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Showing papers in "Open Medicine in 2009"


Journal Article
TL;DR: The QUOROM Statement (QUality Of Reporting Of Meta-analyses) as mentioned in this paper was developed to address the suboptimal reporting of systematic reviews and meta-analysis of randomized controlled trials.
Abstract: Systematic reviews and meta-analyses have become increasingly important in health care. Clinicians read them to keep up to date with their field,1,2 and they are often used as a starting point for developing clinical practice guidelines. Granting agencies may require a systematic review to ensure there is justification for further research,3 and some health care journals are moving in this direction.4 As with all research, the value of a systematic review depends on what was done, what was found, and the clarity of reporting. As with other publications, the reporting quality of systematic reviews varies, limiting readers' ability to assess the strengths and weaknesses of those reviews. Several early studies evaluated the quality of review reports. In 1987, Mulrow examined 50 review articles published in 4 leading medical journals in 1985 and 1986 and found that none met all 8 explicit scientific criteria, such as a quality assessment of included studies.5 In 1987, Sacks and colleagues6 evaluated the adequacy of reporting of 83 meta-analyses on 23 characteristics in 6 domains. Reporting was generally poor; between 1 and 14 characteristics were adequately reported (mean = 7.7; standard deviation = 2.7). A 1996 update of this study found little improvement.7 In 1996, to address the suboptimal reporting of meta-analyses, an international group developed a guidance called the QUOROM Statement (QUality Of Reporting Of Meta-analyses), which focused on the reporting of meta-analyses of randomized controlled trials.8 In this article, we summarize a revision of these guidelines, renamed PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses), which have been updated to address several conceptual and practical advances in the science of systematic reviews (Box 1). Box 1 Conceptual issues in the evolution from QUOROM to PRISMA

46,935 citations


Journal Article
TL;DR: Methods for the imputation of missing values have been the topic of much methodological and empirical research in recent years and some simple approaches that have been around a long time are much more popular, but some concerns about “making up the data” are misplaced.
Abstract: Although randomized trials have been conducted for several decades now, some aspects of their analysis remain contentious. Two such issues are what to do about trial participants who do not adhere to the protocol (for example, if they do not receive the intended treatment) and how to deal with those for whom outcome assessments are missing (for example, because they are lost to follow-up). Both of these issues are relevant to the adoption of so-called “intention to treat” (ITT) analysis – a topic that, not surprisingly, also causes debate. ITT analysis is widely recommended as the preferred approach to analyzing the outcomes of randomized trials.1,2 In an ITT analysis, all randomized patients are included in the analysis in their assigned groups regardless of all considerations, including whether they in fact received the designated intervention. ITT analysis should therefore compare outcomes in groups that correspond exactly to the randomization scheme. Any deviation from that principle may introduce bias. An immediate problem is that some data are missing from almost all randomized trials.3 Clearly, just a few missing outcomes will not be a concern, but one review found that, in about half of randomized controlled trials (RCTs), outcomes are missing for more than 10% of participants.4 A major concern is that being lost to follow-up could be related to a patient’s response to the treatment; indeed, we should assume that this will be so. That concern can be compounded if the reasons for, or frequency of, dropout differs between the treatment groups. No analysis option is ideal here; there is, in effect, a choice between omitting participants without final outcome data or estimating (imputing) the missing outcome data. What should researchers do? A “complete case” (or “available case”) analysis simply omits those for whom data are incomplete. This commonly used approach loses power, and bias may well be introduced, given that the incompleteness of data will not be random. Further, excluding some patients is not compatible with the ITT principle. Imputation of the missing data allows the analysis to conform to ITT analysis but requires strong assumptions that may be hard to justify.5,6 However, some concerns about “making up the data” are misplaced.7 Methods for the imputation of missing values have been the topic of much methodological and empirical research in recent years. The generally preferred imputation methods are quite complex,5-8 and some simple approaches that have been around a long time are much more popular. One of the simplest and most commonly used of these in the analysis of continuous outcomes is “last observation carried forward” (LOCF) analysis, in which missing final values of the outcome variable are replaced by the last known value before the participant was lost to follow-up. LOCF analysis appeals through its simplicity and ease of application, but there are strong grounds for not using it. Specifically, the method may introduce bias in the results, and this bias can, according to circumstance, be in either direction.9 Also, because in LOCF analysis no allowance is made for the uncertainty of imputation, the resulting confidence intervals are too narrow.10 Even if missing outcomes are random across trial participants, LOCF analysis assumes that the missing final values would be the same as the last recorded values. That assumption is often implausible (even as an average), because dropping out is likely to be associated with response to treatment; obvious examples are failure to respond to treatment and adverse effects. In practice, missing data are very likely to be related to response to treatment and prognosis. Molnar and colleagues have discussed these issues in the specific context of trials of dementia therapies.9,11 They found that 34 of 57 RCTs used LOCF as the only form of ITT analysis. Not surprisingly, that is a much higher proportion than the 19% observed in a review of trials across various medical specialties published in 4 general medical journals.4 As Molnar and colleagues note,11 their study cannot quantify the magnitude of the effect of the use of LOCF analysis on trial results, but it does highlight the high prevalence of conditions for which this method of analysis could promote bias in favour of more toxic therapies and against less toxic alternatives. Their study focused on a limited number of trials concerning a single medical condition, but many of the issues it raises apply to all trials. It is known that most trials include some patients whose outcomes are ultimately not known, and for which an ITT analysis is not possible without some type of imputation (although authors commonly mislabel available case analyses as ITT).12,13 Whichever imputation approach is used, it is desirable to report analyses with and without imputation. Also, it may be valuable to explore different imputation approaches. As Molnar and colleagues suggest, “the onus is on the investigators who publish these trials to disprove the possibility that these analyses have introduced bias by performing ITT sensitivity analyses … . This is particularly true for those studies demonstrating higher dropout rates in treatment groups.”11 A further important issue is that this information should be included in the report of a trial. The CONSORT (Consolidated Standards for Reporting of Trials) Statement recommends that authors specify the methods used for all statistical analyses reported.14 The statement’s accompanying explanatory paper included various comments on ITT analysis, but there was no specific mention of imputation.15 Noting that omission, Shapiro wrote: “A variety of options are available to handle missing data from participants who drop out of the trial and it is important for readers to know what strategy the investigators adopted. Without such information, the fact that an intent-to-treat analysis was carried out is only partially informative.”16 That omission will be remedied in the forthcoming 2009 update of the CONSORT Statement. Transparency of reporting facilitates reliable appraisal of the quality and relevance of health research.17 Successful transparency may be judged by whether others are able to reproduce all the methods used. The International Committee of Medical Journal Editors makes the sensible recommendation to “[d]escribe statistical methods with enough detail to enable a knowledgeable reader with access to the original data to verify the reported results” (http://www.icmje.org/). That is very sound advice for all research articles, not just RCTs; indeed, I see no reason why it should not apply to all study methods. Molnar and colleagues have gone further than Shapiro by suggesting that the CONSORT group should give guidance on methods for analysing trials when data are missing.11 However, because the purpose of the CONSORT group is to give guidance on the reporting of what was done, and not to advise on what is good or bad methodology, such guidance will not come from that source. But, given that so many others have warned about the dangers of LOCF analysis, it seems clear that its use as the sole form of analysis should be discontinued.8,9,16,18,19 Finally, as Liu and colleagues observed, it is important in the design and conduct of studies to try to prevent losses to follow-up and to try to minimize the bias caused by the inevitable missing data.20 To that end, they provide helpful guidance for both the conduct and reporting of RCTs where missing outcomes are likely: discuss at the planning stage methods and procedures that maximize the chance of retaining patients (e.g., short course of rescue medicine), continue to collect data post-withdrawal to preserve the ITT population, document the reasons for missing data, anticipate and investigate the types of missing data, pre-specify primary as well as sensitivity statistical analyses, fully report the extent and pattern of missing data, support conclusions based on results from the planned analyses with proper sensitivity assessment.20 Adherence to this advice will lead to better design, analysis, reporting and interpretation of future trials in all medical specialties.

