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Biomedical subjects

D Moher

Publications and source records attributed to D Moher.

At least 91 records · Page 5Linked to original sources
PubMed1992

Effects of a medical team coordinator on length of hospital stay.

OBJECTIVE: To determine the effect of a medical team coordinator (MTC) on the length of stay in a teaching hospital. DESIGN: Randomized controlled trial. SETTING: Two of four general medical clinical teaching units (CTUs). PATIENTS: Patients admitted to the CTUs between July and October 1990 except those who were admitted directly to an intensive care unit or whose death was expected within 48 hours. The 267 patients were randomly assigned to receive either standard medical care or standard medical care plus MTC services. INTERVENTION: The MTC was a baccalaureate nurse whose role was to facilitate administrative tasks such as discharge planning, to coordinate tests and procedures, and to collect and collate patient information. MAIN OUTCOME MEASURES: Length of hospital stay. A subgroup of 40 patients was asked to complete a brief survey on medical care information and satisfaction. RESULTS: The MTC intervention reduced the mean length of stay by 1.97 days (p less than or equal to 0.04, 95% confidence interval [CI] 1.02 to 2.92 days). Subanalysis by diagnostic group revealed that most of this effect was in an ill-defined group of disorders. In the survey more patients in the MTC group than in the other group reported being satisfied with their medical care (89% v. 62%; p less than or equal to 0.05, 95% CI 2% to 52%). CONCLUSIONS: The services of an MTC help to reduce the length of hospital stay for some groups of patients. Further research is necessary to examine which components of the MTC intervention are most effective and in what conditions.

Humans↗
PubMed1992

Ionescu-Shiley valve failure. I: Experience with 125 standard-profile explants.

A group of standard-profile Ionescu-Shiley valve implants, 357 aortic and 190 mitral, was reviewed for cases of failure requiring surgical explantation. To date, 90 (25.2%) of the aortic and 35 (18.4%) of the mitral valves have failed, and are the subject of this analysis. Observations of these explants confirm previous suggestions about the clinical and pathologic patterns of the Ionescu-Shiley valve's failure, but are extended in this study to allow more confident statistical analyses. Cusp tear with insufficiency remains the most important reason for explantation, precipitating removal to date of 19.1% of the aortic and 10.0% of the mitral valves implanted. This difference, aortic versus mitral, is significant (p less than 0.006) and the reverse of observations made in other studies of pericardial valves. In this review there is no significant difference in the proportion of aortic and mitral valves that failed with calcification (2.2% and 3.1%, respectively). Aortic Ionescu-Shiley valves failing with tears had a mean of 3.1 tears per valve, whereas mitral valves had 1.2. Aortic valves also showed considerably more pretear wear than did mitral valves. Although the large number of these Ionescu-Shiley valve failures has been a profound clinical disappointment, it has provided an opportunity to observe and detail the pathology of their failure.

Adolescent↗
PubMed1992

Ionescu-Shiley valve failure. II: Experience with 25 low-profile explants.

A group of patients who had low-profile Ionescu-Shiley valves implanted, 237 aortic and 130 mitral, was reviewed for cases of bioprosthetic failure requiring explantation. Fourteen such aortic and 11 mitral valves were recovered at operation. The most common reason for explantation was valvular insufficiency due to cusp tears, accounting for 50.0% of aortic and 82.0% of mitral explants. Morphologic examination of the valves suggested a common mode of failure with tears, and this is illustrated. The clinical and pathologic patterns of this valve's failure are compared with those of the standard-profile Ionescu-Shiley valve, and many similarities exist. A tendency for a larger proportion of mitral valve failures with tears is, however, in contrast to observations of the standard-profile valve, in which aortic failures are more common. Additionally, low-profile valves, in either the aortic or mitral positions, fail after a shorter time in situ than their standard-profile counterparts, at a mean of 45.1 months versus 78.0 in the aortic position (p less than 0.01) and at 52.2 months versus 73.8 in the mitral position (p less than 0.05). These differences in the performance of the Ionescu-Shiley valve models may have implications for the design of future bioprostheses.

Adult↗
PubMed1992

Epidemiology of abdominal aortic aneurysm: the effect of differing definitions.

