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PubMed2006

International disparities in access to infertility services.

OBJECTIVE: To characterize the international availability of infertility services. DESIGN: A PubMed computer search to identify relevant articles. SETTING: Academic medical center. PATIENT(S): None. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): None. RESULT(S): Epidemiological data suggests that approximately 80 million people worldwide are infertile. Most countries in the industrial west have declining fertility rates marked by late marriage, postponed childbearing, and primary infertility. In contrast, in the developing world, there is little voluntary effort to postpone childbearing and early first marriage is common. However, a high prevalence of sexually transmitted infections and infections acquired as a result of inadequate health care result in increased rates of secondary infertility. In developing societies, childlessness is often highly stigmatized and leads to profound social suffering for infertile women in particular, yet most infertile people in the developing world have virtually no access to effective treatment. Internationally, a minority of countries offer IVF, and even where it is available, on average it is prohibitively expensive and utilized by a fraction of those who could benefit from its use. CONCLUSION(S): Wide disparities exist in the quality, availability, and delivery of infertility services between the developed and developing nations of the world.

Female↗

PubMed2003

Recurrent pancreatitis as a late complication of endoscopic sphincterotomy for common bile duct stones: diagnosis and therapy.

Although long-term complications of endoscopic sphincterotomy (ES) have often been reported, the possible effects of the procedure on the pancreatic duct orifice remain virtually unknown. Three women patients are described who developed attacks of recurrent pancreatitis at 2, 7, and 27 months after ES for bile duct stones. The attacks were apparently caused by a partial stenosis of the pancreatic orifice, arising from post-procedure fibrosis and scarring. The patients were evaluated and treated endoscopically. All three patients benefited from endoscopic therapy; two became symptom-free and one improved. Symptoms recurred in the three patients, after 26, 41, and 23 months. In one patient, re-stenosis was documented and repeat sphincterotomy resulted in complete relief of symptoms during the ensuing 5 months. In the remaining two patients, the symptoms were mild and no further intervention was needed. Concerning complications, one patient suffered a moderately severe pancreatitis without sequelae. Recurrent pancreatitis may emerge as a late complication after ES for common bile duct stones. It is probably causally related to stenosis of the pancreatic orifice brought about by fibrosis and scarring, which may exceptionally develop after the procedure. Endoscopic therapy should probably be considered in the first instance, but the optimal treatment for this condition remains to be determined.

Aged↗

PubMed2004

Physicians' and patients' perceptions of patients' communication competence in a primary care medical interview.

Considerable research suggests that patients and physicians often perceive aspects of the medical interview quite differently. Despite extensive research into physician-patient communication, virtually no attention has been given to assessing patients' and physicians' perceptions of communication competence during the medical interview. The purpose of this research was to determine the extent of agreement between physicians and patients on what behaviors constitute competent patient communication. The results indicate that there is considerable agreement between physicians and patients on the categories of competent patient communication. However, there is little or no evidence for agreement at the dyadic level on the occurrence of competent patient communication. Moreover, there is little evidence that physicians' and patients' perceptions of competence correlate with patients' actual discourse. These results are discussed with respect to implications for future research on patient communication skills training interventions.

Adolescent↗

PubMed1980

Child malnutrition and deprivation--observations in Guatemala and Costa Rica.

Traditional populations consisting of small tribal groups living in close contact with nature may be virtually free from endemic malnutrition owing to the relative absence of infectious diseases. Transition toward modern ways of life and population growth, leading to crowding and underdevelopment, favours endemic malnutrition due to the interaction of malnutrition and infection. Although important features of the traditional culture--breast-feeding, protective child rearing--may remain intact, they are not enough, and such populations exhibit high rates of infectious disease, malnutrition and premature death. In modern industrialized societies, malnutrition often appears related to child abuse and neglect. Organic and metabolic forms are observed but social pathology appears to be the main determinant of most malnutrition observed. Prevention and control of malnutrition requires improvement of the environment and interventions applied in a holistic manner. Emphasis should be given to education and maternal technology, and to promotion of mother-infant interactions, breast-feeding, adequate weaning procedures and detection of factors that may lead to child deprivation and abuse. Improvement is feasible for most developing nations if social forces become conscious of the needed changes, but positive elements of traditinal culture should be preserved.

