The VA HDL intervention trial: clinical implications.
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Cholesterol, HDL↗
Biomedical subjects
D Collins
Publications and source records attributed to D Collins.
Quantification of facial contamination with blood during orthopaedic procedures.
Operative surgery exposes the surgeon to possible blood-borne infections. Risks include pen-etrating injuries and conjunctival contact with infected blood. Visor masks worn during orthopaedic trauma procedures were assessed for blood contamination using computer analysis. This was found to be present on 86% of masks, of which only 15% was recognized by the surgeon intraoperatively. Of the blood splashes 80% were less than 0.6mm in diameter. We conclude that power instrumentation produces a blood particulate mist causing considerable microscopic, facial contamination which is a significant risk to the surgeon.
Blood-Borne Pathogens↗
Laparoscopic appendectomy for simple and perforated appendicitis in children: the procedure of choice?
BACKGROUND/PURPOSE: Whether laparoscopic appendectomy (LA) is superior to open appendectomy (OA) for simple (SA) and perforated appendicitis (PA) in children is debatable. The operative experience of 4 senior pediatric surgeons at a single institution was studied over a 6-year period during a transition from OA in all cases to LA in all cases, to answer this question. METHODS: All appendectomies from December 1993 to December 1999 were reviewed for operative technique (OA, LA), presence of perforation (SA, PA), operating time (OT), length of stay (LOS), morbidity, and mortality. RESULTS: There were 1,128 appendectomies in children aged 14 months to 19 years, including 955 LA (653 in SA, 302 in PA) and 173 OA (86 in SA, 87 in PA). OT was equal for LA and OA in SA (52 minutes), but has dropped to less than 40 minutes for LA in the past year. OT in PA was slightly longer in LA versus OA (68 v. 58 minutes; P < .001) but recently has dropped in LA to less than 60 minutes. LOS in SA was 2 days for LA and 3 days for OA; in PA, LOS was 7 days in both LA and OA, but has dropped to 5 days for LA recently. Postoperative abscess rates and incidence of bowel obstruction did not differ between LA and OA in either group. There was no mortality. CONCLUSIONS: LA is at least as safe and effective as, if not superior to, OA for both simple and perforated appendicitis. Postoperative pain is less, and recovery is faster, thereby reducing LOS and overall cost. The growing demand for this procedure can be satisfied without increase in cost, morbidity, or mortality. Laparoscopic appendectomy is our procedure of choice in children.
Acute Disease↗
Coping with pre- and in-event fluctuations in competitive state anxiety: a longitudinal approach.
The direction of anxiety--the positive or negative nature of competition-related cognitions--is an important distinguishing variable that accounts for significant individual differences. However, very little is known about the pre- and in-event patterning of the construct, specifically how it changes over time. The aims of this study were to establish the extent to which the direction of anxiety is a dynamic or stable longitudinal response to stress and whether this patterning appears to be related to coping. Pre-event, state anxiety intensity and direction data were obtained from 22 youth sport participants in two training and two competition environments within the same season, with the in-event anxiety and coping data being obtained from the 'high-stress' competition condition. The predispositional coping strategies of the participants were assessed by use of the trait version of the 'COPE' scale. The findings revealed significant differences in the patterning of anxiety direction between and within the facilitative and debilitative groups. This was accompanied by distinct qualitatively and quantitatively reported differences in the strategies of coping adopted by each group. Facilitators appeared to use problem- and emotion-focused coping characteristics in response to stress, whereas debilitators appeared limited in their use of coping constructs. Conceptually, the direction of anxiety would appear to be a mechanism that may, in itself, exist as a strong indicator that effective coping is taking place.
Adaptation, Psychological↗
Limitations of long-path averaging instruments.
Long-path averaging instruments measure the average velocity or concentration of a substance or substances over an averaging path. These measurements are then often used for calculation of the average concentration and mass flow rate of the substance. The purpose of this paper is to describe some of the limitations of these instruments and to suggest ways in which these limitations can be minimized. Two limitations were examined: measuring concentration in a single dimension (e.g., ignoring the variation in concentration over the width of the sample plane), and deriving an average concentration without considering velocity effects. The resultant errors will be application-specific. Estimates of the second source of error can be obtained from the covariance of concentration and velocity profiles over the path length. Unfortunately, suitable field data were not available, and to illustrate the method, estimates of the error were obtained for a range of possible concentration and velocity profiles. Errors of 50% or greater in the mass flow were incurred for the concentration and velocity profiles considered. This error was reduced to a negligible level by segmenting the averaging path length. It is recommended that velocity and concentration profiles be obtained for a broad range of applications to enable the importance of covariance errors to be better assessed.
Air Pollution↗
Identification of Mycoplasma fermentans in synovial fluid samples from arthritis patients with inflammatory disease.