There have been several published definitions for abdominal aortic aneurysm (AAA), however, it is not known how different definitions affect what is reported. This paper presents an evaluation of three definitions taken from the literature on (a) aneurysm frequency, (b) prevalence rate and (c) prevalence ratio from an ongoing case-control study evaluating whether male siblings of patients with known AAA have a higher prevalence of aneurysms compared to a control group. Depending on the definition used, the frequency of AAA could vary from a low of five to a high of 23; the prevalence of AAA in siblings could range from 2.1 to 18.8. Changing definitions alters the prevalence ratio (risk of disease) in both magnitude and direction. On the one hand, male sibling of affected patients are at approximately one and a half times (1.6) greater risk of having an AAA compared to controls, whereas using a different definition they are at less than half the risk (0.3).

Aged↗
PubMed1992

Thrombus-trapping efficiency of the LGM (Vena Tech) and titanium Greenfield filters in vivo.

To assess the trapping efficiency of two vena cava filters, 326 radiopaque thrombi 5 mm in diameter were injected into adult sheep: four with LG-Medical (LGM) and four with titanium Greenfield (TG) filters. Thrombi were sequentially injected and not removed. Trapping was monitored fluoroscopically, and the pressure gradient across the filter was measured. The LGM filter trapped 70% of 5 x 5-mm and 100% of 5 x 10-mm thrombi; the TG, 26% of 5 x 5-mm, 34% of 5 x 10-mm, and 37% of 5 x 30-mm thrombi. The LGM filter required an average of 2.0 mL of trapped thrombus to occlude the filter, compared with 6.4 mL for the TG. These differences were statistically significant. These data indicate that in this model, the LGM filter traps thrombi more efficiently than the TG filter but is more likely to produce caval occlusion.

Animals↗
PubMed1991

Decreased coronary sinus oxygen content: a predictor of adverse prognosis in patients with severe congestive heart failure.

Patients with congestive heart failure have abnormal coronary hemodynamics, characterized by decreased coronary sinus oxygen content, increased coronary sinus blood flow and increased myocardial oxygen consumption. To evaluate their prognostic importance, the clinical characteristics and systemic and coronary hemodynamics were related to survival in 91 patients with severe congestive heart failure and decreased ejection fraction (25.5 +/- 10% [mean +/- SD]). In 69 patients congestive heart failure was due to or secondary to coronary artery disease (group 1) and in 22 it was due to idiopathic dilated cardiomyopathy (group 2). Five patients were in functional class II, 48 in class III and 38 in class IV. The median survival time was 20.7 months. As assessed with the Cox proportional hazards model, coronary sinus oxygen content was most strongly associated with a poor prognosis. On the basis of a comparison between the lowest (coronary sinus oxygen content less than or equal to 4.44 vol%) and highest quintile (coronary sinus oxygen content greater than 4.44 vol%), a low coronary sinus oxygen content was associated with a 2.34-fold increased risk of dying (95% confidence interval, 1.31 to 4.08). A low systolic blood pressure and a high diastolic pulmonary artery pressure were also significantly associated with increased mortality. Patients in the subgroup with a low coronary sinus oxygen content had values for functional class, ejection fraction and systemic hemodynamics similar to those of patients in the subgroup with high coronary sinus oxygen content. It is concluded that a low coronary sinus oxygen content indicative of noncompensated metabolic demand suggests a poor prognosis in patients with severe congestive heart failure.

Aged↗
PubMed1991

Methotrimeprazine versus meperidine and dimenhydrinate in the treatment of severe migraine: a randomized, controlled trial.

STUDY OBJECTIVE: To compare the effectiveness of IM administration of methotrimeprazine, a non-narcotic, nonaddicting phenothiazine derivative, with that of a combination of meperidine and dimenhydrinate in the treatment of severe migraine. DESIGN: Double-blind, randomized, controlled trial. SETTING: University hospital emergency department. PARTICIPANTS: Consecutive adult patients with migraine who met eligibility criteria. INTERVENTIONS: Random allocation to receive IM injections of either 37.5 mg methotrimeprazine (Levoprome, Nozinan) or 75 mg meperidine (Demerol) combined with 50 mg dimenhydrinate (Dramamine, Gravol). MEASUREMENTS AND MAIN RESULTS: The 37 patients in each group who completed the study were similar in all demographic and clinical characteristics. There were no statistical differences in pain intensity one hour after treatment, change in pain intensity, or pain relief as measured on a visual-analog scale; need for additional analgesia; persistence of nausea or vomiting; adverse effects; or follow-up status, except for prolonged drowsiness, in the group receiving methotrimeprazine. CONCLUSION: Methotrimeprazine is comparable to meperidine with dimenhydrinate for treating severe migraine and may be considered an effective, nonaddicting, IM alternative to narcotics for the management of this problem.

