Patient and Physician Perceptions of Changes in Surgical Care in Mongolia 9 Years After Roll-out of a National Training Program for Laparoscopy.

INTRODUCTION: In 2005, the general population of Mongolia was not aware of laparoscopic surgery and was skeptical about the safety of surgical care. A 9-year initiative to expand laparoscopic surgery was initiated by Mongolian surgeons. This study examines the current barriers to and perceptions of surgical care following laparoscopic surgical expansion countrywide. MATERIALS AND METHODS: In September 2013, interviews were conducted with 71 patients, and 39 physicians in Mongolia. Patients and physicians were interviewed using separate sets of interview questions. Questions were designed to gauge perceptions of surgical care in Mongolia evaluating for access, affordability, sustainability, barriers to care, quality, and knowledge of laparoscopy. Responses were fine coded for statistical analysis. RESULTS: 79 % of patients felt surgical care was improving in Mongolia, and 76 % would choose laparoscopy if available. Physicians (100 %) felt laparoscopic surgery had improved surgical care in Mongolia. Barriers to care for patients were time to work up and diagnosis (37 %), and funding an operation (39 %). None of the 36 % of patients who stated funding an operation would be difficult identified government sources of funding (p < 0.001). Physicians identified insufficient equipment supply (69 %), insufficient training (41 %), and cost (38 %) as barriers for laparoscopy. 74 % of physicians felt that Mongolian physicians return or stay in Mongolia after training, defying the trend of migration in low-resource settings. DISCUSSION: Improved local patient and physician perception of laparoscopy is propelling the expansion of laparoscopy in Mongolia.

Impact of anti-HER2 therapy on overall survival in HER2-overexpressing breast cancer patients with brain metastases.

BACKGROUND: Trastuzumab-based therapy after diagnosis of brain metastases (BM) may improve survival due to prolonged systemic disease control. We investigated whether lapatinib may yield additional survival benefit. METHODS: Eighty patients with BM from HER2-positive breast cancer were identified. Karnofsky Performance Score (KPS) of at least 70 was required. We included a control group of 37 patients treated before 2003, when continuation of trastuzumab after diagnosis of BM was not yet recommended. Remainders received either trastuzumab or lapatinib and trastuzumab (either concomitantly or sequentially) with or without chemotherapy. RESULTS: Median overall survival (OS) in patients receiving trastuzumab after diagnosis of BM was 13 months; corresponding numbers were 9 months in patients treated with chemotherapy, and 3 months with radiotherapy alone. Median OS was not reached in the lapatinib group. Addition of lapatinib prolonged OS over trastuzumab alone (P=0.002). After correction for potential confounders, lapatinib therapy remained an independent positive predictor for survival (HR 0.279; P=0.012). INTERPRETATION: This retrospective single-centre study suggests that the introduction of lapatinib improved survival in patients with BM from HER2-positive breast cancer. Patients with KPS ≥70 may benefit when treated with lapatinib in addition to trastuzumab after completion of local therapy.

Genetic linkage in Pseudomonas aeruginosa of algT and nadB: mutation in nadB does not affect NAD biosynthesis or alginate production.

The 68-min region of the chromosome of Pseudomonas aeruginosa (Pa) contains the gene algT, encoding a putative alternate sigma factor similar to sigma E in Escherichia coli, that is required for the expression of several genes in the alginate biosynthetic regulon. Sequences immediately upstream from algT were found to contain a divergently expressed open reading frame encoding a 60-kDa protein with 64 and 36% identity to the nadB gene products of E. coli and Bacillus subtilis, respectively. The nadB gene encodes L-aspartate oxidase and has been shown in several bacteria to be essential for de novo nicotinamide-adenine dinucleotide (NAD) biosynthesis. Pa nadB complemented the growth requirement for nicotinic acid in a nadB mutant strain of E. coli, suggesting that this gene encodes a functional homologue of L-aspartate oxidase. A nadB::Tn501 mutant was constructed by gene replacement in the alginate-producing strain, Pa FRD. This NadB- mutant still produced alginate and appeared normal with respect to the regulation of alginate synthesis. Interestingly, the NadB- mutant did not have an auxotrophic phenotype for nicotinic acid, indicating that this nadB was not essential for NAD biosynthesis in Pa. These results suggest the possibility that Pa has an alternate mechanism for de novo NAD biosynthesis.

