Total Study Group Research Articles

Lateral epicondylalgia: a structured programme better than corticosteroids and NSAID

Aim: To evaluate whether patients with lateral epicondylalgia had less pain or function loss two years following treatment by a structured programme and if the number of recurrent episodes and sick leave days differed compared with a control group. Subjects: All of the patients were diagnosed by a physician with the diagnosis code M77.1 (lateral epicondylitis). The intervention group (n = 103) was treated by a physiotherapist and an occupational therapist with a home training programme that included ergonomic advice. Wrist supports and/or night bandages were also available. Controls (n = 194) were diversely treated by different professionals. Major findings: In the total study group (n = 297), 54% of the patients experienced pain and 55% experienced function loss after two years. The intervention group had less pain than patients treated with corticosteroid injections (p < 0.0001) or NSAIDs (p = 0.048) and experienced better function than those treated with corticosteroid injections (p = 0.002). The intervention group had a lower recurrence (p < 0.0001) and fewer sick leave days at the time of the visit to the health care centre (p = 0.005). Principal conclusions: A structured treatment programme was more effective than corticosteroid injections and NSAIDs. Patients did not require additional treatment or sick leave and had learned self-treatment of the disorder.

The contribution of self‐esteem and self‐concept in psychological distress in women at risk of hereditary breast cancer

Clarification of the role of several aspects of self-concept regarding psychological distress in women at risk of hereditary breast cancer will help to target counselling and psychosocial interventions more appropriately. In this study, we aimed (1) to examine the role of general self-esteem and specific aspects of self-concept (i.e. stigma, vulnerability, and mastery) in psychological distress in women at risk of hereditary breast cancer and (2) to compare the relative importance of these self-concept aspects in psychological distress in women with low versus high self-esteem. General and breast-cancer-specific distress, self-esteem, self-concept, and demographics were assessed in 246 women being at risk of hereditary breast cancer, who opted either for regular breast surveillance or prophylactic surgery. In the total study group, self-esteem was negatively associated with general distress. Furthermore, feeling stigmatized was strongly associated with more breast-cancer-specific distress, and to a lesser degree with general distress. In women with low-self esteem, feelings of stigmatization were strongly associated with higher levels of both breast-cancer-specific and general distress, while a sense of mastery was associated with less general distress. For women with high self-esteem, feelings of both stigmatization and vulnerability were associated with more breast-cancer-specific distress, whereas there were no significant associations with general distress. Psychosocial interventions or support groups for women at risk of hereditary breast cancer should focus on self-esteem and feelings of stigmatization and isolation, and consequently tailor the interventions on specific items for respective women.

Caries prevalence in Danish pre-school children delivered vaginally and by caesarean section

Objective. The mode of delivery may significantly influence the diversity and composition of the oral microflora and facilitate early acquisition of mutans streptococci. The aim was to compare caries prevalence and experience in 3-year-old children delivered vaginally and by caesarean section (C-section). Materials and methods. The study had an observational cohort protocol based on extracted information from governmental databases and nationwide registers concerning birth, social and educational levels and dental status. Children born at the Copenhagen University Hospital in 2005 were eligible and the final study group with complete information consisted of 594 children, 443 delivered vaginally and 151 by C-section. Results. The total caries prevalence was 8% and no significant difference was displayed between the groups. When only the children with caries (dmfs > 0) were compared, those delivered by C-section had a higher mean value in comparison with those delivered vaginally (dmfs 6.8 vs 3.2), but the difference was not statistically significant. There was a significant relationship between caries prevalence and low family income in the total study group (OR = 5.8, p < 0.05). Conclusions. Within the limitations of this observational cohort study, caries prevalence in 3-year-old children was not related to the mode of delivery. However, the tendency of more severe caries in the C-section group justifies further studies, preferably with a prospective design.