Adolescent↗
PubMed1991

Comparison of topical Xylocaine with placebo as a local anesthetic in colposcopic biopsies.

Colposcopically directed biopsies cause discomfort for the patient. Topical lidocaine (Xylocaine) had routinely been applied to the cervix before biopsies performed at the colposcopy clinic of the Ottawa General Hospital. A prospective, single-blind trial was performed to compare the effect of topical Xylocaine with that of a placebo. Patients in both groups experienced discomfort; the median pain score in both groups was equal, and statistical analysis of the results by the Mann-Whitney test showed no difference between the two treatment groups.

Anesthesia↗
PubMed1990

Laser treatment of cervical intraepithelial neoplasia and the endocervical button.

A prospective randomized clinical trial was undertaken to investigate the relationship between the shape of cervical tissue vaporized with CO 2 laser and the postoperative location of the squamocolumnar junction. It has been suggested that a button of columnar epithelium may be everted onto the exocervix by vaporizing a shallow 1 mm trench around the endocervical canal after the evaporization cone has been completed. Eighty-eight patients with cervical intraepithelial neoplasia (CIN) suitable for treatment by CO 2 laser were randomized into two groups. The transformation zone was ablated to 6 mm in all patients. In the flat group (n = 45), the base of the cervical defect was flat. In the contour group (n = 43), an additional 1 mm trench was vaporized at the periphery of the defect. Both groups were similar with respect to age, use of oral contraceptives, parity, operative complications, degree of CIN, and volume of tissue ablated. On follow-up at 6 months, significantly more patients in the contour group had an endocervical button of columnar epithelium compared to the flat group. No difference was seen at 3 and 12 months. There was a moderate relationship between the volume of tissue vaporized and the area of the button in the contour groups (p less than 0.001) but not in the flat group. The presence of squamous metaplasia tends to increase with time. There were 2 recurrences of CIN at 1 year follow-up.

Adult↗
PubMed1990

An ultrastructural morphometric study of follicular center lymphocytes: III. The control of lymphocyte nuclear size in reactive hyperplasia and non-Hodgkin's lymphoma.

Since lymphocyte nuclear size and shape play such a key role in the classification of non-Hodgkin's lymphoma (NHL), the mechanisms and nuclear compartments responsible for the control of nuclear size are of fundamental importance to pathologists. To assess the role of condensed chromatin and the interchromatinic region of the nucleus in determining the size of this organelle, morphometric image analysis of total nuclear area and the area occupied by these two compartments was performed on electron micrographs of nuclear profiles from lymphocytes in lymph node biopsies of four cases of reactive lymphoid hyperplasia and ten examples of NHL. Using bivariate linear regression analysis, it was clear that, whether in normal mantle zone and follicular center lymphocytes or in the neoplastic lymphocytes of various NHLs, there is an extremely high correlation (R = 0.96) between the size of the interchromatinic region and the area of nuclear profiles. In contrast, there is a poorer correlation (R = 0.63) between the area occupied by condensed chromatin and nuclear area. The results demonstrate for the first time that even in NHL, where some nuclear features clearly vary from the normal counterpart, the control of nuclear size continues to be largely dependent on a particular subcompartment of the nucleus, the interchromatinic region. How this fact influences the categorization of subtypes of NHL for therapeutic and prognostic purposes will be an essential avenue for further investigation.

Cell Nucleus↗
PubMed1990

Immunologic defects following trauma: a delay in immunoglobulin synthesis by cultured B cells following traumatic accidents but not elective surgery.

The immune status of trauma patients was compared with that of elective surgery patients and normal controls. The trauma patients, the elective surgery patients, and the controls were all male, aged 18 to 36 years, in previous good health and with similar Injury Severity Scores. Only one of eight immunologic activities assayed distinguished between these groups of subjects. It was observed that the synthesis and secretion of immunoglobulins (Ig) in vitro by the circulating B cells of the trauma patients was markedly impaired when compared to Ig synthesis by B cells of the elective surgery patients or controls. Furthermore, it was demonstrated that the B cells, and not the T cells, Null cells, or monocytes, were defective in the trauma patients. The results indicate that diminished Ig synthesis and secretion by the circulating B cells of the trauma patients cannot be attributed to the surgery; rather, it appears that the defects in the B cells are a direct result of the trauma.