Breast Feeding↗

PubMed2006

Pediatric resident education in palliative care: a needs assessment.

OBJECTIVE: The goal was to characterize pediatric residents' perceived educational needs for pediatric palliative care. The data generated from this study will facilitate the planning of specific educational interventions. METHODS: All residents in the Children's Hospital of Pittsburgh pediatrics residency program were asked to complete a survey in September 2003. Participation in the study was voluntary. Residents rated their previous training, personal experience, knowledge, competence, and emotional comfort with 10 specific aspects of pediatric palliative care. This rating was followed by 13 questions related to attitudes about palliative care practices and training. The last section asked the respondents to rank 11 palliative care educational topics in order of importance. RESULTS: Forty-nine of 75 eligible residents participated. Although residents thought that pediatricians should have an important role in providing palliative care, residents reported minimal training, experience, knowledge, competence, and comfort in virtually all areas of palliative care for children. We found no significant improvement in any of these areas from the pediatric level-1 year to the pediatric level-3 year. Residents wanted more training regarding pain management. After pain control, the next 4 educational needs were communication skills, namely, discussing prognosis, bad news, and code status and talking with children about end-of-life care. CONCLUSIONS: There is a clear need for increased efforts in pediatric palliative care education during residency training. Pediatric residents do not think that they are trained adequately in palliative care, and this perception does not improve with time. Pediatric residents view palliative care as important for primary care physicians and desire more education.

Internship and Residency↗

PubMed1993

Protein and amino acid metabolism in cancer cachexia: investigative techniques and therapeutic interventions.

Cancer cachexia is a complex syndrome characterized primarily by diminished nutrient intake and progressive tissue depletion that is manifest clinically as anorexia and host weight loss. The gradual loss of host protein stores is central to this process. This review outlines the techniques that have been used to evaluate human amino acid metabolism, their application in patients with cancer cachexia, and possible therapeutic interventions designed to overcome alterations in host protein and amino acid metabolism associated with malignant cachexia. The techniques of nitrogen balance and 3-methylhistidine excretion provide indirect estimates of overall nitrogen metabolism and skeletal muscle myofibrillar protein breakdown. Measurement of circulating amino acid concentrations, particularly when combined with assessment of arterial-venous differences and regional amino acid balance allows for investigation of interorgan amino acid metabolism. One of the most significant advances in in vivo amino acid metabolic research has been the development of labeled amino acid tracer studies to evaluate whole body and regional amino acid kinetics. The use of stable and unstable amino acid isotopes in these techniques is reviewed in detail. Virtually all of these techniques have now been employed in the evaluation of human cancer cachexia. The results of studies evaluating amino acid concentrations, regional amino acid balance, and 3-methylhistidine excretion are summarized. The use of regional and whole body kinetic studies in cancer cachexia are reviewed extensively. Most investigators have observed increased rates of whole body protein turnover, synthesis, and catabolism in both weight-stable and weight-losing cancer patients. Some studies have suggested a relationship between the extent of disease and the degree of aberration in amino acid kinetic parameters. Investigators have attempted to reverse some of these alterations by provision of substrate (nutritional support) or administration of specific pharmacologic or anabolic agents such as hydrazine sulfate, insulin, growth hormone, and beta-2 agonists. The role of total parenteral nutrition (TPN) in cancer and its effects on protein and amino acid kinetics and tumor growth are addressed. The possible benefits of specific amino acid nutritional formulations with increased branched chain amino acids, arginine, and glutamine are reviewed. Although many of these approaches appear promising, significant impact on clinically definable parameters remains to be demonstrated. A better understanding of the underlying protein catabolic mechanisms of cancer cachexia will likely lead to more effective therapies to reverse the protein calorie malnutrition associated with cancer cachexia.

Amino Acids↗

PubMed1999

Psychiatric disorders among survivors of the Oklahoma City bombing.