Molecular cloning and expression of a prostaglandin E2 receptor of the EP3 beta subtype from rat hepatocytes.

Rat hepatocytes have previously been reported to possess prostaglandin E2 receptors of the EP3-type (EP3-receptors) that inhibit glucagon-stimulated glycogenolysis by decreasing cAMP. Here, the isolation of a functional EP3 beta receptor cDNA clone from a rat hepatocyte cDNA library is reported. This clone can be translated into a 362-amino-acid protein, that displays over 95% homology to the EP3 beta receptor from mouse mastocytoma. The amino- and carboxy-terminal region of the protein are least conserved. Transiently transfected HEK 293 cells expressed a single binding site for PGE2 with an apparent Kd of 15 nM. PGE2 > PGF2 alpha > PGD2 competed for [3H]PGE2 binding sites as did the EP3 receptor agonists M&B 28767 = sulprostone > misoprostol but not the EP1 receptor antagonist SC 19220. In stably transfected CHO cells M&B 28767 > sulprostone = PGE2 > misoprostol > PGF2 alpha inhibited the forskolin-elicited cAMP formation. Thus, the characteristics of the EP3 beta receptor of rat hepatocytes closely resemble those of the EP3 beta receptor of mouse mastocytoma.

Hypertension management: the computer as a participant.

A computerized system called ARTEMIS has been taking part in the management of a referral hypertension clinic since September 1975. From January 1, 1976 to January 1, 1979, 3,624 patients' records were set up and updated, all of them accessible on line. The mean rate of response to 17 questions with obligatory answers concerning patients' past history was 97.6 per cent. The 10 routine laboratory tests included in the initial in-hospital work-up were registered in over 92 per 100 of the 2,651 hospital records examined. Negative responses were registered with the same accuracy as positive ones, when the computerized questionnaires were appropriately drafted. Standardized collection of information insured homogeneity of the medical staff and has already made possible epidemiologic studies. ARTEMIS has detected strategical errors such as the lack of yearly programmed tests for cardiovascular risk-factors associated with hypertension. The computer has helped to achieve a high rate of patient compliance at one year (81.3 per cent), by providing patients up-dated editions of their personal summary reports as well as sending periodical letters of recall to them and to their physicians. At a total annual cost of 11 dollars per patient, the computer provides continuous information on process and outcome, for each patient and physician, and for the entire population followed up at the clinic. It facilitates physician adherence to predefined protocols and reinforces follow-up continuity by creating a communications network between the referral clinic, the patient and the general practitioner.

Efficacy and tolerance of spironolactone in essential hypertension.

The long-term efficacy and tolerance of spironolactone in essential hypertension was evaluated among 20,812 patients referred to the Broussais and St. Joseph systemic hypertension clinics between 1976 and 1985 by using information prospectively collected in the computerized ARTEMIS data bank. In 182 patients (51 men, 131 women) treated with spironolactone alone during a mean follow-up period of 23 months, a mean dose of 96.5 mg decreased systolic and diastolic blood pressure (BP) by 18 and 10 mm Hg, respectively, below pretherapeutic levels. The BP decrease was greater with doses of 75 to 100 mg (12.4% and 12.2%) than with doses of 25 to 50 mg (5.3 and 6.5%, p less than 0.001), but no additional decrease was found with doses above 150 mg. Plasma creatinine level increased modestly (8.3 mumol/liters), as did plasma potassium level (0.6 mmol/liters) (both p less than 0.001); uric acid level increased, but not significantly (10.5 mumol/liter). Fasting blood glucose and total cholesterol levels did not change, triglyceride levels increased slightly (0.1 mmol/liter, p less than 0.05). These changes were similar in both sexes and were not influenced by length of follow-up. Among the 699 men prescribed spironolactone alone or in association with another antihypertensive treatment, 91 cases of gynecomastia developed (13%). Gynecomastia was reversible and dose-related; at doses of 50 mg or less the incidence was 6.9%, but 52.2% for doses of 150 mg or higher. Despite limitations inherent in the interpretation of data banks, it is concluded that spironolactone administered in daily practice reduced BP without inducing adverse metabolic adverse effects and that in patients with essential hypertension, doses should be kept below 100 mg.