141 citations


Journal Article
TL;DR: Although discussions about prognosis occur infrequently for patients who have advanced terminal disease, such discussions with patients and their families may facilitate advance care planning and improve satisfaction with EOL care.
Abstract: Background: Seriously ill patients and their physicians often avoid discussing prognosis, which may compromise optimal end­of­ life (EOL) care planning. The relation between prognosis discussion and patient and family satisfaction with EOL care is un­ known. Methods: Using a 5­domain questionnaire, we surveyed inpatients with cancer or end­stage medical disease and their families on their satisfaction with specific aspects of EOL care and their overall satisfaction with EOL care. Scores were standardized to 0–100 points. We compared the results based on whether or not a physician had discussed the patient’s prognosis with them, as well as on whether the patient and family member agreed on whether the patient was nearing the end of life. Supplementary questions were also asked (e.g., preferred location of death, willingness to discuss cardiopulmonary resuscitation). Results: Of 569 eligible patients and 176 eligible family members, 440 (77%) patients and 160 (91%) family members participated in the study. Overall, 18% of patients and 30.1% of families recalled a prognosis discussion with a physician. Patients who recalled such a discussion were more satisfied with overall care (76.1 v. 73.1 points, difference 3.0, 95% confidence interval [CI] 0.40 to 5.67, p = 0.02) and with communication and decision­making aspects of care (77.9 v. 72.4 points, difference 5.5, 95% CI 1.43 to 9.52, p = 0.008), and were more willing to discuss cardiopulmonary resuscitation status (69.6% v. 55.3%, difference 14.3, 95% CI 2.15 to 26.45, p = 0.03), than those who did not. Patients who were in accord with their family member as to whether they were nearing the end of life also showed significant satisfaction in these 3 areas. Family members’ overall satisfaction was also higher among those who recalled a prognosis discussion (75.3 v. 70.4 points, difference 4.9, 95% CI 0.53 to 9.24, p = 0.03). Multivariate analyses confirmed the significance of the relation between the prognosis discussion and overall satisfaction with care for both patients and family members. Conclusion: Although discussions about prognosis occur infrequently for patients who have advanced terminal disease, such dis­ cussions with patients and their families may facilitate advance care planning and improve satisfaction with EOL care. Encour­ aging discussion regarding EOL status between the patient and family members may also lead to greater satisfaction with EOL care for patients.

121 citations


Journal ArticleDOI
TL;DR: An overview is given of the many therapeutic possibilities that exist for treatment of bacterial infections and how bacteria become resistant to these therapeutics.
Abstract: The development of antimicrobial resistance by bacteria is inevitable and is considered as a major problem in the treatment of bacterial infections in the hospital and in the community. Despite efforts to develop new therapeutics that interact with new targets, resistance has been reported even to these agents. In this review, an overview is given of the many therapeutic possibilities that exist for treatment of bacterial infections and how bacteria become resistant to these therapeutics.

84 citations


Journal Article
TL;DR: A pharmacist-directed, physician-supported AMS program achieved significantly better INR control and reduced rates of thromboembolic complications compared with standard care and resource utilization was substantially reduced during AMS care.
Abstract: Background: Anticoagulation management services (AMSs) are widely used for anticoagulation management in many countries. Our AMS is a pharmacist-run ambulatory clinic with a physician advisory committee that manages patients referred with complicated anticoagulation histories. This paper assesses the adequacy of anticoagulation, rates of anticoagulant-related events and associated health care resource utilization for patients before and after referral to our AMS. Methods: Consecutive patients referred to the AMS with 4 months of prior anticoagulation management who also had anticoagulation management for 4 months within the AMS were included in the evaluation. The primary endpoint was adequacy of anticoagulation (target international normalized ratio [INR] ± 0.5). Secondary outcomes included adverse events requiring an emergency department (ED) visit or hospital stay. These were classified by International Classification of Diseases (ICD) codes as thromboembolic, hemorrhagic, or non-anticoagulant related. Health care system resource consumption data were collected as number of hours spent in an ED and hospitalization costs. Results: A total of 125 patients were included: 57.6% were male, with a mean age of 62.9 (standard deviation [SD]) ± 15.0 years. Indications for warfarin therapy were atrial fibrillation (40.0%), mechanical valve replacement (24.0%) and venous thromboembolism (19.2%). The adequacy of anticoagulant control was significantly greater during AMS care compared with the period before referral; patients were in the target INR range 66.5% versus 48.8% of the time, respectively (95% confidence interval [CI] 13.4%–22.0%; p < 0.0001). The relative risk of a thromboembolic event before referral to AMS care was 17.6 (95% CI 6.0–51.9; p < 0.0001), while the relative risk of a hemorrhagic event before AMS care was 1.6 (95% CI 0.7–3.7; p = 0.25). During AMS care, savings included 572 hours in the ED and Cdn$122,145.40 in hospitalization costs. Conclusions: A pharmacist-directed, physician-supported AMS program achieved significantly better INR control and reduced rates of thromboembolic complications compared with standard care. Resource utilization was substantially reduced during AMS care.

69 citations


Journal Article
TL;DR: The use of HES for acute volume resuscitation of critically ill patients, and in particular those with severe sepsis and septic shock, appeared to be associated with increased use of renal replacement therapy.
Abstract: Background: Hydroxyethyl starch (HES) is a type of colloid fluid that is commonly used for volume resuscitation of patients admitted to the intensive care unit. Data regarding the renal consequences of HES are conflicting. Purpose: To evaluate the effect of HES solutions on renal outcomes and mortality among critically ill patients requiring acute volume resuscitation. Data sources: We searched electronic databases (MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials and the SCOPUS database) from 1950 to 2008. Conference proceedings and grey literature sources were searched from 2002 to 2007. Study selection: We included only randomized controlled trials of acute volume resuscitation of critically ill patients comparing HES fluid with an alternative resuscitation fluid. Data synthesis: Two reviewers independently assessed trial eligibility, extracted data and evaluated trial quality. Random-effects models were used for all summary measures of effect. Results: Twenty-two trials (n = 1865 patients) were included. Patients who received HES were more likely to have received renal replacement therapy (odds ratio [OR] 1.90, 95% confidence interval [CI] 1.22–2.96, I 2 9.5%, n = 749). There was no difference in overall mortality (OR 1.07, 95% CI 0.85–1.34, n = 1657). However, in trials that included patients with severe sepsis and septic shock, in high-quality and multicentre trials, and in trials with adequate allocation concealment, there was a trend toward increased risk of death in association with HES. Limitations: Data regarding adverse events, including renal outcomes, were not reported in the majority of published randomized trials. Considerable clinical and methodologic heterogeneity existed among trials. Conclusions: The use of HES for acute volume resuscitation of critically ill patients, and in particular those with severe sepsis and septic shock, appeared to be associated with increased use of renal replacement therapy. Further randomized controlled trials evaluating clinically important end points are required to examine the efficacy and safety of HES fluids for critically ill patients.