CONTEXT: Disasters expose unselected populations to traumatic events and can be used to study the mental health effects. The Oklahoma City, Okla, bombing is particularly significant for the study of mental health sequelae of trauma because its extreme magnitude and scope have been predicted to render profound psychiatric effects on survivors. OBJECTIVE: To measure the psychiatric impact of the bombing of the Alfred P. Murrah Federal Building in Oklahoma City on survivors of the direct blast, specifically examining rates of posttraumatic stress disorder (PTSD), diagnostic comorbidity, functional impairment, and predictors of postdisaster psychopathology. DESIGN, SETTING, AND PARTICIPANTS: Of 255 eligible adult survivors selected from a confidential registry, 182 (71%) were assessed systematically by interviews approximately 6 months after the disaster, between August and December 1995. MAIN OUTCOME MEASURES: Diagnosis of 8 psychiatric disorders, demographic data, level of functioning, treatment, exposure to the event, involvement of family and friends, and physical injuries, as ascertained by the Diagnostic Interview Schedule/Disaster Supplement. RESULTS: Forty-five percent of the subjects had a postdisaster psychiatric disorder and 34.3% had PTSD. Predictors included disaster exposure, female sex (for any postdisaster diagnosis, 55% vs 34% for men; chi2 = 8.27; P=.004), and predisaster psychiatric disorder (for PTSD, 45% vs 26% for those without predisaster disorder; chi2 = 6.86; P=.009). Onset of PTSD was swift, with 76% reporting same-day onset. The relatively uncommon avoidance and numbing symptoms virtually dictated the diagnosis of PTSD (94% meeting avoidance and numbing criteria had full PTSD diagnosis) and were further associated with psychiatric comorbidity, functional impairment, and treatment received. Intrusive reexperience and hyperarousal symptoms were nearly universal, but by themselves were generally unassociated with other psychopathology or impairment in functioning. CONCLUSIONS: Our data suggest that a focus on avoidance and numbing symptoms could have provided an effective screening procedure for PTSD and could have identified most psychiatric cases early in the acute postdisaster period. Psychiatric comorbidity further identified those with functional disability and treatment need. The nearly universal yet distressing intrusive reexperience and hyperarousal symptoms in the majority of nonpsychiatrically ill persons may be addressed by nonmedical interventions of reassurance and support.

Adaptation, Psychological↗

PubMed1998

Generalized glycogen storage and cardiomegaly in a knockout mouse model of Pompe disease.

Glycogen storage disease type II (GSDII; Pompe disease), caused by inherited deficiency of acid alpha-glucosidase, is a lysosomal disorder affecting heart and skeletal muscles. A mouse model of this disease was obtained by targeted disruption of the murine acid alpha-glucosidase gene (Gaa) in embryonic stem cells. Homozygous knockout mice (Gaa -/-) lack Gaa mRNA and have a virtually complete acid alpha-glucosidase deficiency. Glycogen-containing lysosomes are detected soon after birth in liver, heart and skeletal muscle cells. By 13 weeks of age, large focal deposits of glycogen have formed. Vacuolar spaces stain positive for acid phosphatase as a sign of lysosomal pathology. Both male and female knockout mice are fertile and can be intercrossed to produce progeny. The first born knockout mice are at present 9 months old. Overt clinical symptoms are still absent, but the heart is typically enlarged and the electrocardiogram is abnormal. The mouse model will help greatly to understand the pathogenic mechanism of GSDII and is a valuable instrument to explore the efficacy of different therapeutic interventions.

Animals↗

PubMed2001

Analyzing the relationship of exercise and health: methods, assumptions, and limitations.

The papers in this supplement to Medicine and Science in Sports and Exercise seek to summarize our knowledge of the dose-response relationship of exercise with a variety of health outcomes. This type of rigorous evidence summation has become quite popular in the past 10 years as health care providers and policymakers seek to distinguish interventions that are helpful--the expected benefits justify human and economic costs--from those of no or uncertain benefit (7). Proponents of "evidence-based medicine" argue that in contrast to old-style literature reviews in which the writer, typically an "expert," develops a thesis and cites only those publications that support his point of view, an evidence-based approach finds all of the evidence and objectively weighs it to determine the "truth" (20,22). Although such methods offer the promise of increased objectivity, they are not immune to bias, and readers should understand that the declaration that something is "evidence-based" is no guarantee of its veracity. In fact, because the literature virtually never includes studies that perfectly match the setting and personal circumstance of the patient under treatment, "evidence-informed medicine" would be a more honest title for care grounded in systematic reviews of the literature (23). This paper begins with a discussion of potential theoretical problems with systematic reviews and concludes by considering specific problems that members of the panel were likely to encounter when evaluating the literature on exercise and health. These concepts were presented in the initial lecture of the conference so that the 24 lecturers and 6 members of the consensus panel would be forewarned of the dangers that lay ahead.

