Similar Proportions Of Subjects Research Articles

Hypothyroidism at one year following radioactive iodine therapy; Incidence and associated factors: Report from a tertiary Nigerian Hospital

Background: Although hypothyroidism is a predictable sequelae of radioactive iodine therapy, the time of its occurrence can be many years later. An early induction of hypothyroidism will allow for the prompt detection and treatment of hypothyroidism. Aim: To determine the rate and determinants of hypothyroidism at one year following radioactive iodine (RAI) therapy. Design: Retrospective review of patients case records. Methods: Data on demographic, clinical and biochemical variables were obtained. Primary outcome was thyroid status as hypothyroid or not hypothyroid at 12 months following RAI treatment. Statistical analysis was with SPSS version 10. The level of statistical significance was taken as p < 0.05. Results: Seventy-seven (77) subjects, 63 females received RAI. Their mean age was 41.8 ± 12 years with range of 18-72 years (n=77). Thyroid function status at 12 months post RAI was available for 31 subjects. The incidence of hypothyroidism in these 31 persons was 50%. Thyroid volume was significantly greater in those who were hypothyroid by 12 months compared with those not hypothyroid at 12 months. Both groups had similar proportions of subjects with Graves's disease, toxic and non-toxic goiter. The proportions of subjects treated with 10mci, 15mci or 20mci of RAI and those with raised microsomal antibodies were similar in both groups. Conclusion: The rate of hypothyroidism at 12 months after RAI therapy at doses of 10-20mci was 50%. The tendency to be hypothyroid by 1 year was less increased thyroid volume.

Clinical, electrophysiologic, and pathologic evidence for sensory abnormalities in ALS

Amyotrophic lateral sclerosis (ALS) is a progressive degenerative disease of upper and lower motor neurons. Reports of the nature and frequency of sensory nerve involvement in ALS have varied. We reviewed the Emory University motor neuron disease registry between 1997 and 2004 to identify 103 patients with ALS without coexisting diseases that might cause sensory abnormalities and for whom electrodiagnostic studies were available for review. Neurophysiologic studies were interpreted based on age-adjusted normative data from our laboratory. Twelve control biopsies were evaluated alongside 22 samples from patients with ALS to ensure blinded evaluation of pathologic specimens. Sensory symptoms or signs were present in 32% of patients, sural sensory nerve action potential amplitudes were abnormal in 27%, and pathologic abnormalities were present in 91% of patients. Large-caliber myelinated fibers were predominantly affected (reduced in 73%) and small-caliber myelinated fibers were affected less often (23%). Thinly myelinated fibers were present in 95% and regenerating clusters in 77% of the biopsies. Teased fiber analysis showed an increased frequency of axonal degeneration and regeneration as well as excessive myelin irregularity. Morphometry confirmed the loss of large-caliber fibers. These data indicate that one third of patients with amyotrophic lateral sclerosis report sensory symptoms and sural sensory response amplitudes are reduced in a similar proportion of subjects. Pathologic evidence of sensory nerve pathology was present in 91% of patients who underwent sural nerve biopsy. The electrophysiologic and pathologic findings indicate a pattern of axonal loss that predominantly affects large-caliber myelinated fibers.

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

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/microL 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.

Author reply

Our study confirmed the higher incidence of pancreatic adenocarcinoma noted among African Americans living in California.1 The focus of our study was not on risk factors, and it would be beyond the scope of the article to judge which factors were established or speculative. Our analysis, based on the California Cancer Registry dataset, found that African Americans, non-Hispanic whites, and Hispanics had similar proportions of subjects who reported having medical insurance.1 Although we are aware of the global economic disparities between the demographic groups, our dataset did not demonstrate this disparity and was reported as such. In our analysis, we found that African Americans age younger than 65 years had the highest proportion of tumors occurring in the body or tail of the pancreas (41.5% vs. 32.6% in non-Hispanic whites).1 We mentioned that this may be one possible contributory explanation to our finding that African Americans were least likely to undergo surgery. Although the tail of the pancreas is technically easier to resect, it is well established that tumors involving the tail of the pancreas are less likely to be resectable and to have a worse prognosis than right-sided lesions (the uncinate, head, or neck of the pancreas). A more recent article by the quoted3 Hopkins group reported that among 616 patients who underwent potentially curative resections, 563 cases involved right-sided lesions whereas only 49 of the resectable lesions were found in the body or tail of the pancreas.4 Furthermore, patients with right-sided lesions demonstrated improved 1-year and median survival rates compared with those patients whose tumors occurred in the body or tail of the pancreas. They also stated that tumors occurring in the left side of the pancreas were more often unresectable at the time of presentation and therefore were not included in their analysis. Our finding that African-Americans had a slightly higher proportion of tumors occurring in the body and tail of the pancreas compared with the other racial/ethnic groups has not to our knowledge been reported previously. However, this data point should not influence how a surgeon would approach any individual patient. Despite its dismal prognosis, the research and funding for pancreatic carcinoma is relatively small compared with that for other malignancies such as those of the breast and colon. Moreover, awareness and investigation of racial/ethnic disparities in pancreatic carcinoma patients is barely on the proverbial radar screen. Therefore, we agree with Dr. Hayanga that the focus should be on the facts (i.e., pancreatic adenocarcinoma indeed occurs more commonly in African Americans) and concur with the plea for much-needed investigation and intervention. Kenneth J. Chang M.D.*, * Comprehensive Digestive Disease Center, Gastrointestinal Oncology, University of California, Irvine Medical Center, Orange, California.