53 citations


Journal Article
TL;DR: Comparing the performance of primary care models in delivering health promotion and identified practice factors associated with its delivery may assist practice managers and policy-makers in modifying practice attributes to improve health promotion in primary care.
Abstract: Cigarette smoking, excessive use of alcohol, poor diet and lack of physical activity contribute to most of the leading causes of death and disability in Canada.1 Among Canadians 12 years of age and older, 23% smoke and 21% have alcohol-drinking patterns that can be described as risky.1Only 39% adhere to the recommendations concerning fruit and vegetable consumption and half lead a sedentary lifestyle; 59% of Canadian adults are obese or overweight.2 The economic burden of lifestyle-related health disorders is substantial. In 2002, $2.3 billion was spent in Canada on health care provision for alcohol-related problems alone.3 Nine percent of total health spending in the United States in 1998 was attributable to overweight and obesity.4 Health promotion is commonly defined as “the process of enabling individuals to take control over their health.”5 Improving the quality of health promotion and disease prevention has become a major focus of health care reform efforts internationally6-9 and is viewed as an important part of primary care.10 Clinical practice guidelines produced by the Canadian Task Force on Preventive Health Care recommend that primary care providers discuss healthy habits with their patients.11,12 However, a 1996 study reported that family physicians in Ontario, Canada, were dissatisfied with the extent to which they adhered to recommended guidelines for preventive care,13 and a related study performed on a subset of the same family physicians found significant deficits in the health promotion activities delivered to their patients.14 It is important that practice and organizational structures support the policy objectives of enhancing health promotion in primary care practices. In this article we compare the performance of primary care models of service delivery in Ontario in providing health promotion activities and determine what practice factors are associated with the delivery of health promotion. We evaluated 7 health promotion items derived from the recommendations of the Canadian Task Force on Preventive Health Care: healthy food, home safety, family conflict, exercise, smoking, alcohol consumption and fall prevention (for patients 65 years of age or older). The evaluation was designed to be congruent with a broad conceptual framework for primary care organizations15 and forms part of a larger study funded by the Ontario Ministry of Health and Long-Term Care’s Primary Health Care Transition Fund.

53 citations


Journal Article
TL;DR: The published results of some randomized controlled trials of dementia drugs may be inaccurate, invalid or invalid because of bias introduced through the inappropriate use of last-observation-carried-forward (LOCF) analyses.
Abstract: It is estimated that 24.3 million people worldwide suffer from dementia and that annual costs for Alzheimer’s disease are as high as $155 billion in the United States (1996 US dollars).1,2 One potential way to decrease the negative impact of dementia on people with this condition, on their families and on societies is to optimize the use of dementia medications,2 with due consideration of both their effectiveness and their toxicity. The effectiveness of most medications is tested via randomized controlled trials (RCTs). It is inevitable that some participants drop out of such studies before they are completed. Unfortunately, if analyses include only participants who remain in the trial, then study power is lost and erroneous conclusions may be generated. The principle of intention-to-treat (ITT) analysis, in which all patients are included in the analysis according to the group to which they were assigned at randomization, has become the accepted standard for the analysis of RCTs to try to counteract this problem.3 The strength of ITT analysis is that it not only preserves power but also promotes balance between treatment groups for both known and unknown confounders, thereby preserving the benefits of randomization. Ideally, all possible data are collected on all subjects, including those who drop out of the study; however, this is not always possible. In order for ITT approaches to analyze all patients randomly assigned to a group, several methods to impute missing data have been developed.3-10 Unfortunately, no statistical strategy can deal fully with all the different combinations of reasons for dropping out, dropout rates and different disease courses. At best, these techniques to impute missing data are educated estimates. One commonly employed technique to impute missing data is last-observation-carried-forward (LOCF), also known as end-point analysis. LOCF substitutes subjects’ missing outcomes with the last measurement taken before they dropped out. It requires that 2 basic assumptions be met: the subjects’ responses would have been constant from the last observed value (i.e., the point at which they dropped out) to the end point of the trial; and, missing values are missing completely at random (i.e., dropout is not related to variables such as drug side effects, group assignment, disease severity or symptoms).5-7 Authors have highlighted 3 factors that cause the second condition to be breached in a manner that introduces bias that will exaggerate the effectiveness of treatments as estimated by LOCF analyses; these include earlier dropouts or greater dropout rates in the treatment group and more rapid disease progression in subjects who drop out of the treatment group.3,4,9-11 These factors result in more subjects who drop out of the treatment group having their decline artificially frozen at an earlier stage of disease, thereby potentially biasing results in favour of the drug under study (i.e., overestimating effectiveness relative to the placebo). By extension, study results may also be biased against the drug under study (i.e., underestimating effectiveness) if there are earlier dropouts or greater dropout rates in the control group or if there are subjects whose disease progresses more rapidly among those who drop out of the control group (Figures ​(Figures11 and ​and22) Figure 1 Differential last observation carried forward (LOCF) bias when there are more or earlier dropouts in the treatment group than the control group. Figure 2 Differential last observation carried forward (LOCF) bias when there are more or earlier dropouts in the control group than in the treatment group. Since 1998, researchers have expressed concern that the use of LOCF in dementia drug trials contravenes the assumption of disease stability and the assumption of random missing data and hence risks generating biased results.2,11-21 To better understand the significance of these concerns in dementia research we systematically reviewed the use of ITT and LOCF analyses, contraindications to the use of LOCF analysis, and the use of non-ITT analyses in RCTs of drugs approved for the treatment of Alzheimer’s disease, vascular dementia, mixed dementia and mild cognitive impairment in Canada (i.e., cholinesterase inhibitors such as donepezil, rivastigmine and galantamine, and the N-methyl-D-aspartate (NMDA) receptor antagonist memantine).