A case‐control study assessing oral‐health‐related quality of life after immediately loaded single implants in healed alveolar ridges or extraction sockets

Tooth loss reduces oral-health-related quality of life (OHRQoL) as assessed with the 14-item Oral Health Impact Profile questionnaire (OHIP-14). This prospective multicenter case-control study sought to (i) establish OHRQoL in patients requiring a single implant in the anterior maxilla and to (ii) compare these changes following implant placement and immediate provisionalization in extraction sockets with healed alveolar ridges up to 1 year. Ninety-six patients were enrolled in the study with 102 single implants (OsseoSpeed AstraTech) provisionalized immediately after placement in sockets or after placement in healed ridges. A final crown was cemented after 12 weeks. OHIP-14 was registered before surgery (baseline), after 1 (provisional crown), 6 and 12 months (final crown). Repeated measures ANOVA was performed for the seven conceptual OHIP Domains, the treatment group (extraction site socket vs. healed alveolar ridge) and time as within subjects variables. Two implants failed, 1/48 (2.1%) in the extraction group (n=46 patients) and 1/54 (1.8%) in the healed ridge group (n=50 patients). From 82 patients (87.5%), OHIP-14 was available at all time points. The overall OHIP-14 based on the mean of the seven domains increases between baseline and 6 months and remained stable afterward for the total study group and both treatment groups. Comparison between extraction and healed groups revealed no significant difference at baseline but the healed group showed a significantly higher improvement for functional limitation, physical disability, physical pain and psychological discomfort (P<0.05). Between baseline and 1 year in the healed bone group, all seven domains improved significantly compared with only three domains in the extraction group. However, the overall OHIP-14 score between groups was not substantially different. Hence, both treatment modalities lead to similar OHRQoL improvement. Patients in need of a single-tooth replacement have limited OHRQoL problems as reflected by the OHIP-14 score but improvements in several domains related to oral health were evaluated when implants were placed and provisionalized in healed bone and extraction sites.

Implantable cardioverter/defi brillator interventions in primary prevention: do current implantation criteria really predict ICD interventions?

Background Randomized controlled trials have proven the effi cacy of implantable cardioverter/defi brillators (ICDs) to prevent sudden cardiac death (SCD) in primary prevention. However, long-term data on the incidence of appropriate and inappropriate interventions in real life and on the predictive value of commonly used clinical variables to guide patient selection are scarce.Methods We retrospectively studied 101 patients who received an ICD for primary prophylaxis of SCD: 63.4% with ischaemic heart disease (IHD) and 36.6% with idiopathic dilated cardiomyopathy (IDCM). The mean follow-up period was 26.2 (± 14.8; median 27.8; range 5.6-70.5) months. Age, left ventricular ejection fraction (LVEF), QRS duration, NYHA class and electrophysiological study (EPS) outcome were evaluated as predictors of ICD intervention.Results At 2 years the cumulative incidence of appropriate (17.5% in IHD; 28% in IDCM; P= 0.63) and inappropriate (12.8% in IHD, 15.4% in IDCM; P= 0.62) interventions was similar in both groups. Atrial fi brillation was the most common cause of inappropriate interventions in the IHD group, sinus tachycardia in the IDCM group. Advanced age was associated with less inappropriate interventions (HR: 0.96 (95% confi dence interval (CI) 0.94-0.98); P< 0.01), and a better LVEF with less appropriate interventions (HR: 0.97 (95% CI 0.94-0.99); P < 0.01). This amounted in a signifi cant absolute diff erence in the number of appropriate interventions between the group with a LVEF < 25% and 25-34% after 3 years of follow-up of 42% in IHD (48% vs 6%). A prolonged QRS duration was associated with a slightly elevated risk for appropriate interventions only in the IHD group (HR: 1.01 (95% CI 1.00-1.03); P= 0.04). On the other hand, increased NYHA class was only associated with increased risk for appropriate interventions in the IDCM group (HR: 5.24 (95% CI 1.11-24.74); P= 0.04). No signifi cant statistical association was found between a positive EPS and appropriate or inappropriate interventions.Conclusions In primary prevention, during a mean follow-up of 2 years, one in fi ve patients had a possibly live-saving appropriate intervention. However, the incidence of inappropriate interventions was substantial. Predictors for appropriate interventions were: (i) LVEF in the total study group, (ii) NYHA class in the IDCM group and (iii) QRS duration in the IHD group.

