally adjudicated underlying cause of death for 3,194 fatal events from June 1989 to June 2004 using medical records, death certificates, proxy interviews, and autopsies, and results were compared with underlying cause of death assigned by a trained nosologist based on death certificate only. RESULTS: Comparison of 3,194 CHS versus nosologist underlying cause of death revealed moderate agreement except for cancer (kappa=0.91, 95% confidence interval (CI)=0.89,0.93). kappas varied according to category (coronary heart disease, kappa=0.61, 95% CI=0.58,0.64; stroke, kappa=0.59, 95% CI=0.54,0.64; chronic obstructive pulmonary disease, kappa=0.58, 95% CI=0.51,0.65; dementia, kappa=0.40, 95% CI=0.34,0.45; and pneumonia, kappa=0.35, 95% CI=0.29,0.42). Differences between CHS and nosologist coding of dementia were found especially in older ages in the sex and race categories. CHS attributed 340 (10.6%) deaths due to dementia, whereas nosologist coding attributed only 113 (3.5%) to dementia as the underlying cause. CONCLUSION: Studies that use only death certificates to determine cause of death may result in misclassification and potential bias. Changing trends in cause-specific mortality in older individuals may be a function of classification process rather than incidence and case fatality. [source]

Recovery of Activities of Daily Living in Older Adults After Hospitalization for Acute Medical Illness

JOURNAL OF AMERICAN GERIATRICS SOCIETY, Issue 12 2008
Cynthia M. Boyd MD
OBJECTIVES: To compare functional outcomes in the year after discharge for older adults discharged from the hospital after an acute medical illness with a new or additional disability in their basic self-care activities of daily living (ADL) (compared with preadmission baseline 2 weeks before admission) with those of older adults discharged with baseline ADL function and identify predictors of failure to recover to baseline function 1 year after discharge. DESIGN: Observational. SETTING: Tertiary care hospital, community teaching hospital. PARTICIPANTS: Older (aged ,70) patients nonelectively admitted to general medical services (1993,1998). MEASUREMENTS: Number of ADL disabilities at preadmission baseline and 1, 3, 6, and 12 months after discharge. Outcomes were death, sustained decline in ADL function, and recovery to baseline ADL function at each time point. RESULTS: By 12 months after discharge, of those discharged with new or additional ADL disability, 41.3% died, 28.6% were alive but had not recovered to baseline function, and 30.1% were at baseline function. Of those discharged at baseline function, 17.8% died, 15.2% were alive but with worse than baseline function, and 67% were at their baseline function (P<.001). Of those discharged with new or additional ADL disability, the presence or absence of recovery by 1 month was associated with long-term outcomes. Age, cardiovascular disease, dementia, cancer, low albumin, and greater number of dependencies in instrumental ADLs independently predicted failure to recover. CONCLUSION: For older adults discharged with new or additional disability in ADL after hospitalization for medical illness, prognosis for functional recovery is poor. Rehabilitation interventions of longer duration and timing than current reimbursement allows, caregiver support, and palliative care should be evaluated. [source]

A link between sound producing musculature and mating success in Atlantic cod

JOURNAL OF FISH BIOLOGY, Issue 3 2008
S. Rowe
Individual variability in the mating success of male Atlantic cod Gadus morhua was quantified within an aggregation (n= 59) breeding undisturbed in a large (684 m3) mesocosm tank. Observational and morphometric data were examined to assess the degree to which this mating variation could be explained by aspects of morphology, condition and spawning behaviour. The number of ventral mounts initiated (i.e. mating success) was highly variable; most mounts were initiated by a very small percentage of available males. The significant correlate of male mating success was mass of the sound producing musculature, i.e. drumming muscles. Neither body size, condition, pelvic and median fin morphology nor aggression influenced the number of ventral mounts initiated by a male. The present study suggests a possible link between sound production and mating success in Atlantic cod. [source]

Quality of life in mild to moderate acne: relationship to clinical severity and factors influencing change with treatment

JOURNAL OF THE EUROPEAN ACADEMY OF DERMATOLOGY & VENEREOLOGY, Issue 2 2007
M Jones-Caballero
Abstract Background, Because of its effects on quality of life, acne vulgaris is more than a merely physiological or cosmetic entity. Objectives, To describe the influence of mild to moderate acne on patients' quality of life, measured using Skindex-29, and to correlate changes in Skindex-29 scores with changes in objective and subjective indices in clinical severity after treatment with topical 4% erythromycin 0.2% zinc. Also, to evaluate efficacy and side-effects of the treatment. Methods, Observational, prospective study of 1878 patients cared for by 252 clinicians in Spain. Data included epidemiological information and responses to Skindex-29, a subjective change and objective severity index. Results, Baseline Skindex scale scores were worse in women, older patients, and those with more severe clinical disease. Skindex was sensitive to changes in objective severity but changes in Skindex scale scores were also related to other factors. Patients who reported their skin condition to be ,the same' or ,worse' at the end of the study had significantly worse baseline scores on the ,symptoms' and ,emotions' scales but ,functioning' scores were not worse than for those who reported their condition had improved. Conclusion, The effects of acne vulgaris on quality of life and changes in quality of life after treatment are not only explainable by objective severity of acne. Patients' and clinicians' judgements about acne severity are different. [source]

Meta-analysis: proton pump inhibitor use and the risk of community-acquired pneumonia