52 citations


Journal Article
TL;DR: Although the quality of many original studies remains poor, at least within dermatology, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or better) diagnostic accuracy when compared with face-to-face consultations.
Abstract: Background: Asynchronous telehealth captures clinically important digital samples (e.g., still images, video, audio, text files) and relevant data in one location and subsequently transmits these files for interpretation at a remote site by health professionals without requiring the simultaneous presence of the patient involved and his or her health care provider. Its utility in the health care system, however, still remains poorly defined. We conducted this scoping review to determine the impact of asynchronous telehealth on health outcomes, process of care, access to health services, and health resources. Methods: A search was performed up to December 2006 of MEDLINE, CINAHL, HealthSTAR, the Database of Abstracts of Reviews of Effectiveness, and The Cochrane Library. Studies were included if they contained original data on the use of asynchronous telehealth and were published in English in a peer-reviewed journal. Two independent reviewers screened all articles and extracted data, reaching consensus on the articles and data identified. Data were extracted on general study characteristics, clinical domain, technology, setting, category of outcome, and results. Study quality (internal validity) was assessed using the Jadad scale for randomized controlled trials and the Downs and Black index for non-randomized studies. Summary data were categorized by medical specialty and presented qualitatively. Results: The scoping review included 52 original studies from 238 citations identified; of these 52, almost half focused on the use of telehealth in dermatology. Included studies were characterized by diverse designs, interventions, and outcomes. Only 16 studies were judged to be of high quality. Most studies showed beneficial effects in terms of diagnostic accuracy, wait times, referral management, and satisfaction with services. Evidence on the impact of asynchronous telehealth on resource use in dermatology suggests a reduction in the number of, or avoidance of, in-person visits. Reports from other clinical domains also described the avoidance of unnecessary transfer of patients. Conclusions: A significant portion of the asynchronous telehealth literature involves its use in dermatology. Although the quality of many original studies remains poor, at least within dermatology, there is consistent evidence suggesting that asynchronous telehealth could lead to shorter wait times, fewer unnecessary referrals, high levels of patient and provider satisfaction, and equivalent (or better) diagnostic accuracy when compared with face-to-face consultations. With the exception of a few studies in pediatric asthma, the impact of this intervention on individual health outcomes remains unknown.

45 citations


Journal Article
TL;DR: The approach to performing a comprehensive evaluation of primary care models in Ontario is detailed and may be a useful resource for researchers interested in primary care evaluation.
Abstract: Background: Many industrialized nations have initiated reforms in the organization and delivery of primary care. In Ontario, Canada, salaried and capitation models have been introduced in an attempt to address the deficiencies of the traditional fee-for-service model. The Ontario setting therefore provides an opportunity to compare these funding models within a region that is largely homogeneous with respect to other factors that influence care delivery. We sought to compare the performance of the models across a broad array of dimensions and to understand the underlying practice factors associated with superior performance. We report on the methodology grounding this work. Methods: Between 2004 and 2006 we conducted a cross-sectional mixed-methods study of the fee-for-service model, including family health groups, family health networks, community health centres and health service organizations. The study was guided by a conceptual framework for primary care organizations. Performance across a large number of primary care attributes was evaluated through surveys and chart abstractions. Nested case studies generated qualitative provider and patient data from 2 sites per model along with insights from key informants and policy-makers familiar with all models. Results: The study recruited 137 practices. We conducted 363 provider surveys and 5361 patient surveys, and we performed 4108 chart audits. We also conducted interviews with 40 family physicians, 6 nurse practitioners, 24 patients and 8 decision-makers. The practice recruitment rate was 45%; it was lowest in fee-for-service practices (23%) and in family health networks (37%). A comparison with all Ontario practices in these models using health administrative data demonstrated that our sample was adequately representative. The patient participation (82%) and survey scale completion (93%) rates were high. Conclusions: This article details our approach to performing a comprehensive evaluation of primary care models and may be a useful resource for researchers interested in primary care evaluation.

45 citations


Journal Article
TL;DR: Needle penetration did not confer a specific analgesic advantage over non-penetrating (placebo) needle application and no significant correlation was found between analgesic effect and de qi.
Abstract: Acupuncture has been increasingly accepted as an alternative medical therapy for pain management However, its efficacy has been controversial The strongest evidence has come from single-blind trials in which patients were masked but practitioners were not1,2 Some single-blind trials used placebo or sham needles,3-6 but they failed to meet the methodologic standards for blinding in current medical research7-10 The reason for this is that it cannot be excluded that participants may be biased toward unblinded practitioners7-15 Previously, no procedures or placebo needles were available to allow for a double-blind trial design9,10,15 We recently developed a non-penetrating placebo needle that can be used to blind both acupuncturist and patient16, 17 With this placebo needle, we conducted a double-blind study of the analgesic effect of acupuncture The aim was to determine whether the single, simple needle had specific analgesic effects over the non-penetrating placebo needle16-19 under double-blind conditions

Journal Article
TL;DR: The prevalence of HCV infection was elevated among Aboriginal young people living in Prince George and Vancouver who use drugs and Culturally based prevention, treatment and harm-reduction programs are urgently needed in this population.
Abstract: Background: We sought to estimate the prevalence and incidence of hepatitis C virus (HCV) infection among Aboriginal young people who use drugs and to identify risk factors associated with HCV infection in this population. Methods: The Cedar Project is a longitudinal study involving Aboriginal young people living in Vancouver and Prince George, British Columbia. Eligibility criteria include age from 14 to 30 years and self-reported use (smoking or injection) of illicit drugs (e.g., crystal methamphetamine, crack cocaine, heroin or other opiates, and cocaine) at least once in the month before enrolment. At each visit, participants completed a detailed questionnaire administered by an Aboriginal interviewer. For this analysis, we included information for 512 participants who were recruited between September 2003 and April 2005. Results: Among the 512 participants, the prevalence of HCV infection was 34.8% (95% confidence interval [CI] 30.6%– 38.9%); the rates were similar in Prince George and Vancouver (34.5% and 35.0% respectively, p = 0.37). Among those who reported the use of injection drugs at baseline (n = 286), the prevalence of HCV infection was 59.4% (95% CI 53.8%–65.1%); the rate in this group was slightly higher in Prince George than in Vancouver (62.4% v. 57.1% respectively, p = 0.37). The prevalence was 3.5% among participants who reported smoking drugs (n = 226). In the multivariate logistic regression analysis, factors significantly associated with HCV infection among participants who used injection drugs included daily injection of opiates (adjusted odds ratio [OR] 2.7, 95% CI 1.0–7.4), reuse of syringes (adjusted OR 2.4, 95% CI 1.3–4.4), having at least 1 parent who attended residential school (adjusted OR 1.9, 95% CI 1.1–3.4), female sex (adjusted OR 1.9, 95% CI 1.1–3.4) and duration of injection drug use (per year) (adjusted OR 1.4, 95% CI 1.3–1.5). The crude incidence rate of HCV infection was 10.6% and the incidence density estimate was 9.9 per 100 person-years in this cohort. Interpretation: The prevalence of HCV infection was elevated among Aboriginal young people living in Prince George and Vancouver who use drugs. Culturally based prevention, treatment and harm-reduction programs are urgently needed in this population.