Additional orthognathic surgery following Le Fort III and monobloc advancement

Severe midface hypoplasia in patients with various craniofacial anomalies can be corrected with Le Fort III or monobloc advancement. Often additional corrective orthognathic surgery is indicated to achieve Class I occlusion and a normal inter-jaw relationship. This study evaluated the incidence of, and the surgical indications for, secondary orthognathic surgery following Le Fort III/monobloc advancement. The total study group consisted of 41 patients: 36 patients with Le Fort III advancement and 5 patients with monobloc advancement. Seven patients underwent additional orthognathic surgery. Of the resulting 18 non-operated patients older than 18 years at the end of follow-up, Class I occlusion was observed in 11 patients. In the remaining patients malocclusions were dentally compensated with orthodontic treatment. None of the patients was scheduled for additional orthognathic surgery due to the absence of functional complaints and/or resistance to additional surgery. Le Fort III and monobloc advancement aim to correct skeletal deformities on the level of zygoma, orbits, nasal area and forehead, but Class I occlusion is frequently not achieved. Additional orthognathic surgery is often indicated in patients undergoing Le Fort III or monobloc advancement. Naso-endoscopic analysis of the upper airway and the outcomes of sleep studies may influence the orthognathic treatment plan.

Aortic root dimension changes during systole and diastole: evaluation with ECG-gated multidetector row computed tomography.

Cardiac pulsatility and aortic compliance may result in aortic area and diameter changes throughout the cardiac cycle in the entire aorta. Until this moment these dynamic changes could never be established in the aortic root (aortic annulus, sinuses of Valsalva and sinotubular junction). The aim of this study was to visualize and characterize the changes in aortic root dimensions during systole and diastole with ECG-gated multidetector row computed tomography (MDCT). MDCT scans of subjects without aortic root disease were analyzed. Retrospectively, ECG-gated reconstructions at each 10% of the cardiac cycle were made and analyzed during systole (30–40%) and diastole (70–75%). Axial planes were reconstructed at three different levels of the aortic root. At each level the maximal and its perpendicular luminal dimension were measured. The mean dimensions of the total study group (n = 108, mean age 56 ± 13 years) do not show any significant difference between systole and diastole. The individual dimensions vary up to 5 mm. However, the differences range between minus 5 mm (diastolic dimension is greater than systolic dimensions) and 5 mm (vice versa). This variability is independent of gender, age, height and weight. This study demonstrated a significant individual dynamic change in the dimensions of the aortic root. These results are highly unpredictable. Most of the healthy subjects have larger systolic dimensions, however, some do have larger diastolic dimensions.

MR Enteroclysis in Refractory Celiac Disease: Proposal and Validation of a Severity Scoring System

