YouTube as a source of patient information for transrectal ultrasound-guided biopsy of the prostate.

AIM: To assess the quality of YouTube videos explaining transrectal ultrasound (TRUS)-guided biopsies of the prostate. MATERIALS AND METHODS: A search of YouTube was made for the terms "TRUS", "TRUS biopsy", "transrectal ultrasound", and "prostate biopsy". Videos were selected from the first 10 pages of results and reviewed by three authors against criteria based on written information from the British Association of Urological Surgeons. They were given a qualitative rating based on how well they provided information on factors such as preparation for the procedure, mechanism of the procedure and possible side effects. Data were also collected on view count, country of origin, likes, and dislikes. RESULTS: A total of 41 videos were reviewed, with no videos achieving an "excellent" rating, 32 being rated as "very poor", and only one rated as "good". Despite the poor-quality information, 39 of the videos were from healthcare organisations or individual surgeons. Videos often lacked specific information, or were targeted at healthcare professionals instead of patients. CONCLUSION: The information about TRUS-guided prostate biopsies on YouTube was not of a sufficiently high standard to allow patients to make informed decisions. Healthcare professionals hence have a duty to point patients towards adequate sources of reputable information online. Furthermore, there remains an opportunity to produce high-quality, informative, patient-focussed medical YouTube videos.

Using plant wax markers to estimate the diet composition of grazing Holstein dairy cows.

The objective of this study was to test whether diet selection of dairy cows under grazing conditions could be estimated using plant wax markers. Furthermore, differences between 2 cow strains and the effect of concentrate supplementation on plant species selection were investigated. The experiment was a study with a crossover design performed on an organic farm with 12 Swiss Holstein cows and 12 New Zealand Holstein cows. Both experimental periods consisted of a 21-d adaptation and a 7-d measurement period. All cows grazed full time in a rotational stocking system and received either no concentrate or 6 kg/d of a commercial cereal-grain mix. Representative herbage samples of each grazed paddock were taken and botanical composition of subsamples was manually determined. The average proportions of the plant species were 27.8% Lolium perenne, 6.1% Dactylis glomerata, 10.4% Trifolium repens, and 9.0% Taraxacum officinale. Other grass species were merged as "other grass" (38.2%) and other forb species as "other forbs" (8.5%). n-Alkanes, long-chain fatty acids, and long-chain alcohols (LCOH) were analyzed in the samples of plant species, concentrate, and feces from each cow. A linear discriminant analysis indicated that diet components were differentiated best with LCOH (96%) and worst with the combination of all marker groups together (12%). For each marker, the fecal marker recovery (FR) relative to dosed ytterbium was determined in 2 ways. Estimation of diet composition was performed with the software "EatWhat," and results were compared with botanical composition with the Aitchison distance. The results indicate that the diet composition of grazing dairy cows can be estimated using plant wax markers. Additionally, the calculation of FR led to mostly reliable results, yet this approach needs further validation. The most accurate estimation was achieved with the marker combination of n-alkanes and LCOH with a correction for FR. Less accurate estimations were achieved with long-chain fatty acids alone or in combination with n-alkanes. No difference relating to diet selection between the 2 cow strains was recorded, but supplemented cows apparently ingested higher proportions of T. repens than nonsupplemented cows. Awareness that supplementation influences selection behavior of grazing dairy cows may lead to adaptations in botanical composition of the pasture according to the demand of the animals.

The development and testing of a skin tear risk assessment tool.

The aim of the present study is to develop a reliable and valid skin tear risk assessment tool. The six characteristics identified in a previous case control study as constituting the best risk model for skin tear development were used to construct a risk assessment tool. The ability of the tool to predict skin tear development was then tested in a prospective study. Between August 2012 and September 2013, 1466 tertiary hospital patients were assessed at admission and followed up for 10 days to see if they developed a skin tear. The predictive validity of the tool was assessed using receiver operating characteristic (ROC) analysis. When the tool was found not to have performed as well as hoped, secondary analyses were performed to determine whether a potentially better performing risk model could be identified. The tool was found to have high sensitivity but low specificity and therefore have inadequate predictive validity. Secondary analysis of the combined data from this and the previous case control study identified an alternative better performing risk model. The tool developed and tested in this study was found to have inadequate predictive validity. The predictive validity of an alternative, more parsimonious model now needs to be tested.