Journal Article
TL;DR: Women who were diagnosed with invasive cervical cancer in the province of Manitoba, Canada, had fewer Pap tests but the same frequency of opportunities to be screened as matched controls and the need to educate women about cervical cancer screening and the importance of receiving Pap tests is reinforced.
Abstract: Although rates of cervical cancer are low in Canada, the incidence of the disease could be further reduced by the detection of precursor lesions and early-stage cancers in large populations of asymptomatic women through screening with the Papanicolaou (Pap) test,1 promoting Pap testing among women and physicians, and appropriately following up abnormal results.2 Despite the evidence that screening using a Pap test decreases the incidence of cervical cancer, and in spite of efforts to promote Pap testing, 1 in 4 women aged 18 to 69 who participated in Statistics Canada’s 1994–95 National Population Health Survey reported never having had a Pap test or not having a Pap test in the last 3 years.3 Several reasons have been identified in the literature as to why women do not obtain cervical cancer screening. Patient factors that influence screening include socioeconomic and demographic characteristics, andknowledge and attitudes about cervical cancer.1,4-9 The probability of being screened tends to increase with education and income, and is lower for non-Canadian born women, those who do not speak English and those who have negative beliefs about cancer.6,8,9 System and physician factors that influence screening include lack of regular health care, patients’ inability to access screening services, and missed opportunities to screen by health care providers.10 “Missed opportunities” are instances when a woman has contact with a health care provider but the provider does not perform or recommend the screening test when it would be appropriate to do so.10 Physician characteristics that have been associated with missed opportunities to provide preventive care such as a Pap test include type of specialty, education, physician gender and practice location.11-14 The objectives of this study were to examine the screening history of women diagnosed with invasive cervical cancer, to explore whether there were missed opportunities for screening and to investigate the influence of physician characteristics on Pap test utilization in the province of Manitoba.

Journal ArticleDOI
TL;DR: Plasma lipid peroxidation end product malondialdehyde (MDA) and total antioxidant capacity (TAC) in blood plasma were evaluated in patients with acute myocardial infarction treated by primary percutaneous coronary intervention (PCI), suggesting formation of reactive oxygen species.
Abstract: In the current study, we evaluated the dynamics of oxidative stress markers in patients with acute myocardial infarction (AMI) treated by primary percutaneous coronary intervention (PCI). Thirty consecutive patients with AMI with ST elevation were included. Plasma lipid peroxidation end product malondialdehyde (MDA) and total antioxidant capacity (TAC) in blood plasma were evaluated. Peripheral venous blood samples were obtained prior to reperfusion and at five time points after reperfusion. The control group consisted of 20 ischemic patients without acute coronary syndrome. TAC in the AMI group at admission was lower than in control patients (1.26 + 0.32 vs. 1.52 + 0.24 mmol/l). Within 1 h after reperfusion, in most cases, values significantly declined (1 min, 1.10 + 0.33 mmol/l; 1 h, 1.06 + 0.21 mmol/l [p= 0.03]). After 3 h, values began to increase (1.14 + 0.29 mmol/l) and returned to basal values after 3 d (1.29 + 0.24 mmol/l). MDA levels in AMI patients at admission were higher than in control patients (1.66 + 0.55 vs. 1.44 + 0.55 mmol/l) but showed a sustained decrease over the 3 h after reperfusion of the occluded artery (1 min, 1.57 + 0.37 mmol/l; 1 h, 1.50 + 0.35 μmol/l; 3 h, 1.35 + 0.59 μmol/l [p = 0.03]). Reperfusion of the occluded coronary artery by PCI in AMI lead to an immediate decrease in TAC, suggesting formation of reactive oxygen species. However, the MDA level significantly decreased after reperfusion. This may suggests less reperfusion injury after PCI.

Journal Article
TL;DR: The age of the data used in meta-analyses contained within systematic reviews of medical interventions was examined, and whether authors consider the age of these data in their interpretations was investigated.
Abstract: Background: Evidence for medical interventions sometimes derives from data that are no longer up to date. These data can influence the outcomes of meta-analyses, yet do not always reflect current clinical practice. We examined the age of the data used in meta-analyses contained within systematic reviews of medical interventions, and investigated whether authors consider the age of these data in their interpretations. Methods: From Issue 4, 2005, of the Cochrane Database of Systematic Reviews we randomly selected 10% of systematic reviews containing at least 1 meta-analysis. From this sample we extracted 1 meta-analysis per primary outcome. We calculated the number of years between the study’s publication and 2005 (the year that the systematic review was published), as well as the number of years between the study’s publication and the year of the literature search conducted in the study. We assessed whether authors discussed the implications of including less recent data, and, for systematic reviews containing meta-analyses of studies published before 1996, we calculated whether excluding the findings of those studies changed the significance of the outcomes. We repeated these calculations and assessments for 22 systematic reviews containing meta-analyses published in 6 high-impact general medical journals in 2005. Results: For 157 meta-analyses (n = 1149 trials) published in 2005, the median year of the most recent literature search was 2003 (interquartile range [IQR] 2002-04). Two-thirds of these meta-analyses (103/157, 66%) involved no trials published in the preceding 5 years (2001-05). Forty-seven meta-analyses (30%) included no trials published in the preceding 10 years (1996-2005). In another 16 (10%), the statistical significance of the outcomes would have been different had the studies been limited to those published between 1996 and 2005, although in some cases this change in significance would have been due to loss of power. Only 12 (8%) of the meta-analyses discussed the potential implications of including older studies. Among the 22 meta-analyses considered in high-impact general medical journals, 2 included no studies published in the 5 years prior to the reference year (2005), and 18 included at least 1 study published before 1996. Only 4 meta-analyses discussed the implications of including older studies. Interpretation: In most systematic reviews containing meta-analyses of evidence for health care interventions, very recent studies are rare. Researchers who conduct systematic reviews with meta-analyses, and clinicians who read the outcomes of these studies, should be made aware of the potential implications of including less recent data.

Journal Article
TL;DR: In some case series, about 20% to 40% of patients sustained an acute, prolonged, and profound drop in serum albumin after elective surgery as discussed by the authors, which can lead to delayed mobilization, inadequate vascular access and unnecessary doses of diuretics.
Abstract: Hypoalbuminemia is a common and vexing postoperative complication. In some case series, about 20% to 40% of patients sustained an acute, prolonged, and profound drop in serum albumin after elective surgery. 1 - 3 Acute hypoalbuminemia is sufficiently common in critical care as to be an established risk factor in the APACHE index. 4 Hypoalbuminemia can lead to delayed mobilization, inadequate vascular access and unnecessary doses of diuretics. Where does the albumin go?