To determine magnetic resonance (MR) enteroclysis findings in patients with uncomplicated celiac disease (CD), refractory CD (RCD) type I, and RCD type II, to develop and validate a scoring system to identify patients with RCD II and to determine the diagnostic accuracy of MR enteroclysis to detect CD-related malignancies. This study was performed with approval of the institutional review board. One radiologist blinded to clinical details retrospectively evaluated quantitative and qualitative criteria of 28 studies obtained in symptomatic patients with CD (uncomplicated CD, n = 10; RCD I, n = 8; RCD II, n = 10). A scoring system was developed by using parameters identified in multivariate analysis to be associated with RCD II, which two radiologists evaluated in a second group of 40 symptomatic patients with CD. Accuracy to detect malignancy was assessed in the total study group. Cumulative survival was evaluated in the total study group by using the Kaplan-Meier method. MR enteroclysis could not be used to discriminate between uncomplicated CD and RCD I. The presence of less than 10 folds per 5 cm jejunum, mesenteric fat infiltration, and bowel wall thickening were associated with RCD II. A positive MR score was defined as the presence of two or more of these features. In the validation group, the MR score was positive in 13 of 15 patients with RCD II (sensitivity, 0.87) and negative in 24 of 25 patients without RCD II (specificity, 0.96). The 5-year survival rate was 95% in patients with a negative MR score and 56% in patients with a positive MR score (P < .0001). MR enteroclysis helped to identify the presence of seven of eight malignancies and to diagnose absence of malignancy in 58 of 60 studies. MR enteroclysis can be used to investigate the presence of RCD II or malignancy in symptomatic patients with CD.

Responsiveness of children with celiac disease to different hepatitis B vaccination protocols

We aimed to compare the response rates to hepatitis B virus vaccination in the first year of life, using two different immunization protocols, in children with celiac disease. Study Group 1 included patients with celiac disease who received 10 μg of hepatitis B vaccine intramuscularly at birth (0), 2 and 9-12 months of life. Group 2 included those who received hepatitis B vaccine at 0, 1 and 6 months of life. Healthy children were divided into two control groups according to the above schedules. The total study group included 64 patients and 49 healthy controls. Celiac patients were found to have lower response rates with respect to controls (78.1% vs. 95.9%, respectively). The difference in response rates in the two patient groups was not statistically significant. The response rates of celiac patients to the two different hepatitis B vaccination schedules showed no statistically significant difference.

Health-related quality of life and utility in patients receiving biological and non-biological treatments in rheumatoid arthritis

Biological treatments earn increasing significance in the treatment of rheumatoid arthritis (RA) but are associated with high incremental cost-effectiveness ratio compared to conventional antirheumatic treatments such as disease-modifying antirheumatic drugs. As the most important objective of medical technologies should be to increase life years and/or patients' health-related quality of life (HRQoL), measuring QoL and utility in RA patients treated with biological therapies is crucial. The objective of this study is to compare the utility and QoL of patients treated with biological (n = 85) and non-biological (n = 168) antirheumatic drugs in Hungary in a cross-sectional non-interventional study. A measure of impairment (Disease Activity Score (DAS)-28), QoL measure (EuroQol five Dimension (EQ-5D) Visual Analogue Scale (VAS), Rheumatoid Arthritis Quality of Life (RAQoL)) and utility measures (indirect: EQ-5D index, direct: time trade-off (TTO)) were applied using an interview method. The Pearson correlation was used to assess the strength of the relationship of different measures in the total study group (n = 253). The EQ-5D index (biological treatment: 0.608, non-biological treatment: 0.483; P = 0.012) and DAS-28 (biological treatment: 3.8, non-biological treatment: 4.5; P = 0.003) showed statistically significant difference between the two subcohorts after adjusting data by age, gender and disease duration. Our results indicate that patients on biological treatment have lower disease activity and higher utility; however, it was not statistically significant in all cases. According to our knowledge, TTO was not used previously in Hungarian RA patients. Utility data concerning biological treatments are essential for cost-utility models in health technology assessment reports for public reimbursement.