Computer-assisted techniques for evaluation and treatment of hypertensive patients.

An integrated approach, progressively implemented in the ARTEMIS system since 1975, is described for the computerized management of hypertensive patients. From a medical point of view, computerized programs can be used to memorize patients' individual records and profiles, to facilitate patient management and follow-up, to store medical knowledge about hypertension and to provide facilities for decision making at the level either of the individual patient or of the population followed up. From a technical point of view, the methodology used integrates data and knowledge management facilities into the same software. Five hypertension clinics are presently using the system in France and more than 22,000 records have been registered. Answer rates to 12 mandatory questions regarding past history and examination at first visit were superior to 95% in 19,601 records created between January 1976 and December 1987. Patient database interrogation can be used to evaluate the sensitivity and specificity of various signs and symptoms for the diagnosis of secondary hypertension, and to predict, for each patient, his/her cardiovascular risk, the risk of drop-out, the risk of insufficient blood pressure control and the probable blood pressure level. It also serves to test the content and validity of the associated expert system which is progressively built up. A prospective evaluation of the performance of the expert system on 80 cases of hypertension showed overall agreement between the specialists and the expert system ranging from 58 to 91% depending on the decision.(ABSTRACT TRUNCATED AT 250 WORDS)

An unusual case of urinary incontinence, ataxia-telangiectasia, and metastatic dysgerminoma: case report and review of the literature.

Ataxia-telangiectasia (A-T) is a rare autosomal recessive disease notable for neurodegeneration, chromosomal instability, and a predisposition to cancer. It presents in childhood with a variable phenotype. We report the first case of an A-T related tumor presenting as urinary incontinence, and the first case of 2-year survival in an A-T patient with metastatic dysgerminoma.

Reduction of paraphimosis with hyaluronidase.

The use of hyaluronidase facilitates reduction of paraphimosis. It acts by dispersing extracellular edema, permitting easy reduction of the foreskin. Its use is applicable both in the hospital and outpatient setting. Hyaluronidase is widely available and keeps well if refrigerated. It is effective for children and adults.

Maturation of resistance to lead encephalopathy: cellular and subcellular mechanisms.

The rat pup fed inorganic lead has been studied extensively as an animal model of human lead encephalopathy. As in man, the sensitivity of the brain to lead toxicity is age-dependent. Pups given daily lead feedings for one week beginning in the first week of life show pathologic changes (i.e., hemorrhage, edema, and neuronal necrosis) throughout the brain including the cerebral cortex and cerebellum. Pups begun on daily lead feedings for two weeks between 10-18 days of age show similar pathologic changes almost entirely confined to the cerebellum. Pups receiving very large quantities of lead for two weeks beginning at 20 or 24 days of age develop only minimal edema or no changes by light microscopy. We have proposed that the effects of lead on cellular aerobic energy metabolism are important in the pathogenesis of the encephalopathy in the developing brain. Early in the course of lead feedings begun at 14 days of age, isolated cerebellar mitochondria show a loss of respiratory control. During the second week of lead feedings, respiration with NAD-linked substrates is inhibited in cerebellar mitochondria, but not in cerebral mitochondria, from these animals. Cerebral mitochondrial respiration in pups fed lead from birth also is inhibited while both cerebral and cerebellar mitochondrial respiration in lead-fed adults is not affected. Isolated brain mitochondria exposed to lead in vitro show similar changes; an initial respiratory stimulation (probably reflecting an energy-coupled uptake of lead) and a secondary inhibition of dehydrogenases located in the mitochondrial matrix. Lead also may compete with calcium for brain mitochondrial carrier or binding sites. During maturation, the brain appears to become resistant to lead toxicity by sequestering lead away from the mitochondrial site of action. This hypothesis is based upon the observations that: 1. the in vitro effects of lead are the same in immature and mature cerebellar mitochondria; 2. the cerebral and cerebellar lead concentrations are the same in immature encephalopathic and mature encephalopathy-resistant lead-fed animals and; 3. cerebellar mitochondria from animals fed lead from 14 days of age contain much more lead than cerebral mitochondria from these animals and cerebellar mitochondria from lead-fed adults. This hypothesis is supported further by the results of recent electron microscopic and elemental microprobe studies of lead distribution in the brains of animals fed lead beginning at 14-18 days of age.(ABSTRACT TRUNCATED AT 400 WORDS)

Preparation and antimicrobial assessment of 2-thioether-linked quinolonyl-carbapenems.