Identification of risk factors associated with the development of skin tears in hospitalised older persons: a case-control study.

To identify the risk factors associated with the development of skin tears in older persons four hundred and fifty three patients (151 cases and 302 controls) were enrolled in a case-control study in a 500-bed metropolitan tertiary hospital in Western Australia between December 2008 and June 2009. Case eligibility was defined by a skin tear on admission, which had occurred in the last 5 days; or, a skin tear developed during hospitalisation. For each case, two controls who did not have a skin tear and had been admitted within 1 day of the case, were also enrolled. Data collected from the nursing staff and inpatient medical records included characteristics known, or hypothesised, to be associated with increased vulnerability to skin tears. Data analysis included a series of multivariate stepwise regressions to identify a number of different potential explanatory models. The most parsimonious model for predicting skin tear development comprised six variables: ecchymosis (bruising); senile purpura; haematoma; evidence of a previously healed skin tear; oedema; and inability to reposition oneself independently. The ability of these six characteristics to predict who among older patients could subsequently develop a skin tear now needs to be determined by a prospective study.

The influence of erythrophagocytosis on the interaction of macrophages and salmonella in vitro.

Phagocytosis and killing of Salmonella typhimurium by mouse peritoneal macrophages was inhibited when the bacteria and antibody-coated homologous erythrocytes or heterologous erythrocytes were simultaneously exposed to macrophages in vitro. No inhibition of phagocytosis or killing was observed in experiments employing uncoated or disrupted antibody-coated homologous erythrocytes. Degradation of S. typhimurium as measured by the loss of fluorescence from intracellular salmonella coated with fluorescein-labeled antibody was inhibited in macrophages which had previously ingested antibody-coated homologous erythrocytes. Anti-mouse-erythrocyte serum was found to have a cytotoxic action on mouse macrophages. However, the viability of macrophages was not altered by phagocytosis of antibody-coated homologous erythrocytes or uncoated heterologous erythrocytes.

Hemoglobin Lepore trait: globin synthesis in bone marrow and peripheral blood.

There was decreased synthesis of the beta-globin chain in the peripheral blood, and equal synthesis of alpha- and non-alpha-chains in the bone marrow of three patients with hemoglobin Lepore trait, similar to the findings in patients with heterozygous beta-thalassemia. There is a relative instability of the synthetic mechanism for normal beta-chain in these patients.

Free alpha-globin pool in human bone marrow.

A pool of free alpha-globin chains was found in the bone marrow samples from three controls, two patients with beta-thalassemia trait, three with sickle beta-thalassemia, three with hemoglobin (Hb) Lepore trait, one with alphabeta-thalassemia, four with homozygous beta-thalassemia, and one doubly heterozygous for Hb Lepore and beta-thalassemia. The average percentage of newly synthesized alpha-chains found in the free alpha-globin pool was 6.2% in the controls and 33.0% in the patients heterozygous for thalassemia or Hb Lepore. These controls and patients had balanced beta- and alpha-globin synthesis in the bone marrow. In the homozygous patients and in the one patient doubly heterozygous for thalassemia and Hb Lepore, there was a marked deficit of beta-chain synthesis in the bone marrow and also a large pool of newly synthesized free alpha-chains. The function of this pool of free alpha-chains is not known, but it may be involved in the regulation of globin chain synthesis in normal patients and in the compensatory synthesis of beta-chains that occurs in the bone marrow of patients heterozygous for thalassemia or for Hb Lepore.

Synthesis of globin chains in sickle -thalassemia.

In five patients with sickle beta-thalassemia there was balanced alpha- and beta-globin synthesis in the bone marrow and decreased total beta-chain synthesis relative to that of alpha-chain in the peripheral blood. These findings are similar to those in patients with simple beta-thalassemia trait. Despite a range of hemoglobin concentrations from 6.8 to 12.5 g/100 ml in the patients with sickle thalassemia, there was no evidence of a significant excess of alpha-chains in the red cells of the bone marrow which could contribute to the hemolysis and anemia. In patients heterozygous for beta-thalassemia the capacity to synthesize beta-chain decreases more rapidly than that for alpha-chain. In nonthalassemic subjects the rates of beta- and alpha-chain synthesis decrease equally as the red cell matures. The beta(S)- and beta(A)-chains serve as convenient markers for globin synthesis due to the nonthalassemic and thalassemic alleles in patients with sickle beta-thalassemia. The unbalanced globin synthesis in the peripheral blood of these patients is explained by the decrease in relative synthesis of beta(S)-chain, in comparison with that of alpha-chain. This instability is not present in sickle cell trait. The beta(A)-chain synthesis was only unstable in the two patients who had the most marked anemia. The major mechanism for achieving balanced globin production in the bone marrow in the presence of one thalassemic gene appears to be increased synthesis of beta-chain due to the nonthalassemic allele. In addition, there may be a decrease of total alpha-chain synthesis in some patients.