Since 1970 Mycoplasma fermentans has been suspected of being associated with rheumatoid arthritis. However, this association has been difficult to prove, and this has been our goal. The distribution of M. fermentans was studied in the synovial fluid of patients suffering from different arthritides. Samples of synovial fluid were taken from patients with well-defined disease and a clear diagnosis. After removal of the inflammatory cells and hyaluran, they were treated with proteinase K and tested by a single or fully nested PCR with primers directed against part of the two 16S rRNA genes of M. fermentans. The product was sequenced automatically, by using an ALF Express automatic sequencer, to confirm the mycoplasma species and to identify the strain since the two genes were usually found to be polymorphic. This was also true of the type strain, strain PG18. M. fermentans was detected in 23 of 26 (88%) rheumatoid arthritis patients, and four different strains were found. It was also found in 7 of 8 (88%) of the nonrheumatoid inflammatory arthritis patient group, which consisted of one patient with reactive arthritis, one patient with pauciarticular juvenile chronic arthritis, two patients with gout, two patients with ankylosing spondylitis, and two patients with psoriatic arthritis, only one of whom was infected with M. fermentans. It was not detected in any of the 10 osteoarthritis patients. M. fermentans was therefore found to be a variable and very common organism in arthritic patients with inflammatory joint exudates and may well prove to be important in the etiology of the diseases.
Adult↗
Redefining the overtraining syndrome as the unexplained underperformance syndrome.
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Humans↗
Exercise dependence, social physique anxiety, and social support in experienced and inexperienced bodybuilders and weightlifters.
OBJECTIVES: To investigate psychological correlates of exercise dependence in experienced and inexperienced bodybuilders and weightlifters. Secondary objectives included measuring social physique anxiety, bodybuilding identity, and social support among bodybuilders and weightlifters. METHODS: Thirty five experienced bodybuilders, 31 inexperienced bodybuilders, and 23 weightlifters completed the bodybuilding dependence scale, a bodybuilding version of the athletic identity measurement scale, the social physique anxiety scale, and an adapted version of the social support survey-clinical form. RESULTS: A between subjects multivariate analysis of variance was calculated on the scores of the three groups of lifters for the four questionnaires. Univariate F tests and follow up tests indicated that experienced bodybuilders scored significantly higher than inexperienced bodybuilders and weightlifters on bodybuilding dependence (p<0.001), social identity and exclusivity subscales of bodybuilding identity (p<0.001), and social support scales (p<.001), and significantly lower on social physique anxiety (p<0.001). CONCLUSION: Experienced bodybuilders exhibit more exercise dependence, show greater social support behaviour, and experience less social physique anxiety than inexperienced bodybuilders and weightlifters.
Adult↗
Relation of FEV(1) to clinical outcomes during exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group.
FEV(1) is an objective measure of airflow obstruction used in clinical practice and in therapeutic trials. The precise relationship of FEV(1) to clinical outcomes is generally uncertain. As part of a randomized trial to assess systemic corticosteroid efficacy, we obtained serial FEV(1) measurements in patients hospitalized for exacerbations of chronic obstructive pulmonary disease (COPD). Over the first 14 Study Days at least one FEV(1) value was obtained in 261 subjects. Sixty-four of these subjects experienced treatment failure, defined as death, intubation, readmission for COPD, or intensification of drug therapy, by Study Day 30. After adjustment, both FEV(1) at entry into the study (odds ratio [OR] for a 100-ml increase, 0.87; 95% confidence interval [CI], 0.79 to 0.96) and change in FEV(1) over the first two Study Days (OR for a 100 ml increase, 0.80; 95% CI, 0.69 to 0.92) predicted treatment failure. We identified no baseline characteristic that was significantly related to FEV(1) at entry into the study. Assignment to the systemic corticosteroid treatment arm was associated with a significantly larger FEV(1) at Study Day two (p = 0.01). We conclude that FEV(1) measurements at admission and over the first several days of hospitalization are highly predictive of clinical outcomes during exacerbations of COPD.
Adrenergic beta-Agonists↗
Economic impact of increased clinical intervention rates in community pharmacy. A randomised trial of the effect of education and a professional allowance.