Masked Hypertension Assessed by Ambulatory Blood Pressure Versus Home Blood Pressure Monitoring: Is It the Same Phenomenon?

Masked hypertension is defined as normal clinic blood pressure (CBP) and elevated out-of-clinic blood pressure assessed using either self-monitoring of blood pressure (BP) by the patients at home (HBP) or ambulatory BP (ABP) monitoring. This study investigated the level of agreement between ABP and HBP in the diagnosis of masked hypertension. Participants referred to an outpatient hypertension clinic had measurements of CBP (two visits), HBP (4 days), and ABP (24 h). The diagnosis of masked hypertension based on HBP (CBP <140/90 mm Hg and HBP > or =135/85) versus ABP (CBP <140/90 and awake ABP > or =135/85) was compared. A total of 438 subjects were included (mean age +/- SD, 51.5 +/- 11.6 years; 59% men and 41% women, 34% treated and 66% untreated). Similar proportions of subjects with masked hypertension were diagnosed by ABP (14.2%) and HBP (11.9%). In both treated and untreated subjects, the masked hypertension phenomenon was as common as the white coat phenomenon. Among 132 subjects with normal CBP, there was disagreement in the diagnosis of masked hypertension between the HBP and the ABP method in 23% of subjects for systolic and 30% for diastolic BP (kappa 0.56). When a 5-mm Hg gray zone for uncertain diagnosis was applied to the diagnostic threshold, the disagreement was reduced to 9% and 6% respectively. Similar proportions of subjects with masked hypertension are detected by ABP and HBP monitoring. Although disagreement in the diagnosis between the two methods is not uncommon, in the majority of these cases the deviation of the diagnostic BP above the threshold in not clinically important. Both ABP and HBP monitoring appear to be appropriate methods for the detection of masked hypertension.

Safety and tolerance of rapidly infused Depacon®: A randomized trial in subjects with epilepsy

Background: Valproate sodium injection (Depacon®) is an intravenous form of valproate for use in absence and complex partial seizures when circumstances preclude oral administration. Certain situations may warrant larger and more rapid infusions than permitted by the original labeling. This study evaluated the safety of more rapid infusions. Methods: Subjects with epilepsy were randomized in a 2:1 ratio to receive up to 15 mg/kg of valproate sodium infused at 3.0 or 1.5 mg/kg/min. Up to four infusions were allowed within 24 h to achieve target plasma valproate concentrations of 50–100 mcg/ml. Primary safety endpoints were the changes in the 5-min and minimum post-first infusion blood pressures (BPs). Results: One hundred twelve subjects were treated, (3.0 mg/kg/min group: n=72, 1.5 mg/kg/min group: n=40). No significant treatment differences were detected for changes in the primary BP endpoints. Two subjects in the 3.0 mg/kg/min group had potentially clinically significant low systolic BP values during the study. Similar proportions of subjects in the two groups reported adverse events during or within 6 h following the first infusion. Conclusions: Valproate sodium injection dosages up to 15 mg/kg and rates of 1.5 and 3.0 mg/kg/min were well tolerated in this population.

The use of antidepressants among injecting drug users in Sydney, Australia.

To ascertain the prevalence and patterns of antidepressant use among IDU in Sydney and to determine any harm associated with antidepressant use. Cross-sectional survey. Sydney, Australia. Two hundred and one Sydney injecting drug users (IDU) recruited through advertisements, needle exchanges, methadone maintenance clinics and by word of mouth. Forty per cent of subjects had used antidepressants, 21% in the preceding 6 months. Similar proportions of subjects had used tricyclics (26%) and selective serotonin reuptake inhibitors (SSRIs) (24%), with 8% reporting use of a monoamine oxidase inhibitor. Recent use favoured the SSRIs; however, there was still widespread use of tricyclics. The injection of antidepressants was rare, with only three subjects reporting ever having injected the drugs. Antidepressant use was associated with higher levels of polydrug use, poorer health, higher levels of psychiatric distress and a greater risk of heroin overdose. The excess risk of overdose was specifically associated with tricyclics, rather than SSRIs. The study confirmed that, like other pharmaceutical products, the use of antidepressants was common among IDU in Sydney. The prescription of tricyclics to heroin users would appear to increase their risk of overdose. If it is considered appropriate to prescribe antidepressants to IDU, it would appear safer to prescribe SSRIs.