Bias↗

PubMed2005

Recombinant tissue plasminogen activator (rtPA) for stroke. The perspective at 8 years.

OBJECTIVE: To review the 8-year experience with recombinant tissue plasminogen activator (rtPA) for stroke, with commentary on ramifications for the approach to stroke treatment, directions in stroke research, and sociological aspects of stroke as a disease of concern in our society. BACKGROUND: Approved in 1996, rtPA remains the only drug indicated for the treatment of ischemic stroke. Stroke treatment and research have evolved rapidly in response to opportunities and discoveries related to the advent of rtPA. The presence of rtPA has engendered an increased level of awareness about all aspects of stroke. METHODOLOGY: Literature review was performed, focusing on topics that in the author's view are of greatest relevance to the use of rtPA in clinical practice and to the directions in which the presence of rtPA is moving the field of stroke treatment, research, and politics. RESULTS: Challenges have been raised, and met, regarding the validity of the data upon which the approval for rtPA was based. Limitations in the use of rtPA include the brief time available for treatment, the need for rapid imaging and blood-pressure control, and the fact that large-artery occlusions respond poorly. The major risk of treatment is brain hemorrhage, and although predictors of hemorrhage are known, their presence does not constitute an absolute contraindication to treatment. A virtual subindustry has evolved to enhance the benefit and applicability of rtPA through refined imaging technology and the use of rtPA intra-aterially, as well as in combination with other agents and devices. Sociopolitically, rtPA has elevated the level of awareness of stroke and provided impetus for the stroke center movement and federal legislation to stop stroke. CONCLUSION: The development of rtPA has been the most effective advance in the field of stroke. It has generated healthy debate regarding the design, performance, and interpretation of stroke trials, including cost-benefit considerations. rtPA has stimulated research in a multitude of areas, enhanced our understanding of stroke pathophysiology, and defined important limits and risks for urgent intervention. rtPA is the cornerstone of the stroke center movement, as well as legislation in behalf of stroke at the congressional level.

Brain Ischemia↗

PubMed2001

[Quality of colonoscopy and surgical treatment of perforations].

INTRODUCTION: Perforation during colonoscopy is a well-known complication. The purpose of our study was to evaluate the incidence of acute surgical intervention due to colonic perforations during endoscopy at our department, and evaluate the rate of incomplete examinations. METHODS: The latest 4000 colonoscopies performed at Hvidovre Hospital were examined for possible complications and success rate. RESULTS: Seventeen percent of the colonoscopies were incomplete, mostly due to anatomical difficulties, incomplete bowel preparation, and pain. Twelve (0.3%) of the 4000 patients were operated on due to perforation which occurred during the examination. The mortality rate in these 12 patients was 17% and the survivors had a median hospital stay of eight days. DISCUSSION: Future strategy should focus on improving the quality of colonoscopy, thereby increasing the success rate and lowering patient discomfort. Furthermore, the new non-invasive modalities virtual colonoscopy (CT or MRI) should be developed further so that they might substitute all the diagnostic colonoscopies.

Aged↗

PubMed1997

Mammalian mitochondrial genetics: heredity, heteroplasmy and disease.

Mammalian mitochondrial DNA (mtDNA) is present at high copy number (10(3)-10(4) copies) in virtually all cells of the body. The mitochondrial genome shows strict maternal inheritance and the vast majority of copies are identical at birth (homoplasmy). Occasionally, a subpopulation of mtDNA molecules carry a pathogenic mutation. When this heteroplasmic mtDNA is present during embryogenesis, it can lead to a variety of clinical symptoms predominantly affecting muscle and nerve, but also affecting other tissues. While the importance of mitochodrial heteroplasmy in human disease is unquestioned, we remain largely ignorant of many fundamental aspects of mitochondrial genetics. How do mutations arise and can they be repaired, what influences the segregation and fixation of heteroplasmic mtDNA, do levels of heteroplasmy fluctuate during life, is it possible to modulate these levels by external intervention and, finally, can we predict the segregation and transmission of a mutant genome? The aim of this article is to summarize and discuss recent observations that have addressed several of these fundamental issues and to reiterate how much we still have to learn about mitochondrial genetics.