This reports the synthesis and in vitro antimicrobial properties of a series of 2-thioether-linked quinolonyl-carbapenems. Although the title compounds exhibited broad spectrum activity, the MICs were generally higher than those observed for selected benchmark carbapenems, quinolonyl-penems, and quinolones. Enzyme assays suggested that the title compounds are potent inhibitors of penicillin binding proteins and inefficient inhibitors of bacterial DNA-gyrase. Uptake studies indicated that the new compounds are not substrates for the norA encoded quinolone efflux pump.

Computerized patient management in a nephrology department.

An integrated approach is described for the computerized management of a nephrology department. On a medical point of view, the system comprises a minimum medical record for every patient, different specialized records and knowledge bases presently covering hypertension, diabetes and chronic renal failure. From a technical point of view, the methodology used integrates data and knowledge management techniques. Various individual reports facilitate patient management. For hypertensive patients, an expert system is combined with the record system. The results of a preliminary evaluation are reported and future developments considered.

[Critical evaluation of the functional signs of arterial hypertension]. / Evaluation critique des signes fonctionnels dans l'hypertension artérielle.

Influence of blood pressure levels on the prevalence of symptoms was studied in a group of 1771 untreated hypertensive patients referred to the Saint-Joseph Hypertension Clinic in Paris. Information on symptoms was obtained from a standardized physician-conducted interview during the patient's first visit at the Outpatient Clinic. The most frequent symptoms were headaches (40.5 p. 100), palpitations (28.5 p. 100), nocturia (20.4 p. 100) and dizziness (20.8 p. 100). Except for nocturia, symptom prevalence was higher in females than males. In males as well as in females, no correlation was found between blood pressure level and the presence of headaches, dizziness and palpitations when results were adjusted for age. In contrast, the relationship between two behavioural characteristics, anxiety and lack of regular physical activity, and symptom prevalence was more pronounced than the relationship with the blood pressure level itself. Moreover symptom prevalence differed significantly between the five permanent physicians of the Clinic; comparison of results obtained by physician conducted interview and self administered questionnaire indicated that difference between physicians were not due to difference in patient's characteristics but to differences in physician behaviour.

[Comparison of ambulatory blood pressure determinations using the Remler and Spacelabs devices]. / Comparaison des mesures tensionnelles ambulatoires des appareils Remler et Spacelabs.

Ambulatory blood pressure recorded with the Spacelabs was compared with both Remler recordings and office blood pressures in 11 normotensive and 13 hypertensive volunteers. Analysis of 324 simultaneous measurements with Remler and Spacelabs showed very high correlation for systolic and for diastolic blood pressure. For systolic blood pressure, measurements with Spacelabs recorder were lower than those with the Remler recorder by a mean of 3.6 +/- 6.5 mmHg, principally in hypertensive subjects. Spacelabs measurements were also lower than Remler measurements for diastolic blood pressure by a mean of 5.3 +/- 6.6 mmHg principally in normotensive subjects. The averages of blood pressure variability (standard deviation as index) recorded by each device were identical. Mean systolic and diastolic blood pressure differed by more than 10 and 5 mmHg respectively between the two devices in 11 and 83% of the subjects. These individual discrepancies were unpredictable. Comparison of Spacelabs records with office blood pressure measured with a standard mercury manometer showed discrepancies of more than 10 mmHg for systolic blood pressure and more than 5 mmHg for diastolic blood pressure in 46 and 42% of the 24 subjects, respectively. These discrepancies could be due, in part, to different methods of blood pressure measurements. These data demonstrate that the Spacelabs apparatus provides records for a group, reasonably close to those obtained with the Remler over a wide range of blood pressure. For the management of hypertension, the advantages--as compared to physician's measurements--of ambulatory blood pressures recorded with indirect methods,need to be weighed, taking into consideration the difference between the ambulatory record and the office blood pressure measured with the same device.