Orbital infarction in sickle cell disease.

Bone infarction is a common occurrence in sickle cell disease. Described are three cases in which frontal headache, proptosis, and lid edema were seen with infarction of the orbital bone. Radionuclide scanning was useful in distinguished bone infarction from orbital infection in one case.

Potential impact of linking an emergency department and hospital-affiliated clinics to immunize pre-school-age children.

OBJECTIVE: To determine whether the use of an urban pediatric emergency department (ED) to immunize pre-school-age children would result in an improvement in the percentage fully vaccinated by the end of the second year of life. DESIGN: A retrospective cohort study of two groups: (1) 100 consecutive children (ED group) enrolled at one of two hospital-affiliated primary care clinics were chosen from the ED patient logs if their second birthday occurred in the 12 months prior to November 1990; and (2) 91 age-matched control children (control group) were chosen at random from the same hospital-affiliated clinics' enrollment logs without regard to ED use. The health care provided during the first 2 years of life for each group was compared. RESULTS: The mean number of visits to the ED in the first 2 years of life by the ED group was significantly greater than that of the control group (2.9 [SD] +/- 2.5 vs 1.1 +/- 1.4; P < .001) during the first 2 years of life. In 67% of ED visits, children would have been well enough to receive a vaccination. Both groups had similar types and numbers of visits to the primary clinics. For example, the ED group had 10 +/- 5 visits by age 2 years compared with the control group, which had 9 +/- 4 visits. There was no significant difference in actual immunization percentages achieved in the clinic, with 62% of the ED group having received four diphtheria, pertussis, and tetanus vaccinations; three oral poliovirus vaccinations; and one measles, mumps, and rubella vaccination by age 2 compared with 69% of control children. There were more missed vaccination opportunities during clinic visits in the ED group (7.4 vs 4.6 per 100 clinic visits; P < .01). If immunizations were offered in the ED to those children who needed them, immunization percentages would have been increased an average of 20% compared with percentages achieved in the clinic alone. CONCLUSION: Routine vaccinations in the ED would significantly increase immunization percentages in children enrolled in two hospital-affiliated clinics. Close linkage and coordination between the ED and hospital-affiliated clinics may improve preventive health care in urban children who use EDs.

Prolonged episodes of persistent asthma: A distinct clinical pattern with characteristic clinical features.

STUDY OBJECTIVES: To investigate a clinical pattern of unexplained persistent asthma that is episodic in nature and lasts for months to years. This pattern of prolonged episodes of unexplained, persistent asthma was not defined previously. DESIGNS: Investigating the clinical features using a retrospective cohort design. SETTING AND PATIENTS: Eighteen subjects (ages, 13 to 64 years) from an allergy practice in a large prepaid health maintenance organization who had two or more prolonged episodes of unexplained persistent asthma lasting >/= 2 months during a 12-year period. RESULTS: These subjects accounted for 39 asthmatic episodes lasting from 2 to 74 months (median, 7 months). The duration of the episodes positively correlates with the severity of asthma (p = 0.02) at the initial part of the episodes. All episodes demonstrated a similar pattern, with symptom severity greatest at the onset and gradually diminishing until recovery. The relatively symptom-free intervals between the episodes ranged from 1.5 to 63 months (median, 13 months). Fifty-six percent of the episodes (95% confidence interval [CI], 40% to 72%) were associated with symptoms very suggestive or suggestive of an infection of the upper respiratory tract at the onset of the episodes; 33% of the episodes (95% CI, 19% to 50%) had possible symptoms suggestive of an infection; whereas only 10% of the episodes (95% CI, 3% to 24%) had questionable or no symptoms suggestive of an infection of the upper respiratory tract. Thirty-four episodes had the onset between September and March, whereas only 5 episodes occurred between April and August (p < 0. 001). CONCLUSIONS: These observations indicate that prolonged episodes of unexplained, persistent asthma lasting for months to years constitute a distinct clinical pattern of asthma with characteristic clinical features.