Animals↗

PubMed2003

Gastrointestinal dysfunction in Parkinson's disease.

There is growing recognition that gastrointestinal dysfunction is common in Parkinson's disease (PD). Virtually all parts of the gastrointestinal tract can be affected, in some cases early in the disease course. Weight loss is common but poorly understood in people with PD. Dysphagia can result from dysfunction at the mouth, pharynx, and oesophagus and may predispose individuals to aspiration (accidental inhalation of food or liquid). Gastroparesis can produce various symptoms in patients with PD and may cause erratic absorption of drugs given to treat the disorder. Bowel dysfunction can consist of both slowed colonic transit with consequent reduced bowel-movement frequency, and difficulty with the act of defecation itself with excessive straining and incomplete emptying. Recognition of these gastrointestinal complications can lead to earlier and potentially more effective therapeutic intervention.

Gastrointestinal Diseases↗

PubMed2025

Effect of Physical Exercise on Telomere Length: Umbrella Review and Meta-Analysis.

BACKGROUND: Telomere length (TL) is a marker of cellular health and aging. Physical exercise has been associated with longer telomeres and, therefore, healthier aging. However, results supporting such effects vary across studies. Our aim was to synthesize existing evidence on the effect of different modalities and durations of physical exercise on TL. OBJECTIVE: The aim of this study was to explore the needs and expectations of individuals with physical disabilities and their interventionists for the use of a virtual reality physical activity platform in a community organization. METHODS: We performed an umbrella review and meta-analysis. Data sources included PubMed, Embase, Web of Science, Cochrane Library, and Scopus. We selected systematic reviews and meta-analyses of randomized and nonrandomized controlled clinical trials evaluating the effect of physical exercise on TL. RESULTS: Our literature search retrieved 12 eligible systematic reviews, 5 of which included meta-analyses. We identified 22 distinct primary studies to estimate the overall effect size of physical exercise on TL. The overall effect size was 0.28 (95% CI 0.118-0.439), with a heterogeneity test value Q of 43.08 (P=.003) and I² coefficient of 51%. The number of weeks of intervention explained part of this heterogeneity (Q_B=8.25; P=.004), with higher effect sizes found in studies with an intervention of less than 30 weeks. Exercise modality explained additional heterogeneity within this subgroup (Q_B=10.28, P=.02). The effect sizes were small for aerobic exercise and endurance training, and moderate for high-intensity interval training. CONCLUSIONS: Our umbrella review and meta-analysis detected a small-moderate positive effect of physical exercise on TL, which seems to be influenced by the duration and type of physical exercise. High quality studies looking into the impact of standardized, evidence-based physical exercise programs on TL are still warranted.

Humans↗

PubMed1993

Paediatric management practices in Down syndrome: a follow-up survey.

In a follow-up survey to a 1984 study, 339 paediatricians in Australia were invited to complete a brief questionnaire in 1990, in which they indicated their usual recommendations, practices and advice when managing children with Down syndrome. The response rate was 67%. The results indicated that the most frequent paediatrician-initiated referrals were for early intervention and for discussion with other parents; these options were selected more frequently in 1990 than in 1984. While referral to a social worker was the next most frequent choice, it occurred less in 1990 than in 1984. Other increases in referrals were for physiotherapy and speech therapy. Paediatricians were more likely to support referral to a geneticist, speech therapist or cosmetic surgeon in response to a specific parental enquiry, and less likely to support referral to a social worker or to full-time care. There had been significant increases since 1984 in the likelihood that paediatricians would order audiology and investigation of thyroid and cardiac function. There was less opposition to the use of sedatives, and virtual cessation of the use of tryptophan. Paediatricians were more optimistic about the likelihood of persons with Down syndrome living independently, caring for their own finances, and marrying, but not about other developmental areas.

Adolescent↗

PubMed2004

Race/ethnicity and untreated dental caries: the impact of material and behavioral factors.