[Alcohol consumption and treatment of hypertension. Results of an occupational medicine survey]. / Consommation d'alcool et traitement de l'hypertension artérielle. Résultats d'une enquête en médecine du travail.

The results of a cross-sectional study were analysed in order to assess the therapeutic control of hypertension in relation to alcohol consumption. 6,665 subjects, employed in small and medium-sized companies of the Paris region were examined in a cross sectionnal study. Among the 1,008 hypertensive subjects, awareness of hypertension decreased with increasing alcohol consumption, from 72% among the 304 non-drinkers to 59% among the 201 heavy drinkers (six glasses/day and more) (p less than 0.05). Similarly, the percentage of subjects under current antihypertensive medication on the day of examination was lower in heavy drinkers, 19%, than among tetotalers, 42% (p less than 0.001). An antihypertensive treatment had been prescribed to 510 subjects. Among them, compliance, as stated by the interview, decreased with increasing alcohol consumption, from 70% to 34% (p less than 0.001). Using a logistic regression, the adjusted relative risk of non-compliance among heavy drinkers (6 glasses/day or more) was found to be 1.9. Among the 344 subjects under antihypertensive treatment on the day of examination, systolic and diastolic blood pressure were higher among heavy drinkers, 167/102 mmHg, than among teetotallers, 154/95 mmHg (p less than 0.01 both). The relative hypertension awareness, treatment and control status was thus poorer among, moderate and heavy drinkers than among the light and non-drinkers (table I). (Table: see text). The importance of the problem of alcoholism is thus emphasized, in both the fields of hypertension prevalence and control.

[Predictive factors of resistance to antihypertensive treatment]. / Facteurs prédictifs de la résistance au traitement antihypertenseur.

Results of antihypertensive treatment were analyzed in a group of 5,209 hypertensive patients referred in two hypertension Clinics in Paris from 1976 to 1985. Patients were included in the study if they fulfilled the following criteria: 1) at least four visits in the clinic, 2) follow-up period greater than 6 months, 3) initial diastolic blood pressure greater than or equal to 90 mmHg and/or presence of an antihypertensive treatment. After a mean follow-up period of 43 months, blood pressure was reduced from 177/105 mmHg to 148/89 mmHg. However, in spite of at least two antihypertensive drugs, 16.7 p. 100 of these patients had a diastolic blood pressure above 95 mmHg at the end of the follow-up period and were defined as uncontrolled hypertensives (UH). By comparison with controlled hypertensives (CH), UH patients were more frequently males (67.9 vs 56.6 p. 100, p less than 0.001), had a greater known duration of hypertension (11.6 vs 8.7 years, p less than 0.001), and presented at the first visit with higher blood pressures (188/113 vs 174/103 mmHg, p less than 0.001/p less than 0.001), despite a higher rate of antihypertensive treatment (66.6 vs 53.8 p. cent, p less than 0.001), a higher ponderal index (26.3 vs 25.3/kg/m2, p less than 0.01) and a higher prevalence of end-organ damage (23.2 vs 16.3 p. 100, p less than 0.001). Sokolov index, serum creatinine and uric acid levels were higher among UH than among CH patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Testing an expert system for hypertension]. / Expérimentation d'un système expert en hypertension artérielle.

An Expert System (ES) has been connected to a database management system for the management and follow-up of hypertensive patients. The patient data base, called Artemis, contains approximately 18,000 medical records. About 90% of the initial informations used by the ES is contained in the medical records of the Artemis data base. The knowledge base consists of 870 rules. A first group of rules allows the description of knowledge structures (hierachies, graphs and mutual exclusions). The second group consists of production rules which describe the dynamic reasoning of the expert. The inference engine uses a combination of forward and backward chaining. The ES produce diagnostic hypotheses (possible causes of hypertension) and therapeutic suggestions before and after requiring additional information (patient supplementary interrogation, biological or radiological investigations). The evaluation of the diagnostic performance of the ES was made on 40 confirmed cases of secondary hypertension (SH) and 40 cases of essential hypertension (EH). The initial initial diagnosis, just after the forward chaining step, was correct in 17 cases of SH and 32 cases of EH. The final diagnosis proposed after several steps of forward and backward chaining was correct in 37 cases (92%) of SH and 36 (90%) of EH. Averages of 5 (EH) and 8 (SH) questions were formulated by the ES to reach the final diagnosis. The integration of the ES to the database is expected to facilitate the validation of the knowledge base and to enhance its overall acceptability. Whether or not such an integration will be useful and accepted as a complementary tool by physicians remains however an open question.