Adult↗
PubMed1989

The prevalence and impact of pain after day-care tubal ligation surgery.

Empirical data from controlled studies using standardized, reliable measures on the amount and quality of pain after laparoscopic tubal ligation and the consequences of this pain on the activities of daily living are extremely scarce. In a study of 54 women admitted to a day-care unit for this procedure, validated measures were utilized to assess the incidence, intensity and duration of pain after tubal ligation (McGill Pain Questionnaire) and the impact of pain on the activities of daily living (Modified Functional Assessment Inventory). Psychological measures (Brief Symptom Inventory, Kranz Health Opinion Survey, and the State-Trait Anxiety Inventory) were employed to test their use as possible predictors for pain, analgesic usage and the time taken to resume a normal activity level after tubal ligation surgery. The results showed that pain is a significant problem after tubal ligation although pain rating scores over the 7-day study period were lower than those reported after major abdominal surgery. Eighty-five percent of our sample reported that pain and/or fatigue impacted on their recovery and contributed to an average delay of return to normal activity level of 4.4 days, not including the day of surgery. The psychological measures did not prove to be strong predictors of postoperative pain, time of return to normal activity level or analgesic usage. The most powerful predictor of return to normal activity was the total amount of pain experienced, as measured by the McGill Pain Questionnaire, during the 7 day post-operative period.

Activities of Daily Living↗
PubMed1988

Morphologic studies of lymphocyte nuclei in follicular and diffuse mixed small- and large-cell (lymphocytic-histiocytic) lymphoma.

Twelve examples of mixed small- and large-cell lymphoma (eight follicular, one follicular and diffuse, and three diffuse) were investigated morphometrically using plastic-embedded tissue in order to study nuclear characteristics of lymphocyte populations in this form of non-Hodgkin's lymphoma (NHL) and to test morphologic bases for current NHL classification systems. This study illustrates that there are many inaccuracies, illusions, and misconceptions in the morphologic criteria currently used to classify mixed small- and large-cell lymphoma. A principal finding was that lymphocyte nuclear profiles in mixed-cell lymphomas tend to be smaller in size (P less than .005) and more irregular in shape (P = .0001) than the morphologically similar counterparts in germinal centers of lymph nodes with reactive hyperplasia. Intercase comparison of mixed small- and large-cell lymphomas revealed a considerable range of mean nuclear area values, some of which were within the size range of normal, small lymphocytes. At the magnifications used for morphometric assessment, a high proportion of lymphocyte nuclear profiles had shallow invaginations, but only a limited number of profiles (4% to 14%) had deep (cleaved) indentations. Contrary to current definitions for this subtype of NHL, lymphocytes with "small" nuclei had the same proportion of the nuclear diameter occupied by nuclear invaginations as lymphocytes with "large" nuclei and, in fact, mean nuclear invagination depth was shallower in "small" nuclei than in "large" nuclei. Furthermore, regardless of whether it is nuclear area or shape that is evaluated, lymphocytes in mixed-cell lymphoma do not separate into two populations of small-cleaved and large noncleaved cells. Morphometry reveals that only four of the 12 examples of mixed small- and large-cell lymphoma had a proportion of the lymphocytes in the size range of fully transformed germinal center lymphocytes that exceeded 25%, and none of the cases approached 50% even though the population of lymphocyte nuclei appearing "transformed," and therefore "large," ranged from 28% to 57%. Such results indicate that the large, noncleaved and cleaved component, as seen in histologic sections of mixed small- and large-cell lymphoma, do not have nuclei of uniform size and many, in fact, are not actually large. The morphometric findings indicate reasons for the poor observer reproducibility in classifying this subtype of NHL.

Cell Nucleus↗
PubMed1986

Cervical carcinoma in women aged 34 and younger.

This presentation addresses three questions concerning invasive cervical carcinoma in women 34 years of age and younger. Is there an increase in the incidence of the disease? Is it more or less susceptible to prevention by cervical screening? Is the clinical behavior different for this age group? Three separate studies are reported: (1) Incidence data in the younger age group have been reviewed at the national, provincial, and local levels. (2) Cytologic screening histories of 125 patients who subsequently developed cervical carcinoma were reviewed. (3) The clinical histories of 121 women 34 years of age and younger, with invasive cervical carcinoma, were reviewed and compared with those of 242 control women 35 years of age and older. Results indicate an increase in incidence in the younger age groups in the three prairie provinces only. Cytologic histories are similar except for an increase in false negative reports in the younger age group. Clinical behavior of the disease is similar for both age groups.