ALIMENTARY PHARMACOLOGY & THERAPEUTICS, Issue 11 2010
J. JOHNSTONE
Aliment Pharmacol Ther,31, 1165,1177 Summary Background, Observational studies examining the association between proton pump inhibitor (PPI) use and risk of community-acquired pneumonia are conflicting. Aim, To assess systematically the association between risk of community-acquired pneumonia and PPI use in adults. Methods, We searched MEDLINE, EMBASE and CINAHL databases between 1988 and January 2010. Two reviewers independently selected studies based on eligibility criteria and extracted data. Included studies evaluated adults (,18 years) who took PPIs as an out-patient. The primary outcome was community-acquired pneumonia. Only observational studies with a comparison arm were included. Results, Over 2600 citations were reviewed. Six studies were included. All were nested case-control studies. Meta-analysis found an increased risk of community-acquired pneumonia associated with PPI use [OR 1.36 (95% CI 1.12,1.65)]; significant heterogeneity remained (I2 92%, P < 0.001). In exploratory subgroup analysis, short duration of use was associated with an increased odds of community-acquired pneumonia [OR 1.92 (95% CI 1.40,2.63), I2 75%, P = 0.003], whereas chronic use was not [OR 1.11 (95% CI 0.90,1.38), I2 91%, P < 0.001], a significant interaction (P < 0.005). Conclusions, Heterogeneity precluded interpretation of the summary statistic. Exploratory analysis revealed that duration of PPI use may impact the risk of community-acquired pneumonia, a finding that should be explored in future studies. [source]

Liver cirrhosis in HIV-infected patients: prevalence, aetiology and clinical outcome

JOURNAL OF VIRAL HEPATITIS, Issue 3 2008
C. Castellares
Summary., Liver disease is frequently seen in HIV+ patients as a result of coinfection with hepatitis B (HBV) or C (HCV) viruses, alcohol abuse and/or exposure to hepatotoxic drugs. The aim of this study was to assess the prevalence of liver cirrhosis, its main causes and clinical presentation in HIV+ patients. Observational, cross-sectional, retrospective study of all HIV+ individuals followed at one reference HIV outpatient clinic in Madrid. Liver fibrosis was measured in all cases using transient elastometry (FibroScan®). All 2168 HIV+ patients on regular follow-up (76% males, 46% injecting drug users) were successfully examined by FibroScan® between October 2004 and August 2006. Liver cirrhosis was recognized in 181 (overall prevalence, 8.3%), and the main aetiologies were HCV, 82.3%; HBV, 1.6%; dual HBV/HCV, 2.8%; and triple HBV/HCV/ hepatitis delta virus (HDV) infection, 6.6%. The prevalence of cirrhosis differed among patients with distinct chronic viral hepatitis: HCV, 19.2%; HBV, 6.1%; HBV/HCV, 41.7%; and HBV/HCV/HDV, 66.7%. In 12 patients with cirrhosis (6.7%), no definite aetiology was recognized. Overall, cirrhotics had lower mean CD4 counts than noncirrhotics (408 vs 528 cells/,L respectively; P = 0.02), despite similar proportion of subjects with undetectable viraemia on highly active antiretroviral therapy. Clinical manifestations of liver cirrhosis were: splenomegaly, 61.5%; oesophageal varices, 59.8%; ascites, 22.6%; encephalopathy, 12.1%; and variceal bleeding, 6.1%. Liver cirrhosis and hepatic decompensation events are relatively frequent in HIV+ individuals. Chronic HCV and alcohol abuse, but not chronic HBV, play a major role. Transient elastometry may allow the identification of a significant number of HIV+ individuals with asymptomatic liver cirrhosis. [source]

OPERATIONALIZING OPPORTUNITIES AND CREATING PUBLICS IN SALVADORAN CHURCHES: FINDINGS FROM AN ETHNOGRAPHIC PROCESS EVALUATION

ANNALS OF ANTHROPOLOGICAL PRACTICE, Issue 1 2010
James Huff
This article explores how one faith-based nonprofit organization and its various Pentecostal and evangelical church partners in El Salvador are creating associational contexts within which local community development projects are identified and implemented. Observational and interview data derived from a process evaluation of a project identification exercise are examined to explore how different community and organizational stakeholders attempt to implement local development initiatives that will presumably build on local assets and associations. The study details the patterns of participation that emerged as members of local churches negotiated with their neighbors over how to best direct social change in their community. Corresponding analysis of interview data portrays how these same actors relied on diverse social logics,which are both religious and practical in nature,to make sense of and assess some of the key assumptions of a particular form of faith-based development. The case is a good example of how faith-based organizations play key roles in the formation of publics, wherein actors from diverse networks come together to deliberate over the aims and outcomes of local development projects in contemporary El Salvador. [source]

Variation in Institutional Review Board Responses to a Standard, Observational, Pediatric Research Protocol