OBJECTIVE: To determine the economic impact of an interventional programme aimed to increase the rate of clinical interventions undertaken in community pharmacy. STUDY DESIGN AND PERSPECTIVE: A randomised controlled trial of 4 parallel groups of pharmacies, conducted from a government perspective. Economic evaluations were based on savings/costs attributable to healthcare costs avoided, healthcare costs incurred by the pharmacists' actions, change in medication costs, pharmacy time and telephone calls made by the pharmacist. The study was conducted during November and December 1996 and costings were based on 1997 figures. INTERVENTIONS: A professional fee-for-service [10 Australian dollars ($A; $A1 = 6.50 US dollars) per intervention] and education (an intensive 1-week course or advanced education) were implemented in an attempt to increase clinical interventions by the pharmacists. Group A pharmacies (n = 10) served as a control group and received neither education nor remuneration; group B received education and professional remuneration (n = 9); group C had received prior continued education and now received advanced education and professional remuneration (n = 11); and group D received professional remuneration with no education. MAIN OUTCOME MEASURES AND RESULTS: The proactive clinical interventions in group C saved a mean of $A85.35 per 1000 prescriptions [95% confidence interval (CI)-$A157.11 to $A24.95). This was 4 times greater than savings generated by pharmacies in group B (mean savings of $A25.65 per 1000 prescriptions) and 6 times greater than control pharmacies. A sensitivity analysis which extrapolated results to Australian prescription figures showed that the control group was capable of generating savings in the order of $A2.4 million per year while pharmacists in group C would save the healthcare system $A15 million per year. CONCLUSIONS: These results provide the first economic estimates for the provision of clinical interventions in Australian community pharmacies. It is believed that they illustrate the value of pharmaceutical services to the healthcare system and to the Australian community in terms of both quality of care and savings.
Australia↗
An acute stroke service: potential to improve patient outcome without increasing length of stay.
Acute stroke is associated with a high morbidity and mortality: up to 24% of patients may not survive their hospital admission. Stroke unit care has been shown in a meta-analysis to reduce this morbidity and mortality. We present a three-year audit of the first acute stroke service in an Irish teaching hospital. The audit was carried out prospectively on 193 patients admitted to the acute stroke service, from July 1996 to end of June 1999. Details regarding patients, type and severity of stroke, length of stay and outcome were collected prospectively on a standard pro-forma. We observed a reduction in mortality from 19% to 15% to 9%, and an increasing percentage of patients discharged home from 55% to 64% to 68%, in year 1, year 2 and year 3 respectively. A trend towards a greater number of patients, younger age and improved outcome with lower mortality was observed from year to year, without significant change in length of stay. This study confirms the value to patients of organised stroke care in terms of reduction in mortality and morbidity without increasing length of stay or disability. We suggest that every acute hospital should have organised stroke care.
Acute Disease↗
Use of the Diprifusor in a latex allergic individual.
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Anesthesia, General↗
Time on your side. Interface to coding system saves hours each day at acute care facility.
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Abstracting and Indexing↗
Gemfibrozil for the secondary prevention of coronary heart disease in men with low levels of high-density lipoprotein cholesterol. Veterans Affairs High-Density Lipoprotein Cholesterol Intervention Trial Study Group.
BACKGROUND: Although it is generally accepted that lowering elevated serum levels of low-density lipoprotein (LDL) cholesterol in patients with coronary heart disease is beneficial, there are few data to guide decisions about therapy for patients whose primary lipid abnormality is a low level of high-density lipoprotein (HDL) cholesterol. METHODS: We conducted a double-blind trial comparing gemfibrozil (1200 mg per day) with placebo in 2531 men with coronary heart disease, an HDL cholesterol level of 40 mg per deciliter (1.0 mmol per liter) or less, and an LDL cholesterol level of 140 mg per deciliter (3.6 mmol per liter) or less. The primary study outcome was nonfatal myocardial infarction or death from coronary causes. RESULTS: The median follow-up was 5.1 years. At one year, the mean HDL cholesterol level was 6 percent higher, the mean triglyceride level was 31 percent lower, and the mean total cholesterol level was 4 percent lower in the gemfibrozil group than in the placebo group. LDL cholesterol levels did not differ significantly between the groups. A primary event occurred in 275 of the 1267 patients assigned to placebo (21.7 percent) and in 219 of the 1264 patients assigned to gemfibrozil (17.3 percent). The overall reduction in the risk of an event was 4.4 percentage points, and the reduction in relative risk was 22 percent (95 percent confidence interval, 7 to 35 percent; P=0.006). We observed a 24 percent reduction in the combined outcome of death from coronary heart disease, nonfatal myocardial infarction, and stroke (P< 0.001). There were no significant differences in the rates of coronary revascularization, hospitalization for unstable angina, death from any cause, and cancer. CONCLUSIONS: Gemfibrozil therapy resulted in a significant reduction in the risk of major cardiovascular events in patients with coronary disease whose primary lipid abnormality was a low HDL cholesterol level. The findings suggest that the rate of coronary events is reduced by raising HDL cholesterol levels and lowering levels of triglycerides without lowering LDL cholesterol levels.
Aged↗
Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. Department of Veterans Affairs Cooperative Study Group.