The Effectiveness of Supported Employment in People With Dual Disorders

Objective: This study compared the effectiveness of the Individual Placement and Support (IPS) model of supported employment to control vocational rehabilitation programs for improving the competitive work outcomes of people with a severe mental illness and co-occurring substance use disorder. Methods: A secondary data analysis was conducted drawing from four randomized controlled trials comparing IPS-supported employment to conventional vocational rehabilitation programs for severe mental illness and focusing on the 106 clients with a recent (past 6 months) substance use disorder. Competitive work outcomes were tracked across an 18-month follow-up period. Analyses compared the IPS and comparison vocational programs on cumulative work over the 18 months, including attainment of work, hours and weeks worked, job tenure, wages earned, and days to first job. Results: In the total study group, clients who participated in IPS had better competitive work outcomes than those who participated in a comparison program, with cumulative employment rates of 60% vs. 24%, respectively. Among clients who obtained work during the study period, those receiving IPS obtained their first job significantly more quickly and were more likely to work 20 or more hours per week at some point during the 18-month follow-up. Conclusions: The IPS model of supported employment is more effective than alternative vocational rehabilitation models at improving the competitive work outcomes of clients with dual disorders.

An analysis of HER-2/neu gene status in invasive ductal carcinomas using immunohistochemistry and fluorescence in situ hybridization

To determine the concordance rates between results from immunohistochemistry (IHC) and fluorescence in situ hybridization (FISH) assays for the HER-2/neu gene in cases of invasive ductal carcinoma. IHC and FISH are 2 of the most frequently used methods to determine HER-2/neu gene status in invasive breast carcinomas. Materials and methods: The present study includes 59 female patients with invasive ductal carcinoma. The mean age was 57.8 years. Axillary lymph node status could be evaluated in 30 patients with axillary dissection. HER-2/neu gene overexpression and amplification were analyzed in primary tumor tissues by IHC and FISH assays, respectively. The evaluation of the IHC assay was performed using a score of 0, 1+, 2+, or 3+, while a HER-2/neu-to-CEP17 ratio greater than 2 was accepted as positive for HER-2/neu gene amplification. Results: The overall rate of HER-2/neu gene amplification was 28.8% (17 cases) among all members of the study group, while this rate was 48% (12 cases) in the group with axillary lymph node metastasis. The rate of HER-2/neu overexpression (score of 3+) was 11.9% (7 cases). HER-2/neu gene amplification was associated with tumor grade (P < 0.05). There was a significant relationship between the results of the IHC and FISH assays (P < 0.001). All of the cases with a score of 3+ were FISH-positive, while 97% of cases with a score of 0 and 44% of cases with a score of 1+ were FISH-negative. HER-2/neu gene amplification was determined in 80% of the cases with a score of 2+. Among cases with positive lymph node status, the concordance rates were 100% in cases with scores of 0, 2+, and 3+, while this rate was found to be 29% in cases with a score of 1+. Conclusion: Our found rate (11.9%) of HER-2/neu overexpression was lower than the rates reported in the literature, while our HER-2/neu gene amplification rate (28.8%) was compatible with the reported rates. HER-2/neu gene amplification was associated with tumor grade. Although high rates of concordance between HER-2/neu gene overexpression and amplification in cases with scores of 2+ and 3+ were obtained, the discordance rate in cases with a score of 1+ was higher than those of other studies. The discordance rate in cases with a score of 1+ and positive lymph node status was higher than that of the total study group. According to our results, a score of 1+ indicated less conclusive immunostaining for the HER-2/neu

Aflatoxin levels, plasma vitamins A and E concentrations, and their association with HIV and hepatitis B virus infections in Ghanaians: a cross-sectional study.