Journal Article
TL;DR: The available evidence does not clearly differentiate between reference pricing and tiered formularies in terms of policy outcomes, and reference pricing appears to have a slight evidentiary advantage, given that patients’ health outcomes under tieredFormularies have not been well studied and that tieredformularies are associated with increased rates of medicine discontinuation.
Abstract: Objectives: To synthesize and contrast comparable quality evidence from published literature regarding the outcomes of tiered formularies or therapeutic reference pricing of prescription drugs. Data Sources: We searched the following electronic databases: ABI-Inform, CINAHL, Clinical Evidence, Digital Dissertations and Theses, EBM Reviews (ACP Journal Club, CENTRAL, CDSR, CMR, DARE, HTA, NHSEED), EconLit, EMBASE, International Pharmaceutical Abstracts, MEDLINE, NLM Gateway, PAIS International and PAIS Archive, and the Web of Science. Reference lists of relevant articles were also searched, as were several grey literature sources. Review Methods: We sought English-language studies published from 1986 to 2007 that examined drug plan enrolees in developed countries who were subject to the introduction of either therapeutic reference pricing or tiered formularies, reported on outcomes relevant to patient care and cost effectiveness, and employed quantitative study designs that included concurrent or historical comparison groups. Potentially appropriate articles were abstracted and assessed using a modified version of the Cochrane Effective Practice and Organisation of Care Group (EPOC) data abstraction form. Results: From an initial list of 2,964 citations, 12 studies were deemed eligible for inclusion in our review: 3 studies of reference pricing and 8 studies of tiered formularies. Reference pricing is associated with reduced plan spending, switching to preferred medicines, reduced overall drug utilization, and short-term increases in the use of physician services. Reference pricing (as implemented in British Columbia) is not associated with adverse health impacts. Tiered formularies are associated with reduced plan expenditures, increased patient costs, and increased rates of patient non-compliance. More research is required to examine the hypothesis that tiered formulary policies may result in increased use of physician services and potentially worse health outcomes Conclusion: The available evidence does not clearly differentiate reference pricing and tiered formularies in terms of policy outcomes. Reference pricing has a slight evidentiary advantage given that patient health outcomes under tiered formularies have not been well studies and that tiered formularies are associated with increased rates of medicine discontinuation.

Journal Article
TL;DR: Even in jurisdictions with universal health insurance, decision-makers should be aware that efforts to increase capacity may exacerbate disparities in access according to socioeconomic status, which underscores the need for simultaneous initiatives that strive to improve the appropriateness of health services utilization.
Abstract: Background: Ontario has recently made considerable investments to improve access to magnetic resonance imaging (MRI) services. We hypothesized that this has been associated with a widening of previously existing disparities in MRI utilization according to socioeconomic status. Methods: Analysis of all Ontario Health Insurance Plan claims for outpatient MRI scans performed between April 1, 2002 and March 31, 2007. Age- and sex-standardized rates of MRI utilization were determined using Statistics Canada population and income data. Results: Over the five-year period, the annual age- and sex-adjusted rate of MRI scanning increased from 1,511/100,000 to 2,976/100,000 (97% increase). In 2002, individuals living in neighbourhoods in the wealthiest quintile were 25% more likely to receive an MRI than individuals living in neighbourhoods in the poorest quintile (age- and sex-adjusted rates of MRI scanning of 1,702/100,000 versus 1,358/100,000). Despite this, the most marked increases in rates of MRI scanning in the subsequent five years were seen among those living in the highest income neighbourhoods (increases of 83%, 87%, 95%, 112% and 102% for the lowest to highest neighbourhood income quintiles, respectively), so that by 2007, those in the highest quintile neighbourhoods were 38% more likely to receive an MRI than those in the lowest quintile neighbourhoods. Conclusions: Even in jurisdictions with universal health insurance, decision-makers should be aware that efforts to increase capacity may exacerbate disparities in access according to socioeconomic status. This underscores the need for simultaneous initiatives that strive to improve the appropriateness of health services utilization.

Journal Article
TL;DR: Sequence analysis of the plasmodial cytochrome b gene confirmed a contribution of atovaquone resistance to treatment failure in severe Plasmodium falciparum malaria acquired by a non-immune traveller to the Indian subcontinent.
Abstract: We report the first case of atovaquone/proguanil treatment failure in severe Plasmodium falciparum malaria acquired by a non-immune traveller to the Indian subcontinent. Recrudescent infection was complicated by neurological involvement 14 days after directly observed therapy with atovaquone/proguanil. Sequence analysis of the plasmodial cytochrome b gene confirmed a contribution of atovaquone resistance to treatment failure. The recrudescent isolate had a single mutation at position 268 (Tyr268Cys). Video recordings illustrate dramatic but ephemeral manifestations of malaria with neurological involvement.

Journal Article
TL;DR: The first publication to be housed on the Open Medicine wiki is a scoping review of studies examining the use of asynchronous telehealth by Deshpande and colleagues, and it is important to acknowledge the guidelines and protocols that researchers have developed to improve the reporting quality of systematic reviews.
Abstract: This past month marked an exciting development at Open Medicine: the launch of the Open Medicine wiki. The first publication to be housed on the wiki is a scoping review of studies examining the use of asynchronous telehealth1 by Deshpande and colleagues. The interactive article allows users to log in and edit, delete or add content to the review and to look at changes other users have made to the document. Why are we using wiki technology as a publishing platform? Wikis enable a network of users to edit documents collaboratively and on an ongoing basis. This may be particularly relevant to scoping and systematic reviews, which, depending on their area of focus, can quickly become outdated as new studies are published.2 A wiki — a potentially revolutionary tool for knowledge transfer — makes it possible to keep reviews as current and relevant as possible. Just as knowledge evolves in medicine, a wiki evolves as new evidence emerges and is incorporated into it. Providing authors and readers with the means to update documents has rarely been done by biomedical publishers, despite some clear advantages. First, updates are publicly available as soon as they are incorporated into the wiki. Second, wikis create a centralized platform for easy editing. Third, they offer their own form of post-publication peer review in an open space where readers can see what changes have been made to a document and — if anonymous editing is prohibited — who made those changes; consequently, contentious points undergo close scrutiny and monitoring. It is important to note that as the authorship of the article expands to those contributing to the wiki, responsibility for the content expands as well. “Peers,” in this sense, are defined as those having adequate knowledge of an area to make responsible contributions. However, unlike three popular medical wikis — AskDrWiki, Ganfyd and Medpedia — Open Medicine will not limit contributions to qualified biomedical researchers, clinicians and experts. Contributors to the wiki may be patients who have undergone telehealth procedures, or health care practitioners who have used those procedures. Such contributions may lead to a re-evaluation of how credible research, objective reporting and intellectual rigour are defined. Keeping the Open Medicine wiki open to everyone is an experiment, and we watch with interest. Some medical wikis ask contributors to send copies of their qualifications, something that not everyone is prepared to do. We have decided not to verify the credentials of contributors, since this can be onerous and intrusive, and may limit user participation. The option of allowing anonymous editing on Open Medicine’s wiki files triggered debate within our editorial team. As an open access journal, we are committed to removing barriers to shared medical research, and there is no doubt that permitting anonymous editing on the wiki would increase participation levels. However, as we have noted, authorship and responsibility are linked, and although anonymous contributors do forego credit for their work, they are also abdicating their responsibility for content. Moreover, anonymity allows participants to bypass the declaration of competing interests that is essential to credibility and public trust. Ultimately, anonymous editing contravenes the guidelines on authorship, peer review and competing interests set by the International Committee of Medical Journal Editors and the World Association of Medical Editors.3,4 We therefore require all contributors to state their name and affiliation (if any) and to complete a statement of competing interests before they contribute to the Open Medicine wiki; this information will appear on the site. Having said this, we welcome your thoughts on whether, and how, anonymous editing can be safely incorporated in the future. It is important to acknowledge the guidelines and protocols that researchers have developed to improve the reporting quality of systematic reviews. Open Medicine endorses the new PRISMA Statement, as it did the previous QUOROM guidelines. It may be a challenge for a systematic review that is updated on a wiki to adhere to these protocols, and if it is, the usefulness of the review may be compromised. This new wiki provides an opportunity to clarify procedures around the use of wikis in medical publishing and to determine where boundaries should be set with respect to using social media and large-scale, open editing of medical research articles. We realize that establishing procedures that ensure accuracy, quality and safety is critical before any systematic reviews of therapies for disease states are placed on wikis that can be edited by any identified reader. We also recognize that the openness associated with a wiki makes it a controversial and even problematic platform.5 Moreover, some say that wikis should not be used for medical research because the highest standards of accuracy must be maintained to ensure human safety.6 However, we believe that by instituting appropriate guidelines on wiki use, public trust in medical research can be maintained and the body of scientific knowledge extended in new and exciting ways. As with all Open Medicine publications, the scoping review by Deshpande and colleagues underwent rigorous peer review and editing before publication. We have published and archived the baseline version so that subsequent iterations can be compared against it. This will allow us to identify how the wiki is used, and what impact this technology has on updating scoping and systematic reviews. We may publish future versions of the article in a traditional format when, or if, it becomes materially different from its original version. To protect against spam and dangerous fabrication, Deshpande and colleagues will monitor changes to the wiki. Unresolved disputes will be mediated by the Open Medicine editorial team and may involve consultation with peer reviewers. Our use of Web 2.0 tools at Open Medicine reflects our commitment to innovative medical publishing. As our use of open source software shows,7 we take seriously our mandate to push the boundaries of new technologies for publishing and knowledge generation. As such, we thank Deshpande and colleagues, and their study sponsors, the Canadian Agency for Drugs and Technology in Health, for the idea to create the wiki and their support in placing it online. We acknowledge the contributions of the People, Health Equity and Innovation Group at the Centre for Global eHealth Innovation at the University of Toronto and University Health Network, who participated in the study design and who are responsible for its evaluation. We invite authors of future systematic and scoping reviews to post their work online in a similar wiki format. And we invite you to join Open Medicine in exploring other ways we can improve or even change medical publishing: we are limited only by your ideas and willingness to share them.