ACADEMIC EMERGENCY MEDICINE, Issue 4 2007
Jonathan Mansbach MD
Abstract Background: Multicenter studies are becoming more common, and variability in local institutional review board (IRB) assessments can be problematic. Objective: To investigate the variability of IRB responses to a multicenter observational study of children presenting to emergency departments. Methods: The authors collected the original IRB applications, subsequent correspondence, and a survey assessing submission timing and response and the nature of IRB queries. The study was conducted as part of the Emergency Medicine Network http://www.emnet-usa.org Results: Of 37 sites initiating the IRB process, 34 (92%) participated in this IRB-approved study. Institutional review boards returned initial applications in a median of 19 days (IQR, 11,34 d), and 91% considered the protocol to be minimal risk. Of 34 submissions, 13 required no changes, 18 received conditional approvals, and 3 were deferred. The median time from initial submission to final approval was 42 days (IQR, 27,61 d). Seven sites did not participate in patient recruitment: two had institutional issues, one obtained IRB approval too late for participation, and four sites (12%) reported that IRB hurdles contributed to their lack of participation. Nonetheless, 68% of sites that recruited patients reported that the overall experience made them more likely to participate in future multicenter research. Conclusions: There was substantial variation in IRB assessment of a standard protocol in this study. The burden of the application process contributed to some investigators not participating, but the majority of investigators remain enthusiastic about multicenter research. A national IRB may streamline the review process and facilitate multicenter clinical research. [source]

Non-invasive assessment of endothelial function , relation between vasodilatory responses in skin microcirculation and brachial artery

CLINICAL PHYSIOLOGY AND FUNCTIONAL IMAGING, Issue 6 2004
Jimmy Hansell
Summary Objective:, To compare different non-invasive methods for determination of human endothelial function in peripheral circulation. Design:, Observational, cross-sectional study in 39 healthy subjects (21 females, age 17,56 years). Setting:, Vascular research laboratory at university hospital. Methods:, Laser Doppler (LD) flowmetry was used to compare skin microvascular perfusion changes during postocclusive reactive hyperaemia with those induced by iontophoretic administration of acetylcholine (ACh), an endothelial-dependent vasodilator. LD measurements were compared with ultrasonographic measurements of postocclusive flow-mediated dilatation (FMD) in the brachial artery (n = 21). Results:, Local ACh induced a larger and more sustained skin perfusion increase than reactive hyperaemia after 4 min of regional arterial occlusion (P<0·001). A significant correlation was found between the magnitude of ACh-induced vasodilatation and peak reactive hyperaemia, both in absolute (r = 0·62, P<0·001) and relative terms (r = 0·58, P<0·001). A correlation was also found between brachial artery FMD and the magnitude of ACh-induced skin perfusion increase (r = 0·43, P<0·05) but not between FMD and reactive hyperaemia. Conclusion:, Endothelial function, an early marker of cardiovascular risk, can be non-invasively assessed and graded by LD and FMD-measurements and despite inherent differences, both methods do correlate. [source]

Common infections in diabetes: pathogenesis, management and relationship to glycaemic control

DIABETES/METABOLISM: RESEARCH AND REVIEWS, Issue 1 2007
Anton Y. Peleg
Abstract Specific defects in innate and adaptive immune function have been identified in diabetic patients in a range of in vitro studies. However, the relevance of these findings to the integrated response to infection in vivo remains unclear, especially in patients with good glycaemic control. Vaccine efficacy seems adequate in most diabetic patients, but those with type 1 diabetes and high glycosylated haemoglobin levels are most likely to exhibit hypo-responsiveness. While particular infections are closely associated with diabetes, this is usually in the context of extreme metabolic disturbances such as ketoacidosis. The link between glycaemic control and the risk of common community-acquired infections is less well established but could be clarified if infection data from large community-based observational or intervention studies were available. The relationship between hospital-acquired infections and diabetes is well recognized, particularly among post-operative cardiac and critically ill surgical patients in whom intensive insulin therapy improves clinical outcome independent of glycaemia. Nevertheless, further research is needed to improve our understanding of the role of diabetes and glycaemic control in the pathogenesis and management of community- and hospital-acquired infections. Copyright © 2006 John Wiley & Sons, Ltd. [source]

Parental care in response to natural variation in nest predation pressure in six sunfish (Centrarchidae: Teleostei) species

ECOLOGY OF FRESHWATER FISH, Issue 4 2008
S. J. Cooke
Abstract,,, Parental care is an important, energetically costly component of the life history of many fishes. Despite this importance, little is known about how different species of fish vary parental care in response to natural nest predator burdens. In this study, underwater videography was used to quantify parental care activity of six species of syntopic nesting male centrarchid fishes in Lake Opinicon, Ontario, in response to natural predators. This approach was used to test the hypothesis that as offspring develop from eggs to wrigglers, parental care activity should decrease or remain static for fish guarding nests with low predator burden and increase for those with high predator burden, reflecting different external risks. Principal components analysis (PCA) was used to derive common aeration and nest defence variables. Aeration and predator defence activity of the fish varied extensively among species. Parental care behaviours indicative of defence and vigilance (e.g., turning, departures, time away from nest, displays) tended to be highest for species that had the most predation attempts, although this was not entirely consistent. There was also a positive relationship between the defence PCA metric and attempted predation. Defence did not vary with stage of offspring development, although interactions between defence and developmental stage were noted for several species. A trade-off between aeration and defence was not observed. In fact, species that provide high levels of aeration also simultaneously provide high levels of defence. Stage-specific patterns of defence in this study were less apparent than those documented by studies using responses to staged predator intrusions making it unclear as to the extent that fish were responding to the level of the risk to offspring than to the value of the brood. Therefore, combined use of observational and experimental assessments of parental care investment may be most appropriate for refining current theoretical paradigms. [source]