Adenocarcinoma↗
PubMedDate not supplied

LGM (Vena Tech) vena caval filter: experience at a single institution.

PURPOSE: The authors describe their experience with LG-Medical (LGM [Vena Tech]) filter placement and follow-up. PATIENTS AND METHODS: LGM vena cava filters were placed in 63 patients. Follow-up was obtained by means of duplex sonography of the introduction vein and inferior vena cava (IVC) and abdominal radiography in 50 patients, and by means of autopsy in an additional four patients. In eight, only clinical follow-up was obtained and one patient was lost to follow-up. RESULTS: Major complications of placement occurred in three patients, all when the right internal jugular vein was used for introduction: In one patient a filter was inadvertently placed in the right renal vein and in two the filter failed to open fully. No serious complications of placement occurred when either the right or left common femoral veins were used. Pulmonary embolism (PE) recurred in four patients (6%) and was fatal in one. Septicemia from an infected filter was the probable cause of death in another patient. Introduction vein thrombosis occurred in five patients (8%) and was symptomatic in two (3%). Occlusion of the IVC occurred in 15 patients (24% of the total patient group, but 28% of those with objective follow-up) and was symptomatic in 12 (19%). Two patients with IVC occlusion had recurrent PE. CONCLUSION: These data suggest that the rate of IVC occlusion is higher than most previous reports have suggested and that IVC occlusion may be a potentially serious complication.

Equipment Design↗
PubMedDate not supplied

Ultrastructural morphometric study of follicular center lymphocytes: I. Nuclear characteristics and the Lukes-Collins' concept.

A combined ultrastructural and morphometric image analysis study was carried out on the nuclear profiles of follicular center and mantle zone lymphocytes of six cases of reactive hyperplasia in human lymph node biopsies. For accuracy of morphological observations and sampling at low magnifications, sections were mounted on formvar-covered slot grids. Measurements of nuclear profile features of small (untransformed) lymphocytes in mantle zones served as the standard for a supposed unimodal population in each case. Analysis of nuclear profile area values indicated that during lymphocyte transformation in follicular centers nuclei had a gradual and progressive increase in size and that the sampled nuclear profiles in both the mantle zone and follicular center were unimodal. Lymphocyte nuclear shape (contour index) was a more complex, and likely biologically independent, feature than nuclear area in both the mantle zone and follicular center. Nuclear profile contour indexes of mantle zone lymphocytes were more irregular than suspected and in some cases had mean values greater than those of follicular center lymphocytes. Furthermore, the frequency distribution of nuclear contour index was not normally distributed in either the follicular center or mantle zone due to the presence of a small proportion of highly irregularly shaped nuclear profiles in both sites. The results indicated that some premises of existing concepts of follicular center cells and the process of lymphocyte transformation in follicular centers were incorrect and should not be directly extrapolated to the nuclear profile characteristics in non-Hodgkin's lymphoma.

Cell Nucleus↗
PubMedDate not supplied

Ultrastructural morphometric study of follicular center lymphocytes: II. Analyses of cleaved-cell populations do not support the Lukes-Collins' concept.

Ultrastructural morphometric analysis was carried out on six cases of lymph node biopsies with reactive hyperplasia to establish the frequency and depth of invaginations in nuclear profiles situated in the mantle zones and follicular centers. The frequency distribution of the depth of invaginations was similar in nuclear profiles whether in the small lymphocytes of mantle zones or the small, partially transformed (centrocytes) and fully transformed (centroblasts) lymphocytes of follicular centers. Invaginated and cleaved lymphocytes were not confined to the partially transformed (centrocytic) lymphocytes of follicular centers, and nuclear profiles with invaginations bore no resemblance to those depicted in the Lukes-Collins model. A considerable proportion of mantle zone lymphocyte nuclear profiles had invaginations (ranging from 7.5% to 53.6%) and there was no difference between the frequency of deep indentations or clefts in mantle zone lymphocytes (8.1 +/- 5.4%) and the small unstimulated (9.3 +/- 5.3%) and partially transformed (8.4 +/- 1.4%) lymphocytes in follicular centers. Computer modeling of stylized nuclei with conical indentations indicated that all lymphocytic nuclei likely have multiple invaginations or groove-like creases.

Cell Nucleus↗