Journal ArticleDOI
TL;DR: The study suggests that resistin concentrations was not associated with hsCRP levels, and whether or not there are correlations between CRP and resistin levels that have not previously been studied in PCOS in the context of resistin is clarified.
Abstract: Resistin has been associated with obesity and type 2 diabetes. The elevated serum resistin level in human diabetes is often associated with a pro-inflammatory milieu. In vitro data suggest that C-reactive protein (CRP) significantly increases resistin expression in cultured human PBMC, yet the relationship in vivo is largely unknown. The purpose of this study was to determine the concentrations of CRP and resistin in women with polycystic ovary syndrome (PCOS) and to clarify whether or not there are correlations between CRP and resistin levels that have not previously been studied in PCOS in the context of resistin. Serum resistin and hsCRP levels of forty-five women with PCOS were analyzed. Compared with the control group, women with PCOS had significantly higher serum concentrations of resistin (p=0.009). Women with PCOS had higher hsCRP levels compared with controls, but these differences were not statistically significant (p>0.05). There was no correlation between serum resistin and hsCRP levels (r=0.128, p=0.404). Our study suggests that resistin concentrations was not associated with hsCRP levels

Journal Article
TL;DR: In this paper, the authors examined the factors associated with the time to publication of Cochrane reviews and found that misrepresentation of the literature and subsequent inappropriate decisions may result when this happens.
Abstract: Background: Cochrane reviews are regarded as scientifically rigorous, yet a review’s time to publication can be affected by factors such as the statistical significance of the findings. When this happens, misrepresentation of the literature and subsequent inappropriate decisions may result. We aimed to examine the factors associated with the time to publication of Cochrane reviews.

Journal Article
TL;DR: An association between a lack of prescription drug coverage and reporting an unmet need for health care is suggested and warrants further investigation.
Abstract: Background: Despite Canada’s universal health insurance coverage, many Canadians still report an unmet need for health care. I investigated whether not having prescription drug insurance increases the likelihood of reporting an unmet need for health care. I hypothesized that people without prescription drug insurance would be more likely than those with insurance to report an unmet health care need. Methods: I included 31 630 people in Ontario 64 years of age or younger who had participated in the Canadian Community Health Survey Cycle 3.1. Multivariate logistic regression models were used to obtain an adjusted odds ratio (OR) for the association between having prescription drug insurance and reporting an unmet need for health care in the past 12 months, adjusting for age, sex, socio-economic status, health status and having a regular medical doctor. The reasons for reporting an unmet need for care were stratified into reasons related or not related to prescription drug insurance. Three separate multivariate logistic regressions were performed to obtain an adjusted OR for the association between prescription drug insurance and unmet need based on the reasons for reporting unmet need. Results: Not having prescription drug insurance that covers all or part of prescription medication costs increased the likelihood of reporting an unmet need for health care services (adjusted OR 1.27, 95% confidence interval [CI] 1.16–1.39). Not having such insurance significantly increased the likelihood of reporting an unmet need for health care for reasons that were related to prescription drug insurance (adjusted OR 2.21, 95% CI 1.80–2.71). This relation was not significant when the analysis was restricted to people who reported unmet need for health care for reasons that did not relate to prescription drug insurance (adjusted OR 1.12, 95% CI 1.00–1.23). Conclusions: These results suggest an association between a lack of prescription drug coverage and reporting an unmet need for health care. This association warrants further investigation.

Journal ArticleDOI
TL;DR: There was statistically significant reduction in blood loss and duration of surgery in patients who underwent preoperative embolization in the management of Shamblin type III carotid body tumours.
Abstract: Henoch The aim of the study was to evaluate the efficacy of preoperative embolization in the management of carotid body tumours. Of the 15 patients admitted to the Department of Vascular Surgery (General Surgery Unit II), Christian Medical College, Vellore, from January 1st 2002 to December 31st 2006 for management of carotid body tumours, 4 patients underwent preoperative embolization and were grouped together. Of the remaining 9 patients who underwent surgical excision, there were 5 with comparable tumour size and these were grouped together into the control group. Surgical outcome of both the groups were compared in terms of operating time, intraoperative blood loss, nerve injury, postoperative morbidity and mortality. There was statistically significant reduction in blood loss and duration of surgery in patients who underwent preoperative embolization. In conclusion, the preoperative embolization is effective in the management of Shamblin type III carotid body tumours.