Assessment of functional cerebral laterality for language using magnetoencephalography.

The purpose of the study was to examine the feasibility of using magnetoencephalography (MEG), a noninvasive functional brain imaging technique, to assess cerebral laterality for language. The magnetic flux normal to the scalp surface was measured with a whole-head neuromagnetometer while subjects (n = 16) were engaged in a word-matching and a tone-matching task. The effect of hemisphere and task on the number of satisfactory equivalent current dipole (ECD) solutions obtained during the late portion of the responses to the word and tone stimuli was examined. An interhemispheric ECD laterality index was also computed. Satisfactory ECD solutions were localized in perisylvian cortices during both tasks. A greater number of ECDs was found in the left hemisphere in 14 (87%) of 16 of the subjects in the word-matching task, a proportion that approaches the reported incidence of left-hemisphere dominance among right-handers. A similar proportion of subjects also showed a clear asymmetry in the number of ECDs favoring the left hemisphere in the language task as compared to the nonlanguage task. These findings suggest that MEG is a promising tool for laterality assessment. Magnetoencephalography-based functional asymmetry data are currently being compared against invasive presurgical procedures (i.e., intracarotid amobarbital procedure).

Group and multifamily behavioral treatment for obsessive compulsive disorder: A pilot study

Recent trends toward managed care in mental health settings require investigation of the efficacy and cost-effectiveness of treatments conducted over shorter time frames or with less therapist involvement. Findings are presented in an uncontrolled trial of two types of group behavioral treatments for OCD: group (GBT) and multifamily (MFBT). Seventeen patients (10 women and 7 men) diagnosed with OCD received a partially manualized GBT delivered by co-therapy teams in three groups of ten 2-hr sessions. Mean interview-based YBOCS scores reduced significantly at posttest and at 1-year follow-up, as did measures of overall functioning on the Sheehan Disability Scale at posttest and follow-up. A second cohort of 19 patients (14 women and 5 men) was treated with MFBT that included spouses/partners and parents in three co-therapy groups. Two groups received ten 2-hr sessions and one received twelve 2-hr sessions. YBOCS scores reduced significantly at posttest and at 1-year follow-up, with corresponding gains in disability scores. Both group treatments showed large effects comparable to those reported for a more intensive individual behavioral treatment. Comparisons of treatments indicated that similar proportions of subjects were reliably changed at posttest and follow-up respectively, but more MFBT than GBT participants were clinically significantly improved. These promising cost effective group treatments remain to be tested in a controlled trial.

Binge Eating Disorder Affects Outcome of Comprehensive Very‐Low‐Calorie Diet Treatment

To determine the effects of binge eating disorder (BED) on weight loss and maintenance in women undergoing treatment for obesity, we studied the weight changes of 38 women (body mass index > 30 kg/m2), 21 of whom met proposed criteria for BED and 17 of whom reported few problems with binge eating, during and after a 26-week comprehensive very-low-calorie diet (VLCD) treatment program. All 17 subjects without and 16/21 subjects with BED returned for four follow-up visits over 12 months (p = 0.05). While a similar proportion of subjects with and without BED reported absolute adherence to both the modified fast and refeeding, those with BED showed a significantly different distribution in energy intake from those without BED, with fewer small and more large lapses among those who deviated from the diet (p < 0.05). There was no significant difference in mean weight loss over the 26 weeks of treatment, but subjects with BED showed significantly diminished weight loss during the middle third of treatment (p < 0.05). Black subjects, regardless of the presence of BED, lost significantly less weight during treatment than white subjects (p < 0.005). Although there was no significant difference in mean weight loss at any of the four follow-up visits between subjects with and without BED, 25% of subjects with BED had regained > 50% of their lost weight by three-month follow-up, vs. no subjects without the disorder (p < 0.05). One year after completing treatment, approximately half of BED (+) and BED (-) subjects had a good outcome, maintaining a weight loss > or = 10% of initial body weight. However, 35% of subjects with BED, and none of the subjects without BED, had a poor outcome (p < 0.05). We conclude that many individuals with BED will respond well to a medically supervised comprehensive VLCD program, attaining medically significant weight loss. However, this subgroup appears to be at risk for early major regain of lost weight and for poor outcome one year following weight-loss treatment.