The Impact of the Demand for Clinical Productivity on Student Teaching in Academic Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 12 2004
Todd J. Berger MD
Objective: Because many emergency medicine (EM) attending physicians believe the time demands of clinical productivity limit their ability to effectively teach medical students in the emergency department (ED), the purpose of this study was to determine if there is an inverse relationship between clinical productivity and teaching evaluations. Methods: The authors conducted a prospective, observational, double-blind study. They asked senior medical students enrolled in their EM clerkship to evaluate each EM attending physician who precepted them at three academic EDs. After each shift, students anonymously evaluated 10 characteristics of clinical teaching by their supervising attending physician. Each attending physician's clinical productivity was measured by calculating their total relative value units per hour (RVUs/hr) during the nine-month study interval. The authors compared the total RVUs/hr for each attending physician to the medians of their teaching evaluation scores at each ED using a Spearman rank correlation test. Results: Seventy of 92 students returned surveys, evaluating 580 shifts taught by 53 EM attending physicians. Each attending physician received an average of 11 evaluations (median score, 5 of 6) and generated a mean of 5.68 RVUs/hr during the study period. The correlation between evaluation median scores and RVUs/hr was ,0.08 (p = 0.44). Conclusions: The authors found no statistically significant relationship between clinical productivity and teaching evaluations. While many EM attending physicians perceive patient care responsibilities to be too time consuming to allow them to be good teachers, the authors found that a subset of our more productive attending physicians are also highly rated teachers. Determining what characteristics distinguish faculty who are both clinically productive and highly rated teachers should help drive objectives for faculty development programs. [source]

Emergency Physician,Verified Out-of-hospital Intubation: Miss Rates by Paramedics

ACADEMIC EMERGENCY MEDICINE, Issue 6 2004
James H. Jones MD
Abstract Objectives: To prospectively quantify the number of unrecognized missed out-of-hospital intubations by ground paramedics using emergency physician verification as the criterion standard for verification of endotracheal tube placement. Methods:The authors performed an observational, prospective study of consecutive intubated patients arriving by ground emergency medical services to two urban teaching hospitals. Endotracheal tube placement was verified by emergency physicians and evaluated by using a combination of direct visualization, esophageal detector device (EDD), colorimetric end-tidal carbon dioxide (ETCO2), and physical examination. Results: During the six-month study period, 208 out-of-hospital intubations by ground paramedics were enrolled, which included 160 (76.9%) medical patients and 48 (23.1%) trauma patients. A total of 12 (5.8%) endotracheal tubes were incorrectly placed outside the trachea. This comprised ten (6.3%) medical patients and two (4.2%) trauma patients. Of the 12 misplaced endotracheal tubes, a verification device (ETCO2 or EDD) was used in three cases (25%) and not used in nine cases (75%). Conclusions: The rate of unrecognized, misplaced out-of-hospital intubations in this urban, midwestern setting was 5.8%. This is more consistent with results of prior out-of-hospital studies that used field verification and is discordant with the only other study to exclusively use emergency physician verification performed on arrival to the emergency department. [source]

The feeding behavior of Trichogramma brassicae: new evidence for selective ingestion of solid food

ENTOMOLOGIA EXPERIMENTALIS ET APPLICATA, Issue 1 2000
Z.X. Wu
Abstract A descriptive study of the feeding behavior and structures of Trichogramma brassicae Bezdenko (Hymenoptera: Trichogrammatidae) was conducted. Based on direct observational and biochemical evidence, larvae feed predominantly on particulate materials, starting ca. 25 h post-oviposition. Feeding lasted for ca. 9 h, at 25±1 °C. During this feeding period the shape of the larvae changed from vermiform to pyriform and then to sacciform, resulting in a ca. 40-fold increase in body size. Larvae used elaborate feeding behaviors as they pulled solid food particles to their oral opening, broke small particles from larger ones, and took the particles into the stomodaeum, which is a powerful pump. In the stomodaeum, peristaltic movement further macerated the particles, which eventually passed through the cardiac valve into the midgut. As indicated by changes in fluorescently labeled casein, digestive enzymes aid in the extra-oral chemical digestion of food. The contents of the gut, during and shortly after feeding, were almost entirely closely packed solid particles. The behavioral activity of feeding larvae centered almost exclusively on processing and ingesting solid food particles. The rapid larval growth is much more plausibly explained by their feeding on the highly concentrated nutrients found in solid foods, rather than the extensive concentration required if dilute liquids were the principal source of nutrients. The implications of these findings for the development of practical artificial diets are discussed. [source]

Social Behavior of Larvae of the Neotropical Processionary Weevil Phelypera distigma (Boheman) (Coleoptera: Curculionidae: Hyperinae)