BackgroundMicronutrient deficiencies occur commonly in people infected with the human immunodeficiency virus. Since aflatoxin exposure also results in reduced levels of several micronutrients, HIV and aflatoxin may work synergistically to increase micronutrient deficiencies. However, there has been no report on the association between aflatoxin exposure and micronutrient deficiencies in HIV-infected people. We measured aflatoxin B1 albumin (AF-ALB) adduct levels and vitamins A and E concentrations in the plasma of HIV-positive and HIV-negative Ghanaians and examined the association of vitamins A and E with HIV status, aflatoxin levels and hepatitis B virus (HBV) infection.MethodsA cross-sectional study was conducted in which participants completed a demographic survey and gave a 20 mL blood sample for analysis of AF-ALB levels, vitamins A and E concentrations, CD4 counts, HIV viral load and HBV infection.ResultsHIV-infected participants had significantly higher AF-ALB levels (median for HIV-positive and HIV-negative participants was 0.93 and 0.80 pmol/mg albumin, respectively; p <0.01) and significantly lower levels of vitamin A (-16.94 μg/dL; p <0.0001) and vitamin E (-0.22 mg/dL; p <0.001). For the total study group, higher AF-ALB was associated with significantly lower vitamin A (-4.83 μg/dL for every 0.1 pmol/mg increase in AF-ALB). HBV-infected people had significantly lower vitamin A (-5.66 μg/dL; p = 0.01). Vitamins A and E levels were inversely associated with HIV viral load (p = 0.02 for each), and low vitamin E was associated with lower CD4 counts (p = 0.004).ConclusionsOur finding of the significant decrease in vitamin A associated with AF-ALB suggests that aflatoxin exposure significantly compromises the micronutrient status of people who are already facing overwhelming health problems, including HIV infection.

Follow-up period of 13 years after endoscopic total extraperitoneal repair of inguinal hernias: a cohort study

BackgroundEndoscopic inguinal hernia repair was introduced in the Netherlands in the early 1990s. The authors’ institution was among the first to adopt this technique. In this study, long-term hernia recurrence among patients treated by the total extraperitoneal (TEP) approach for an inguinal hernia is described. A cohort study was conducted.MethodsBetween January 1993 and December 1997, 346 TEP hernia repairs were performed for 318 patients. After a mean follow-up period of 13-years, a senior resident examined each patient. An experienced surgeon subsequently examined the patients with a diagnosis of recurrent hernia. Data were collected on an intention-to-treat basis, meaning that conversions were included in the analysis. Univariant tests were used to analyze age older than 50 years, chronic obstructive pulmonary disease, body mass index, smoking habit, hernia type, history of open hernia repair, conversion, and surgeon as potential risk factors.ResultsThe analysis included 191 patients (62%) with 213 hernias. Of the original 318 patients, 59 patients died, and 68 were lost to follow-up evaluation. Perioperatively, 105 lateral, 55 medial, and 53 pantalon hernias were observed. Of the 213 hernias, 176 were primary and 37 were recurrent. The overall recurrence rate was 8.9% (8.5% for primary and 10.8% for recurrent hernias). Of the total study group, 48% of the patients experienced a bilateral inguinal hernia during their lifetime. No predicting factor for recurrent hernia could be identified.ConclusionsThe current long-term results for TEP repair of primary and secondary inguinal hernia show an overall recurrence rate of 8.9%, which is slightly higher than in previous studies. The thorough examination at follow-up assessment, the learning curve effect, and the intention-to-treat-analysis may have influenced the observed recurrence rate. Also, the percentage of bilateral hernias was higher than known to date. Therefore, examination of the contralateral side should be standard procedure.

Anatomical Versus Nonanatomical Resection of Colorectal Liver Metastases: Is There a Difference in Surgical and Oncological Outcome?

BackgroundThe increased use of neoadjuvant chemotherapy and minimally invasive therapies for recurrence in patients with colorectal liver metastases (CLM) makes a surgical strategy to save as much liver volume as possible pivotal. In this study, we determined the difference in morbidity and mortality and the patterns of recurrence and survival in patients with CLM treated with anatomical (AR) and nonanatomical liver resection (NAR).MethodsFrom January 2000 to June 2008, patients with CLM who underwent a resection were included and divided into two groups: patients who underwent AR, and patients who underwent NAR. Patients who underwent simultaneous radiofrequency ablation in addition to surgery and patients with extrahepatic metastasis were excluded. Patient, tumor, and treatment data, as well as disease-free and overall survival (OS) were compared.ResultsEighty-eight patients (44%) received AR and 113 patients (56%) underwent NAR. NAR were performed for significant smaller metastases (3 vs. 4 cm, P < 0.001). The Clinical Risk Score did not differ between the groups. After NAR, patients received significantly less blood transfusions (20% vs. 36%, P = 0.012), and the hospital stay was significantly shorter (7 vs. 8 days, P < 0.001). There were no significant differences in complications, positive resection margins, or recurrence. For the total study group, estimated 5-year disease-free and OS was 31 and 44%, respectively, with no difference between the groups.ConclusionsOur study resulted in no significant difference in morbidity, mortality, recurrence rate, or survival according to resection type. NAR can be used as a save procedure to preserve liver parenchyma.