Journal ArticleDOI
TL;DR: The acute antihypertensive effect of continuous positive airway pressure therapy for SAHS significantly reduced the episodes of apnea and hypopnea and the secondary component of hypertension caused by excessive sympathetic stimulation.
Abstract: Ambulatory blood pressure monitoring and parallel polysomnographic study were performed in 116 adult males divided into 6 groups. Thirty blood-pressure (BP) and polysomnographic variables were measured to test their usefulness for screening for both arterial hypertension and sleep apnea-hypopnea syndrome (SAHS). The development of severe breathing disorders and hypoxemia during sleep was attributed to SAHS, when compared with measurements in healthy controls and in patients with arterial hypertension. Such disorders manifested as an increased apnea-hypopnea index, apnea index, duration of arterial oxygen saturation of less than 85%, and decrease of average arterial oxygen saturation that correlated with nocturnal average diastolic BP (p=0.0049, p=0.0027, p=0.049 and p=0.0457, respectively). These respiratory disorders resulted in various nocturnal, rather than diurnal, and diastolic and systolic BP variables. The acute antihypertensive effect of continuous positive airway pressure therapy for SAHS significantly reduced the episodes of apnea and hypopnea and the secondary component of hypertension caused by excessive sympathetic stimulation. For the SAHS-induced, dose-dependent component of hypertension that responded to continuous positive airway pressure, the following variables, in decreasing significance, were useful: nocturnal average systolic and diastolic BP and 24-hour average systolic and diastolic BP, as well as percent time elevation and mean blood pressure load. The monitoring of these variables could contribute to early diagnostic and prognostic stratification of complications and adequate therapy of the secondary component of hypertension caused by SAHS.

Journal ArticleDOI
TL;DR: A case report and review of current literature as to the best management of Adenocarcinomas of Ileal Duplication Cysts.
Abstract: Adenocarcinomas of Ileal Duplication Cysts are an extremely rare occurrence, this is a case report and review of current literature as to the best management of this condition.

Journal ArticleDOI
TL;DR: It appears that with routine screening for diabetic predisposition and effective control of gestational diabetes the risk of fetal damage can be reduced substantially, and universal screening and rigid diabetic control are effective measures for the prevention of excessive fetal growth and intrapartum complications deriving from it.
Abstract: The study explores the roles of routine prenatal diabetic screening and control in the occurrence of neurological birth injuries associated with shoulder dystocia. The investigation involved retrospective review of 226 medical records that contained information about the antenatal events in cases that resulted in permanent neonatal injuries following arrest of the shoulders at delivery. Close attention was paid to diabetic screening and management of mothers with evidence of glucose intolerance. Analysis of the records revealed that one-third of all women, including those with predisposing factors, received no diabetic screening during pregnancy. The majority of confirmed diabetic patients were not treated adequately. Among babies of diabetic women, birth weights exceeding 4500 g were about 30-fold more frequent than among those with normal glucose tolerance. The data suggest that universal screening and rigid diabetic control, including mothers with borderline glucose tolerance, are effective measures for the prevention of excessive fetal growth and intrapartum complications deriving from it. If ignored, impaired maternal glucose tolerance may become a major predisposing factor for neurological birth injuries. It appears therefore that with routine screening for diabetic predisposition and effective control of gestational diabetes the risk of fetal damage can be reduced substantially.

Journal Article
TL;DR: Improving the working conditions in source countries would help counter the factors that push health professionals to seek better conditions elsewhere and make work healthier for those who remain, and thereby reduce work absenteeism and exposure to biological, chemical and physical hazards.
Abstract: Health care systems worldwide continue to be plagued by difficulties in recruiting and retaining health workers, resulting in a shortage of health human resources that is now considered a global crisis.1,2 However, although the gap between the need for health care workers and the supply is experienced globally, it widens disproportionately, so that the regions with the greatest need have the fewest workers: sub-Saharan Africa and southeast Asia together have 53% of the global disease burden but only 15% of the world’s health care workforce.3 Moreover, the shortage experienced by countries that can least afford it is exacerbated by health worker migration to high-income countries. South Africa, for example, has fewer than 7 doctors per 10 000 people, but reported in 2002 that 14% of the physicians who had trained there had emigrated to the US or to Canada.4 And the problem is not going away:5 in the UK, US, Canada and Australia, 23% to 28% of all physicians are international graduates.6 Efforts to reduce migration usually focus on reducing recruitment by high-income countries, and these efforts are gaining a higher profile.7,8 Improving the working conditions in source countries has not received the same attention, however, even though this would help counter the factors that push health professionals to seek better conditions elsewhere. It would also make work healthier for those who remain, and thereby reduce work absenteeism, as well as occupational concerns such as injuries, violence and stress, and exposure to biological, chemical and physical hazards. Although concerns about healthy work conditions exist to varying degrees around the world, they are greatest in nations with few resources, and particularly in Africa,9 where work conditions are the most challenging. It is well documented that health workers in low- and middle-income countries experience fear and frustration when caring for patients with tuberculosis and blood-borne diseases, and that they do so often in difficult work environments10 and under the ever-present stigma associated with exposure.11 It is now also well established that health workers are indeed at higher risk of acquiring numerous infectious diseases.12,13

Journal Article
Kumar Hn H, Jayaram S, Rao Mr, Kumar S Sg, Kotian M 
TL;DR: Since the first report of human immunodeficiency virus (HIV) infection in South India in 1986, HIV prevalence in India has steadily increased, and prevalence estimates for India have been controversial.
Abstract: Since the first report of human immunodeficiency virus (HIV) infection in South India in 1986, HIV prevalence in India has steadily increased. The current estimates of the National AIDS Control Organisation (NACO) of the Government of India suggest that national adult HIV prevalence in India is approximately 0.36%, amounting to between 2 and 3.1 million people. If an average figure is taken, this comes to 2.5 million people living with HIV and AIDS, almost 50% of the previous estimate of 5.2 million.1 Although prevalence estimates for India have been controversial,2 control of HIV infection in India indisputably remains an important goal.

Journal ArticleDOI
TL;DR: The study conducted in order to estimate uric acid levels in patients with metabolic syndrome and coexisting cardiovascular system diseases found significant correlation between serum uric level and the CAD presence and severity of coronary atherosclerosis confirmed by coronary angiography.
Abstract: The association of elevated serum uric acid (hyperuricemia, gout) with the presence of classical coronary risk factors and coronary artery disease (CAD) or myocardial infarction (MI) has been analysed in many epidemiological studies. Numerous studies have revealed that hypertension, high body mass index (BMI), lipid disorders (especially raised triglyceride (TG) levels and low high dense lipoprotein cholesterol (HDL-C) level), and increased creatinine or insulin levels have caused hyperuricemia. Gout has often occurred with typical disorders for the metabolic syndrome X. Significant correlation of the serum uric level and the CAD presence and severity of coronary atherosclerosis confirmed by coronary angiography has been observed in women. Hyperuricemia has also indirect influence on progress of CAD by physical activity restriction, what causes sedentary mode of life and lead to obesity. Therefore, we conducted our study in order to estimate uric acid levels in patients with metabolic syndrome and coexisting cardiovascular system diseases.