ETHOLOGY, Issue 7 2004
James T. Costa
Socially gregarious behavior among free-living leaf-eating insect larvae occurs mostly among Lepidoptera, Symphyta, and a few Chyrsomelidae (Coleoptera). However, the Neotropical hyperine curculionid Phelypera distigma has also evolved this lifestyle, exhibiting a suite of social behaviors unique among beetles. The larvae are nomadic processionary foragers that punctuate foraging bouts with rosette-shaped resting formations (cycloalexy). Larvae also vibrate or bob their heads rapidly when moving, especially when in contact with conspecifics, and this suggests acoustic or vibrational communication. In this study we used observational and experimental approaches to investigate the basis of processionary, cycloalexic,and head-vibration behavior of this species. Larvae used both trail pheromones and thigmotactic signals to organize themselves into head-to-tail processionary columns. The trail pheromone, produced from the center of the abdomen, remains active for up to 4 h. Processions are not consistently led by particular individuals, but dynamically change over time and often temporarily break into two or more subprocessions. Subprocessions reunite through use of the trail pheromone. We found no evidence that head-bobbing generates attraction through substrate-borne or acoustic signals, but this behavior functions in direct contact to excite group activity. Time-lapse videography used to analyze cycloalexic group formation showed that larvae transition from feeding in a line along the leaf margin to cycloalexic formations on the upper leaf surface via a coordinated back-up movement that brings the posterior tip of their abdomens into contact. We identify three phases of cycloalexic formation: line-up, back-up, and an adjustment phase. Complete assembly can be achieved in as little as 5 s, but often the two phases establishing the basic rosette lasts 5,10 min, while the adjustment phase slowly tightens the group over a period of up to an hour. Collectively these studies present the first documented case of chemical trail marking in a beetle, and provide insight into a remarkable social-behavioral repertoire convergent in key respects with the better-studied social caterpillars and sawflies. [source]

Quality of life in 1000 patients with early relapsing,remitting multiple sclerosis

EUROPEAN JOURNAL OF NEUROLOGY, Issue 6 2009
N. Putzki
Background and purpose:, To examine the quality of life (QoL) in a large cohort of untreated patients with relapsing,remitting multiple sclerosis (RRMS) and to investigate the impact of intramuscular (IM) interferon beta-1a (IFNß-1a) treatment. Methods:, Prospective, observational, open-label, multicentre study conducted in Germany. Untreated patients with RRMS who initiated treatment with IM IFNß-1a were included and followed for 12 months. QoL was measured using the EQ-5D questionnaire. Clinical response was assessed by relapse rate and disability (Expanded Disability Status Scale; EDSS). Results:, A total of 1157 patients were included [mean age 37.6 years, median disease duration 13 months, mean relapse rate 1.7 (95%CI: 1.58,1.73), median EDSS score 2.0]. Relapse rate was reduced to 0.6 at 12 months (95%CI: 0.51,0.69, P < 0.0001). EDSS did not change significantly. At baseline, QoL was considerably lower in MS patients compared with the general German population, but was improved after treatment initiation [utilities of EQ-5D: 0.77 (95%CI: 0.75,0.78) vs. 0.75 (95%CI: 0.74,0.76) at baseline, 95%CI for difference: 0.01,0.03, P = 0.0046]. Higher disease activity and inability to work were negative predictors of QoL. 14.7% of patients were incapable of working for MS-related reasons. Conclusions:, Quality of life is considerably impaired in early stages of MS. Treatment initiation with IM IFNß attenuates MS disease activity and improves QoL. Inability to work early during the disease is a major challenge for the social security systems. [source]

Advance Directives in Skilled Nursing Facility Residents Transferred to Emergency Departments

ACADEMIC EMERGENCY MEDICINE, Issue 12 2001
Michael Lahn MD
Abstract Objective: Ten years have passed since Congress enacted the Patient Self-Determination Act to promote the use of advance directives (ADs). This study was performed to determine the frequency, type, demographic distribution, and utility of ADs that accompany residents of skilled nursing facilities (SNFs) transferred to emergency departments (EDs). Methods: This was an observational, cross-sectional cohort of SNF residents, transferred to two urban, academic EDs. Chart review and physician interviews were conducted on consecutive patients arriving during 12-hour data collection shifts. Results: Among 715 patients entered, 315 [44%, 95% confidence interval (95% CI) = 40% to 48%] had an AD. Advance directives were significantly more prevalent among white (50%) than African American (34%) or Hispanic (39%) patients (p < 0.001), and varied from 0% to 94% among SNFs. Of the 315 patients with ADs, do-not-resuscitate (DNR) orders were the most prevalent (65%, 95% CI = 58% to 69%). Although 75% (95% CI = 69% to 81%) of the DNR orders addressed cardiopulmonary resuscitation (CPR), only 12% (95% CI = 8% to 16%) addressed intubation. Among 39 patients who required intubation or CPR, 44% had ADs, 82% (95% CI = 57% to 96%) of which were deemed useful. Conclusions: Despite a decade of legislation promoting their use, ADs are lacking in most SNF residents transferred to EDs for evaluation and in most settings in which a clinical indication exists for intubation or CPR. Variation in their prevalence appears to be associated with both ethnicity and SNF origin. Although about three-fourths of DNR ADs addressed CPR, only about one in ten offered guidance regarding intubation. When available, ADs are used in most instances to guide emergency care. [source]

Marital Research in the 20th Century and a Research Agenda for the 21st Century

FAMILY PROCESS, Issue 2 2002
John M. Gottman Ph.D.
In this article we review the advances made in the 20th century in studying marriages. Progress moved from a self-report, personality-based approach to the study of interaction in the 1950s, following the advent of general systems theory. This shift led, beginning in the 1970s, to the rapid development of marital research using a multimethod approach. The development of more sophisticated observational measures in the 1970s followed theorizing about family process that was begun in the decade of the 1950s. New techniques for observation, particularly the study of affect and the merging of synchronized data streams using observational and self-report perceptual data, and the use of sequential and time-series analyses produced new understandings of process and power. Research in the decades of the 1980s and 1990s witnessed the realization of many secular changes in the American family, including the changing role of women, social science's discovery of violence and incest in the family, the beginning of the study of cultural variation in marriages, the expansion of the measurement of marital outcomes to include longevity, health, and physiology (including the immune system), and the study of co-morbidities that accompany marital distress. A research agenda for the 21st century is then described. [source]