Prophylaxis of urinary tract infection in persons with recent spinal cord injury: A prospective, randomized, double-blind, placebo-controlled study of trimethoprim-sulfamethoxazole

purpose: To determine the efficacy of trimethopriin-sulfamethoxazole (TMP-SMX) for prophylaxis of urinary tract infection in persons with recent spinal cord injury, during the first 4 months of intermittent catheterization. patients and methods: One hundred twentynine adults (112 men, 17 women) with recent acute spinal cord injury participated in a randomized, double-blind, placebo-controlled trial, and were studied for up to 16 weeks. Low-dose TMP-SMX (TMP 40 mg, SMX 200 mg) or placebo was given once daily. Clinical observations, urine cultures, and cultures of rectal and urethral swabs were made weekly. Subjects who developed breakthrough bacteriuria received conventional antimicrobial therapy and prophylaxis was continued. results: Sixty-six TMP-SMX recipients (57 men, 9 women) and 60 placebo recipients (52 men, 8 women) are evaluable for efficacy. Among male subjects, bacteriuria was present during 50% or more of study weeks in 30% of TMP-SMX recipients and in 56% of placebo recipients (p = 0.003). The interval to the onset of bacteriuria was prolonged in TMP-SMX recipients (p <0.0001). TMP-SMX recipients without bacteriuria in any given week had a lower probability of having bacteriuria the subsequent week (0.26) than did placebo recipients (0.49) (p <0.0001). At least 1 episode of definite symptomatic bacteriuria (bacteriuria and fever and at least 1 classical manifestation of urinary infection) occurred in 4 of 57 TMP-SMX-treated men and in 18 of 52 placebo-treated men (p <0.0003). We observed similar trends in women, but differences did not reach statistical significance, perhaps because the number of females was small. Adverse events suspected to be due to medications were frequent in this population of patients with recent severe injuries and led to discontinuation of the study in 10% of the TMPSMX group and 8% of the placebo group. Adverse events included neutropenia (TMP-SMX: two; placebo: three), pseudomembranous colitis (TMP-SMX: one), severe skin rash (TMP-SMX: two; placebo: one), and drug fever (TMP-SMX: one). The proportion of all episodes of bacteriuria that were due to TMP-SMX-resistant organisms was unexpectedly high in the placebo group (51%), and increased progressively according to year of enrollment in the study. By Year 3, all subjects in the placebo group had at least one episode of TMP-SMX-resistant bacteriuria. Gram-negative enteric bacilli resistant to TMP-SMX were recovered from rectal swabs (TMP-SMX 49%, placebo 42%) and urethral swabs (TMP-SMX 33%, placebo 26%) in similar proportions of subjects in the two study groups. conclusions: Prophylaxis with TMP-SMX significantly reduces bacteriuria and symptomatic urinary tract infection in persons with recent acute spinal cord injury during bladder retraining using intermittent catheterization. However, adverse reactions attributable to TMP-SMX are common in this population. Colonization and breakthrough bacteriuria with TMP-SMX-resistant organisms are frequent and may seriously limit the usefulness of this strategy, particularly in an institutional setting.

Suicide and panic disorder: a review

This article reviews the risk of suicide in panic disorder beginning with early studies showing increased mortality, including suicide, among patients belonging to the broad category of neuroses. More recent follow-up studies of patients with anxiety disorders have found about 20% of deaths due to suicide, a proportion similar to that found in depressive disorders. Also, suicide attempts have been reported by similar proportions of subjects with panic disorder and major depression from the general population. Preliminary data indicate that more severely ill patients with coexisting depression and substance abuse are more likely to attempt or complete suicide. Thus, although limited, the data indicate that the risk of suicide in panic disorder is substantial. As a consequence, clinicians should alert themselves to this preventable outcome and approach treatment with added caution.

Clinical markers of androgenicity in acne vulgaris.

Androgenic stimulation of sebaceous glands is necessary for development of acne. If hyperandrogenaemia were a major determinant of acne in women, the frequency of other clinical markers of androgenicity should increase with acne severity. To investigate this, 268 female subjects (aged 12-44 years) were studied. Subjects were divided into groups on the basis of acne severity: physiological, moderate, and severe. With exclusion of women taking oral contraceptives or anti-androgen therapy, subjects in each group were similar with respect to age at menarche and incidence of menstrual irregularity of amenorrhoea. Reports of excessive body hair, and clinical hirsutes on examination were few and there were no significant differences between acne severity groups. No correlation was observed between acne and hirsutes grades in all subjects (rank correlation coefficient = 0.096). Mild male pattern androgenic alopecia occurred in similar proportions of subjects in the three groups. Female pattern androgenic alopecia was observed in only two subjects. We have shown no correlation between acne severity and clinical markers of androgenicity in women. This suggests that in most cases factors other than hyperandrogenaemia are necessary for the development of acne.