Epidemiology of allergic reactions to hymenoptera stings in Irish school children

The aim of this was to study generate the first epidemiological data regarding the prevalence of hymenoptera allergy among school children in Ireland. Questionnaires, including six sting-specific questions (1), were distributed to the parents of primary school children aged 6-8 and 11-13, divided equally between rural and urban backgrounds. From 110 schools, 4112 questionnaires were returned. A total of 1544 (37.5%) children had been stung in their lifetime. Among the total, 5.8% of children stung experienced a large local reaction, 3.4% had a mild (cutaneous) systemic reaction (MSR) and 0.8% experienced a moderate/severe systemic reaction (SSR); these figures respectively represent 2.2%, 1.3% and 0.2% of the total study group. On logistic regression analysis, older children and rural children were at a higher risk of being stung (OR 1.7; 95% CI 1.4-2.; OR 1.6; 95% CI 1.4-1.8 respectively). Rural dwellers and asthma sufferers were more likely to experience an SSR (OR 4.3; 95% CI 1.4-13.5 and OR 2.8; 95% CI 1.8-4.3, respectively). Hymenoptera stings are more common in rural than urban dwelling Irish children. Asthma imparted a greater risk of SSR in this study population. Severe reactions are unusual overall, occurring in <1% of those stung, a lower prevalence than in Israeli teenagers but in keeping with other European reports relating to young children.

Utilization of Residential Alcoholism Treatment in Bipolar Disorder

Despite the high prevalence rate of comorbid alcohol dependence and bipolar disorder, little is known about how many bipolar patients are actively engaged in addiction treatment or the alcohol consumption characteristics of this group. This retrospective study reviewed the medical records from patients with alcohol dependence admitted to residential treatment at our institution (n = 588). The analyses focused on alcoholism severity measures and discharge clinical diagnoses. Patients with alcoholism + bipolar disorder compromised only 5% of the total study group. The number of drinking years was lower for patients with alcoholism + bipolar disorder (23.1 ± 17.7) than for those with alcoholism + depression (26.8 ± 13.9) or alcoholism alone (28.1 ± 13.2). A trend of higher mean lifetime maximum daily drinks was observed for patients with alcoholism + bipolar disorder; this was because of the significantly higher maximum drinks for women with bipolar disorder (21.0 ± 11.5) than for women in other diagnostic groups. Despite high rates of comorbidity in community-based studies, this retrospective study suggests that patients with bipolar disorder are not highly represented in residential alcoholism addiction treatment. Future studies are encouraged to better understand utilization rates of addiction treatment among patients with bipolar disorder and to identify clinical correlates that predispose bipolar women to high-dose drinking.

Late hematologic toxicity following treatment of rattlesnake envenomation with crotalidae polyvalent immune Fab antivenom