[Decentralization of the ARTEMIS system in a nephrology service in a general hospital]. / Expérience de dècentralisation du système "ARTEMIS" dans un service de néphrologie en hôpital général.

"ARTEMIS" is a standardized and computerized medical file which is intended for improving the follow-up of hypertensive patients, the efficacy of treatment and for realising national-wide surveys. The software "LIED" of data base for "ARTEMIS" is nowadays transposable on mini-computer. In Nephrology Unit of General Hospital from Colmar, the system has been working since September 1985 with MICRO-MEGA E 32 (Thomson). The administrative and medical data are directly acquired by the doctors and secretaries of the Unit on a conversational mode from six terminals. There is no writing collecting of data. An evaluation of the system was realized with the 113 first hypertensive patients. The results were compared to those obtained from patients of Paris area.

[Effect of socio-occupational category on iterative hemodialysis treatment of advanced chronic renal insufficiency. Results of the DIAPHANE computerized Dialysis Registry cooperative program]. / Influence de la catégorie socio-professionnelle sur le traitement par hémodialyse itérative de l'insuffisance rénale chronique avancée. Résultats du programme coopératif DIAPHANE Dialyse Informatique.

The hypothesis that inequalities may be observed between patients of different socio-professional categories (S.P.C.) was assessed in a group of 1267 men treated by chronic haemodialysis (C.H.) in 34 dialysis centers throughout France and followed up in the computerized DIAPHANE Dialysis Registry. The percentages of manual workers and farmers were found lower than those calculated on the whole active french population. In contrast, the percentages of senior executives and patient with liberal professions were higher. Primary renal disease was detected sooner in patient of the higher S.P.C. than in other groups. Patients of the higher S.P.C. were more frequently treated in university or in private hospitals than in general hospitals. They were more likely on evening or night dialysis schedules than on daylight schedules; they more frequently received hypotensive drugs, vitamin D, calcium, iron, prescriptions of blood transfusions than patients of the lower categories. Survival rates were not correlated with the S.P.C., but the rehabilitation rate, expressed as the percentage of part or full time employments, was greater in patients of the higher S.P.C. Results indicate that, in patients treated by chronic haemodialysis, inequalities in favor of the patients of the higher socio-economic categories are observed and that these inequalities concern both the access and the delivery of care.

[Treatment of arterial hypertension. Comparative effectiveness of the day care hospital and classical hospitalization]. / Traitement de l'hypertension artérielle. Efficacité comparée de l'hôpital de jour et de l'hospitalisation classique.

Four years of activity in the one-day hospital (ODH) and the several-day hospital care (SHC) of the Hypertension Clinic at the Hôpital Saint-Joseph, Paris, were evaluated and compared. All data were recorded using the computerized Artemis system. Evaluation was performed by means of two prospective studies: a controlled trial of 121 patients randomized to either ODH or SHC, and a prospective follow-up study of 633 patients. Criteria for admission to the controlled study were: diastolic BP between 95 and 120 mmHg, age between 30 and 65 years, no anti-hypertensive treatment at first visit, no major cardiovascular or renal complication and no suspicion of secondary hypertension. Similar criteria applied to the uncontrolled study. The results, assessed after 2 years, were the same in both studies, with a drop-out rate of about 15%, a mean diastolic BP lower than 95 mmHg in 80% of the patients and a bodyweight reduction of about 1 kg in obese patients. The percentage of smokers who stopped cigarette smoking was higher in the SHC groups than in the ODH groups. It is concluded that the ODH system is effective in the initial management of hypertensive patients but that greater educational efforts are needed to effectively reduce cigarette smoking in OHD patients and bodyweight excess in both OHD and SHC patients.