Proposed Curriculum for an "Observational" International Emergency Medicine Fellowship Program

ACADEMIC EMERGENCY MEDICINE, Issue 4 2000
C. James Holliman MD
Abstract. This article presents information on considerations involved in setting up and conducting fellowship training programs in emergency medicine (EM) for physicians from other countries. General goals for these programs are to assist in providing physicians from other countries with the knowledge and skills needed to further develop EM in their home countries. The authors report their opinions, based on their cumulative extensive experiences, on the necessary and optional structural elements to consider for international EM fellowship programs. Because of U.S. medical licensing restrictions, much of the proposed programs' content would be "observational" rather than involving direct "hands-on" clinical EM training. Due to the very recent initiation of these programs in the United States, there has not yet been reported any scientific evaluation of their structure or efficacy. International EM fellowship programs involving mainly observational EM experience can serve as one method to assist in EM development in other countries. Future studies should assess the impact and efficacy of these programs. [source]

Effect of tick parasitism on the health status of a passerine bird

FUNCTIONAL ECOLOGY, Issue 6 2008
D. J. A. Heylen
Summary 1Little information is available on the ecological interactions between ticks and their hosts under natural conditions, and particularly so for avian hosts. To understand this host,parasite interaction it is necessary to assess the physiological harm ticks can do to their host. 2We combined observational and experimental (field and laboratory) data to examine the effects of a common tick species with major economic importance, the sheep tick (Ixodes ricinus), on the health status of a common passerine bird, the great tit (Parus major). 3In the laboratory experiment a parallel group design was carried out in which the birds of the experimental group were infested with 3,10 nymphs, whereas the birds of the control group were kept free of ticks and received a sham treatment. Both groups were stratified according to age and sex. Health parameters were measured the day before and 3 days after infestation or sham treatment: haematocrit level, erythrocyte sedimentation rate, leucocyte concentration and general body condition (body mass corrected for body size). 4No effects of age were observed on any of the health parameters. The decrease in haematocrit level in the experimental group was significantly greater than in the control group. Moreover, infested males suffered more blood depletion than infested females. The increase in sedimentation rate was greater in the experimental group than in the control group. Surprisingly, no treatment effects were found on leucocyte concentrations, which may indicate immunoregulation by the ticks on components of the birds' cellular immune response. Also no difference in general body condition between the treatment groups was found. None of the infested birds died during infestation. 5Lower haematocrit levels in infested birds, but unaffected leucocyte concentrations and general body condition are confirmed by field data (experimental and observational) of adult birds during breeding season. 6Neither haematocrit level nor general body condition was associated with parasite intensity among infested birds, suggesting that immature Ixodes ricinus are not resource limited at high natural densities. Still, the measurable direct harm caused by sheep tick infestations calls for further study on its importance for the evolutionary ecology of passerine hosts. [source]

Pharmacoepidemiology of anabolic androgenic steroids: a review

FUNDAMENTAL & CLINICAL PHARMACOLOGY, Issue 1 2005
Ingemar Thiblin
Abstract Non-prescribed use of anabolic androgenic steroids (AAS) has been associated with a number of physical and psychiatric/behavioural complications, some of which are potentially lethal. Here, we review both observational and experimental studies on human subjects concerned with such side-effects. The only physical complication of AAS use that receives definitive support from such investigations is unfavourable changes in blood lipid profiles. Support for various psychiatric complications has also been provided by a number of cross-sectional studies, most involving comparisons between weight-training individuals who use or do not use AAS. Certain of these complications, in particular hypomania and increased aggressiveness, have been confirmed in some, but not all, randomized controlled studies. Epidemiological attempts to determine whether AAS use triggers violent behaviour have failed, primarily because of high rates of non-participation. Studies regarding the prevalence of AAS use in different populations typically report life-time prevalences of 1,5% among adolescents. However, the life-time prevalence (i.e. use on at least one occasion) is of doubtful relevance in attempting to estimate the number of individuals at risk for side-effects, as most of these complications appear to develop during prolonged use of AAS. Furthermore, it is reasonable to assume that the symptoms and signs of AAS use are often overlooked by healthcare professionals, so that the number of cases of possible AAS-related complications is virtually unknown. These limitations, together with an apparently low prevalence of prolonged AAS use among the general population, indicate that future epidemiological research in this area should focus on retrospective case,control studies and, perhaps, also on prospective cohort studies of populations selected for a high prevalence of AAS use, rather than attempting to perform large-scale population-based studies. [source]

Sulphur isotopes and the search for life: strategies for identifying sulphur metabolisms in the rock record and beyond