BACKGROUND AND METHODS: Although their clinical efficacy is unclear and they may cause serious adverse effects, systemic glucocorticoids are a standard treatment for patients hospitalized with exacerbations of chronic obstructive pulmonary disease (COPD). We conducted a double-blind, randomized trial of systemic glucocorticoids (given for two or eight weeks) or placebo in addition to other therapies, for exacerbations of COPD. Most other care was standardized over the six-month period of follow-up. The primary end point was treatment failure, defined as death from any cause or the need for intubation and mechanical ventilation, readmission to the hospital for COPD, or intensification of drug therapy. RESULTS: Of 1840 potential study participants at 25 Veterans Affairs medical centers, 271 were eligible for participation and were enrolled; 80 received an eight-week course of glucocorticoid therapy, 80 received a two-week course, and 111 received placebo. About half the potential participants were ineligible because they had received systemic glucocorticoids in the previous 30 days. Rates of treatment failure were significantly higher in the placebo group than in the two glucocorticoid groups combined at 30 days (33 percent vs. 23 percent, P=0.04) and at 90 days (48 percent vs. 37 percent, P=0.04). Systemic glucocorticoids (in both groups combined) were associated with a shorter initial hospital stay (8.5 days, vs. 9.7 days for placebo, P=0.03) and with a forced expiratory volume in one second that was about 0.10 liter higher than that in the placebo group by the first day after enrollment. Significant treatment benefits were no longer evident at six months. The eight-week regimen of therapy was not superior to the two-week regimen. The patients who received glucocorticoid therapy were more likely to have hyperglycemia requiring therapy than those who received placebo (15 percent vs. 4 percent, P=0.002). CONCLUSIONS: Treatment with systemic glucocorticoids results in moderate improvement in clinical outcomes among patients hospitalized for exacerbations of COPD. The maximal benefit is obtained during the first two weeks of therapy. Hyperglycemia of sufficient severity to warrant treatment is the most frequent complication.
Administration, Oral↗
EEG alpha rhythm, intention and oculomotor control.
A replication of Wertheim's (1981) visual pursuit tracking study examined the reactivity of the posterior EEG alpha rhythm to two tracking tasks. Twelve subjects visually tracked a light spot moving in a predictable or an unpredictable path. The EEG was recorded from O1, O2, P3, P4, T5, and T6, referenced to linked mastoids, and power for the alpha frequency band was calculated for 60 s trial epochs. Results showed significantly higher occipital and posterior temporal alpha power during the predictable tracking trials in agreement with Wertheim's findings. The significance of this for his attention/intention model is discussed.
Adult↗
The displacement, velocity and frequency profile of the frontal plane motion produced by the cervical lateral glide treatment technique.
OBJECTIVE: To investigate the specificity of linear and angular displacement, peak velocity and frequency of oscillation of the frontal plane motion produced by the lateral glide treatment technique of the cervical spine. DESIGN: A within-subjects design was used. BACKGROUND: The lateral glide treatment technique of the cervical spine has previously been shown to produce specific neurophysiological effects, whereas the technique's biomechanical effects remain uninvestigated. A relationship may exist between a technique's biomechanical effects and its clinical outcome. METHODS: Eight asymptomatic subjects participated in the study. Retroreflective markers were placed dorsally at the occiput, and the C5, T1, T3 and T5 vertebrae. Movement of these markers was recorded by a video processor. The same physiotherapist applied the treatment technique to each subject. RESULTS: Linear displacement (3.336 cm) and peak velocity (13.643 cm/s) between C5 and T1 markers was greater than between T1 and T3, Occiput and C5, and T3 and T5. Angular displacement about C5 (26.5 degrees ) was twice that about T1 and T3, but unlike T1 and T3 occurred in the opposite direction to that of the treatment technique. Frequency of oscillation was 1. 255 Hz. CONCLUSION: The lateral glide treatment technique produced a characteristic ipsilateral displacement rather than side flexion, predominantly at its region of application. RELEVANCE: This study provides the basis for further investigations of the mechanisms of action of the lateral glide treatment technique. It also provides clinicians with guidelines for the application of this technique.
Adolescent↗
Cytomegalovirus pneumonia in a patient with breast cancer on chemotherapy: case report and review of the literature.
Cytomegalovirus (CMV) pneumonia in the setting of non-transplantation patients is a rarity. We present a case of CMV pneumonitis in a woman with stage IV breast cancer, with brain metastases, receiving both chemotherapy and systemic corticosteroids. A review of the literature reveals this as a unique case. Potential viral etiologies should therefore be considered in cancer patients with pneumonia receiving non-transplantation chemotherapy-regimens, particularly if steroids are a component of their therapy.
Antineoplastic Combined Chemotherapy Protocols↗