BackgroundNorth American rattlesnake envenomations commonly produce defibrination, coagulopathy and/or thrombocytopenia, which may be reversed following treatment with Crotalidae Polyvalent Immune Fab Ovine (FabAV). Despite initial resolution with FabAV, late onset or recurrence of venom-induced hematologic effects may occur. Time at which onset of late hematotoxicity may first be detected is unknown. The purpose of this study was to identify the incidence and time of onset of recurrent or new late hypofibrinogenemia, coagulopathy, or thrombocytopenia in a cohort of rattlesnake envenomation patients seen in outpatient follow-up after treatment with FabAV, and to report hematologic outcomes in these patients. MethodsReview of 66 charts of patients with rattlesnake envenomation who were treated with FabAV, and subsequently had outpatient follow-up evaluation at least 48 h after last FabAV, was performed. Demographic information, rattlesnake and bite characteristics, dose and timing of antivenom administration, adverse events, in-patient laboratory values, length of hospital stay, and follow-up laboratory values were collected.The primary outcome parameters were recurrent or delayed onset coagulopathy, hypofibrinogenemia, or thrombocytopenia identified no sooner than 48 h after last dose of FabAV. ResultsPrior to control of the envenomation with FabAV, 42 patients (63.6%) experienced hematologic toxicity. At follow-up, 21 patients (32%) were found to have late coagulopathy, hypofibrinogenemia, or thrombocytopenia. Of twenty-three patients (35%) with more than one follow-up visit, fifteen had normal laboratory findings at the first follow-up visit. Five of these 15 patients (8% of total study group; 33% of this subgroup) with normal hematologic studies at first follow-up exhibited late hematologic toxicity at second follow-up. Severe late hematologic toxicity developed in five of 66 (8%) patients. One patient was retreated with FabAV for late severe thrombocytopenia. ConclusionRecurrent and delayed onset of hematologic toxicity in rattlesnake envenomation victims treated with FabAV is common. Follow-up more than three days after treatment is necessary to detect all cases of late hematologic toxicity.

Three-Dimensional Airway Changes after Le Fort III Advancement in Syndromic Craniosynostosis Patients

To investigate the changes of upper airway volume in syndromic craniosynostosis patients following Le Fort III advancement, computed tomographic scans were analyzed and related to the amount of advancement. In this retrospective study, the preoperative and postoperative computed tomographic scans of 19 patients with syndromic craniosynostosis who underwent Le Fort III advancement were analyzed. In four cases, preoperative polysomnography demonstrated obstructive sleep apnea. The airway was segmented using a semiautomatic region growing method with a fixed Hounsfield threshold value. Airway volumes of hypopharynx and oropharynx (compartment A) and nasopharynx and nasal cavity (compartment B) were analyzed separately, as was the total airway volume. Advancement of the midface was recorded using lateral skull radiographs. Data were analyzed for all patients together and for patients with Crouzon/Pfeiffer and Apert syndromes separately. Airway volume increased significantly in compartment A (20 percent; p = 0.044) and compartment B (48 percent; p < 0.001), as did total airway volume in (37 percent; p < 0.001) in the total study group. No significant differences in volume changes were found comparing Apert with Crouzon/Pfeiffer patients. No distinct relation could be found between advancement of the midface and volume gain either in the total study group or in Apert and Crouzon/Pfeiffer patient groups separately. Postoperative polysomnography showed significant improvement of obstructive sleep apnea in all four patients. A significant improvement of the upper airway after Le Fort III advancement in syndromic craniosynostosis patients is demonstrated. No distinct relation could be observed between advancement and airway volume changes.

Sense of coherence and health among home-dwelling older people

Sense of coherence (SOC) is important for maintaining health. The aim of this study was to investigate if the SOC experience among home-dwelling physically active older people differs from that of hospital patients with the same age and sex. Data were collected with questionnaires and structured interviews containing Antonovsky's SOC scale in an age- and sex-matched study group (n=160). Non-parametric statistical analyses were performed. No differences were found in SOC between home-dwelling individuals and patients. Ninety-five percent of the home-dwelling individuals perceived themselves as being in good health and 42.5% among the patients (p<0.001). SOC and disease were predictors for health in the total study group. Among the home-dwelling individuals, SOC, disease and being single were predictors for health and among the patients solely SOC. When using the components of the SOC concept, comprehensibility and disease predicted health for the home-dwelling individuals and meaningfulness predicted health for the patients.