GEOBIOLOGY, Issue 5 2008
D. T. JOHNSTON
ABSTRACT The search for life can only be as successful as our understanding of the tools we use to search for it. Here we present new sulphur isotope data (32S, 33S, 34S, 36S) from a variety of modern marine environments and use these observations, along with previously published work, to contribute to this search. Specifically, we use these new data to gain a sense of life's influences on the sulphur isotope record and to distinguish these biologically influenced signatures from their non-biological counterparts. This treatment extends sulphur isotope analyses beyond traditional (34S/32S) measures and employs trace isotope relationships (33S/32S, 36S/32S), as the inclusion of these isotopes provides unique information about biology and its role in the sulphur cycle through time. In the current study we compare and contrast isotope effects produced by sulphur-utilizing microorganisms (experimental), modern and ancient sedimentary records (observational) and non-biological reactions (theoretical). With our collective search for life now extending to neighbouring planets, we present this study as a first step towards more fully understanding the capability of the sulphur isotope system as a viable tool for life detection, both on Earth and beyond. [source]

Including species interactions in risk assessments for global change

GLOBAL CHANGE BIOLOGY, Issue 9 2007
R. W. SUTHERST
Abstract Most ecological risk assessments for global change are restricted to the effects of trends in climate or atmospheric carbon dioxide. In order to move beyond investigation of the effects of climate alone, the climexÔ model was extended to investigate the effects of species interactions, in the same or different trophic levels, along environmental gradients on a geographical scale. Specific needs that were revealed during the investigations include: better treatment of the effects of temporal and spatial climatic variation; elucidation of the nature of boundaries of species ranges; data to quantify the role of species traits in interspecies interactions; integrated observational, experimental, and modelling studies on mechanisms of species interactions along environmental gradients; and high-resolution global environmental datasets. Greater acknowledgement of the shared limitations of simplified models and experimental studies is also needed. Above all, use of the scientific method to understand representative species ranges is essential. This requires the use of mechanistic approaches capable of progressive enhancement. [source]

European Study on Orthopaedic Status of haemophilia patients with inhibitors

HAEMOPHILIA, Issue 5 2007
M. MORFINI
Summary., ,Development of inhibitors against factor VIII (FVIII) or factor IX (FIX) in haemophilia patients is one of the most serious complications of repeated exposure to replacement therapy and has major clinical and economic consequences. To evaluate the relationship between inhibitor status of haemophilia patients and their quality of life (QoL) and degree of arthropathy and to compare the orthopaedic status of patients with/without inhibitors. An observational, cross-sectional, case control study enrolling: group A (n = 38), males aged 14,35 years, with severe congenital haemophilia A or B who had inhibitors against FVIII/FIX >5 years; group B (n = 41), as group A, but aged 36,65 years and group C (n = 49), as group A, but without inhibitors. Socio-demographics: medical history, clinical characteristics and QoL were assessed. In groups A and B, 16% and 27% were hospitalized for orthopaedic procedures vs. 4% in group C. Patient mobility was also severely reduced in groups A and B, with 24% and 22% using wheelchairs vs. 4% in group C, and 50% and 51% needing a walking aid vs. 29% in group C. Significantly more joint pain was reported by patients in group A vs. those in group C; clinical/radiological orthopaedic scores were also worse in group A vs. group C. Significantly more joint abnormality was reported by patients in group A vs. group C. The burden of orthopaedic complications and the impact on QoL are more severe in haemophilia patients who have developed inhibitors than in those without inhibitors. [source]

Effect of Evidence-Based Acute Pain Management Practices on Inpatient Costs

HEALTH SERVICES RESEARCH, Issue 1 2009
John M. Brooks
Objectives. To estimate hospital cost changes associated with a behavioral intervention designed to increase the use of evidence-based acute pain management practices in an inpatient setting and to estimate the direct effect that changes in evidence-based acute pain management practices have on inpatient cost. Data Sources/Study Setting. Data from a randomized "translating research into practice" (TRIP) behavioral intervention designed to increase the use of evidence-based acute pain management practices for patients hospitalized with hip fractures. Study Design. Experimental design and observational "as-treated" and instrumental variable (IV) methods. Data Collection/Extraction Methods. Abstraction from medical records and Uniform Billing 1992 (UB92) discharge abstracts. Principal Findings. The TRIP intervention cost on average $17,714 to implement within a hospital but led to cost savings per inpatient stay of more than $1,500. The intervention increased the cost of nursing services, special operating rooms, and therapy services per inpatient stay, but these costs were more than offset by cost reductions within other cost categories. "As-treated" estimates of the effect of changes in evidence-based acute pain management practices on inpatient cost appear significantly underestimated, whereas IV estimates are statistically significant and are distinct from, but consistent with, estimates associated with the intervention. Conclusions. A hospital treating more that 12 patients with acute hip fractures can expect to lower overall cost by implementing the TRIP intervention. We also demonstrated the advantages of using IV methods over "as-treated" methods to assess the direct effect of practice changes on cost. [source]

The precipitation climate of Central Asia,intercomparison of observational and numerical data sources in a remote semiarid region

INTERNATIONAL JOURNAL OF CLIMATOLOGY, Issue 3 2008
Reinhard Schiemann
Abstract In this study, we systematically compare a wide range of observational and numerical precipitation datasets for Central Asia. Data considered include two re-analyses, three datasets based on direct observations, and the output of a regional climate model simulation driven by a global re-analysis. These are validated and intercompared with respect to their ability to represent the Central Asian precipitation climate. In each of the datasets, we consider the mean spatial distribution and the seasonal cycle of precipitation, the amplitude of interannual variability, the representation of individual yearly anomalies, the precipitation sensitivity (i.e. the response to wet and dry conditions), and the temporal homogeneity of precipitation. Additionally, we carried out part of these analyses for datasets available in real time. The mutual agreement between the observations is used as an indication of how far these data can be used for validating precipitation data from other sources. In particular, we show that the observations usually agree qualitatively on anomalies in individual years while it is not always possible to use them for the quantitative validation of the amplitude of interannual variability. The regional climate model is capable of improving the spatial distribution of precipitation. At the same time, it strongly underestimates summer precipitation and its variability, while interannual variations are well represented during the other seasons, in particular in the Central Asian mountains during winter and spring. Copyright © 2007 Royal Meteorological Society [source]