OBJECTIVE: To use nationally representative data, group variables into categories of material and behavioral factors, and assess their relative contribution to racial/ethnic variation in untreated caries. METHODS: Participants were from the Third National Health and Nutrition Examination Survey (NHANES III), aged 20-50 years. Material factors were income, education, employment status, dental insurance status, and urban residence. Behavioral factors were marital status, tobacco use, alcohol use, obesity, and social support. All models were additionally adjusted for age, gender, and quartile of missing teeth. The outcome was three or more carious teeth. RESULTS: Non-Hispanic blacks and Mexican-Americans displayed excess risk of untreated caries compared with non-Hispanic whites when adjusted for age, sex, and missing teeth (adjusted odds ratios 1.73 and 1.69, respectively). The addition of behavioral factors to this model resulted in virtually no changes in the adjusted odds ratios for race/ethnicity and untreated caries. When material factors were added to the basic model the excess risk for untreated caries among non-Hispanic blacks was reduced by approximately 21% and that of Mexican-Americans was no longer statistically significant compared with non-Hispanic whites (adjusted odds ratios 1.36 and 0.83, respectively). CONCLUSIONS: Much of the excess risk for untreated dental caries among non-Hispanic blacks and Mexican-Americans compared with non-Hispanic whites was eliminated when material factors were controlled, while no risk reductions were observed when behavioral factors were controlled. Addressing material factors may provide greater reductions in untreated caries disparities than behavioral interventions, and these risk reductions may vary with racial/ethnic group.

Adult↗

PubMed2001

The death watch: certifying death using cardiac criteria.

In the past, inadequate diagnostic instruments sometimes led to incorrect diagnoses of death, so careful and prolonged observation--the "death watch"--was required. Diagnostic instruments are now accurate and determining the presence or absence of circulation and cerebral function is easy in virtually all cases. Still, ambiguity and controversy in diagnosing death persists because the current criteria, irreversible cessation of cardiac or whole brain function, are ambiguous. Recent reintroduction of non-heart-beating organ donation has highlighted the controversy. Data on the ability to achieve restoration of spontaneous circulation are quite consistent, but they support several different sets of reasonable death criteria. This article concludes with a rejection of a fixed notion of "irreversibility" because it does not conform to current practice, is potentially deleterious to social events at the time of death, and the reversibility of cardiopulmonary arrest is dependent on available means of resuscitation. Finally, the time required to ensure irreversible cessation of cardiac function despite potential intervention is too broad to be clinically applicable and is unreasonable. Diagnosis of death should be based on the context in which it occurs because the medical means available determine what is irreversible.

Brain Death↗

PubMed2002

Effects of inspiratory flow waveforms on lung mechanics, gas exchange, and respiratory metabolism in COPD patients during mechanical ventilation.

STUDY OBJECTIVE: The clinical usefulness of varying inspiratory flow waveforms during mechanical ventilation has not been adequately studied. The aim of this study was to compare the effects of three different respiratory waveforms on the pulmonary mechanics, gas exchange, and respiratory metabolism of ventilated patients with COPD. DESIGN: A randomized and comparative trial of consecutive patients. SETTING: Medical ICUs of a 2,000-bed university hospital. PATIENTS: Fifty-four patients with COPD were enrolled. INTERVENTIONS: Constant, decelerating, and sine waveforms were applied to each patient in a random order. MEASUREMENTS AND RESULTS: With tidal volume, inspiratory time, and inspiratory frequency being kept constant, the decelerating waveform produced statistically significant reductions of peak inspiratory pressure, mean airway resistance, physiologic dead space ventilation (VD/VT), PaCO(2), and symptom score. There was also a significant increase in alveolar-arterial oxygen pressure difference with the decelerating flow waveform, but there were no significant changes in mean airway pressure, arterial oxygenation, heart rate, mean BP, and other hemodynamic measurements. In addition, assessment on the work of breathing (WOB) revealed that ventilator WOB values were reduced with the decelerating waveform. Oxygen consumption and carbon dioxide output were virtually not affected by changing inspiratory flow waveforms. Except for VD/VT, the effects of constant square and sine waveforms were similar to each other and could not be separated statistically. CONCLUSIONS: The most favorable flow pattern for ventilated patients with COPD appeared to be the decelerating waveform. There are possibilities for the improvement of ventilation in these patients by selecting an appropriate inspiratory flow.

Aged↗