Sensitivity of the southern African circulation to dipole sea-surface temperature patterns in the south Indian Ocean

INTERNATIONAL JOURNAL OF CLIMATOLOGY, Issue 4 2002
C. J. C. Reason
Abstract Previous observational work suggests that when sea-surface temperature (SST) is warm (cool) in the southwest Indian Ocean and cool (warm) in the southeast Indian Ocean, increased (decreased) summer rains may occur over large areas of southeastern Africa. In this study, an atmospheric general circulation model is used to investigate the sensitivity of the regional circulation and rainfall over southern Africa to these dipole SST anomalies in the subtropical south Indian Ocean. When the model is forced with positive SST anomalies in the west and negative SST anomalies in the east, increased rainfall occurs over southeastern Africa as a result of the enhanced convergence of moister than average air over the region. Enhanced evaporation occurs over the warm pole in the southwest Indian Ocean and this moist air is advected towards southeastern Africa as a result of the low-pressure anomaly generated over this pole, which strengthens the onshore flow. Increased and more intense extra-tropical cyclones occur to the southeast of South Africa, favourable for tropical,temperate trough formation. When the SST poles are reversed in sign, decreased precipitation occurs over southeastern Africa as a result of increased low-level divergence of low-level flow and this flow being drier than average. Weaker and fewer extra-tropical cyclones occur southeast of South Africa in this case. The model results are sensitive to the proximity of the southwest Indian Ocean pole to southeastern Africa. There is also sensitivity in the model low-level wind changes and precipitation anomaly over low-latitude southern Africa (but not over South Africa to any significant extent) to the presence or absence of the SST pole over the southeast Indian Ocean. Although the model resolution does not capture the details of the local SST and topographic gradients as well as one would like, the changes in model circulation and precipitation in the experiments with different SST anomalies are consistent with previous observational and theoretical work, hence increasing confidence in the robustness of the results. Copyright © 2002 Royal Meteorological Society [source]

Subtropical cold surges: regional aspects and global distribution

INTERNATIONAL JOURNAL OF CLIMATOLOGY, Issue 10 2001
René D. Garreaud
Abstract Shallow surges of cold dry air are frequently observed to the east of the major mountain ranges, moving from mid-latitudes well into the Tropics in about 4 days. Because of their strong impact on weather, regional aspects of cold surges have received considerable attention, particularly over Southeast Asia, to the east of the Rockies and Mexican Sierras, and to the east of the subtropical Andes. Both observational and numerical studies reveal a similar structure and evolution of cold surges in different regions. These common aspects are reviewed in this work, as well as the mechanisms responsible for the development and subsequent advance of cold surges over the subtropics. Atmospheric reanalysis data are used to document the global distribution of cold surges on the basis of their continental-scale imprints on relevant fields, as well as to estimate their contribution on the regional and global energy balances. It is found that cold surges have a major cooling and drying effect over the regions where they are prevalent (e.g. subtropical South America) and represent a sizeable sink of energy for the Tropics. Copyright © 2001 Royal Meteorological Society [source]

Improved preoperative iron status assessment by soluble transferrin receptor in elderly patients undergoing knee and hip replacement

INTERNATIONAL JOURNAL OF LABORATORY HEMATOLOGY, Issue 6 2006
M. BASORA
Summary A poor preoperative haemoglobin (Hb) status is frequently encountered among adult patients scheduled for corrective surgery of the locomotive system, representing the main risk factor for blood transfusion. The soluble transferrin receptor (sTfR) has become a highly specific parameter for the detection of iron deficits as it can differentiate between iron deficiency anaemia and anaemia of chronic disease, because of the lack of effect by associated inflammation, unlike ferritin. The objectives of this study were to evaluate patients with the prevalence of risk for transfusion, the effect of inflammation on ferritin (F) values and functional iron deficiency in elderly patients with advanced degenerative arthropathy scheduled for hip or knee replacement. This observational, prospective study included patients over 50 years, operated for hip or knee replacements between April and June 2004. Of 218 patients studied, 87 (39%) presented with Hb levels between 10 and 13 g/dl. The prevalence of functional iron deficit was 27% (sTfR > 1.76 mg/l), while only 8.6% of patients displayed F levels below normal. As expected, C-reactive protein levels were elevated in 24.8% of patients and erythrocyte sedimentation rate was elevated in 50%. These inflammatory markers did not correlate with levels of either F or sTfR. Multiple factors can affect F levels, such as the inflammatory status of osteoarthritis in the elderly, obesity, nonsteroidal anti-inflammatory drugs therapy and low physical performance. As sTfR is not affected by inflammation, it has emerged as a primary parameter for the evaluation of iron status during preoperative assessment among patients scheduled for arthroplasty surgery. Our data strongly suggest that sTfR measurement contributes to improve patient management. [source]