Reference values and hematologic changes from birth to 5 years in patients with sickle cell disease. Cooperative Study of Sickle Cell Disease.

OBJECTIVE: To examine hematologic changes from birth to 5 years of age and establish hematologic reference values for infants and children with sickle cell disease. RESEARCH DESIGN: Prospective natural history study. SETTING: Nineteen pediatric sickle cell centers across the United States. PATIENTS: Six hundred ninety-four infants with sickle cell disease (sickle cell anemia, sickle cell-hemoglobin C disease, and sickle-beta-thalassemia) who were enrolled in the Cooperative Study of Sickle Cell Disease at younger than 6 months of age. Median follow-up time through 5 years of age was 4.1 years. MEASUREMENTS AND RESULTS: We present longitudinal analyses of total hemoglobin concentration, percent fetal hemoglobin values, mean corpuscular volumes, total bilirubin concentration, and red blood cell (RBC), "pocked" RBC, white blood cell, platelet, and reticulocyte counts. Anemia was apparent by 10 weeks of life in infants with sickle cell anemia (SS infants). This anemia was associated with a rising reticulocyte count consistent with a hemolytic process. The reticulocyte count of SS infants increased steadily, exceeding 12% at 5 years of age. The fetal hemoglobin concentration of SS infants declined more slowly than that of infants with sickle cell hemoglobin C disease (SC infants). Pocked RBC counts rose sharply after 6 months of age, and by 1 year, 28% of SS infants had abnormal counts, above 3.5%, indicating poor splenic function. At 3 years of age, 78% of SS patients and 32% of SC patients had abnormal pocked RBC counts. The SS patients with concurrent alpha-thalassemia had, after 6 months of age and throughout early childhood, a slightly higher mean total hemoglobin concentration and lower mean pocked RBC and reticulocyte counts than SS patients without alpha-thalassemia. The hematologic profile of SC infants more closely resembled that of normal black infants, but there was mild anemia (10.5 g/dL) and slightly elevated mean values for reticulocytes (3%) and fetal hemoglobin (3%) during early childhood.

The influence of infant and maternal sickle cell disease on birth outcome and neonatal course.

OBJECTIVE: To compare the influence of maternal hemoglobin phenotype as well as that of the infant on birth outcome and neonatal complications. RESEARCH DESIGN: Prospective, natural history study with retrospective chart review for neonatal complications. SETTING: Nineteen pediatric sickle cell centers across the United States. PATIENTS: Four hundred eighty infants with sickle cell disease (SCD) who were enrolled in the Cooperative Study of Sickle Cell Disease at less than 6 months of age, as well as a comparison cohort of 118 infants with sickle cell trait born to women with sickle cell anemia in the Cooperative Study. RESULTS: In the SCD cohort, overall rates of preterm (< 37 weeks), low-birth-weight (< 2500 g), and small-for-gestational age births were 9%, 10%, and 8%, respectively; no significant differences were found according to infant hemoglobin phenotype. Term births accounted for 59% of the infants with low birth weight, significantly higher than the 41% US rate for black low-birth-weight infants (P = .014). Expectant mothers with sickle cell anemia are 2.5 times more likely to bear newborns who are small for gestational age than are women with other types of sickle cell disease, sickle trait, or C-trait. The most common prepartum and neonatal complications in infants with SCD were jaundice (25%), fetal distress (13%), anemia (10%), and respiratory distress (6%). Complication rates did not differ significantly by hemoglobin phenotype in the infants with SCD, but infants born to women with sickle cell anemia had higher rates of jaundice (P < .0001). CONCLUSIONS: Rates of adverse birth outcomes and neonatal complications in infants with SCD are similar to the rates for normal infants, although preterm birth accounts for fewer of the low-birth-weight outcomes among newborns with SCD relative to US black newborns. The hemoglobin phenotype of infants with SCD does not influence birth outcome and neonatal course, but infants born to women with sickle cell anemia are at greater risk of preterm birth, low birth weight, being small for gestational age, and neonatal jaundice.

Congenital bleeding disorders: hemophilia and von Willebrand's disease.

Treatment of hemophilia and von Willebrand's disease has become easier in recent years because of the development of more effective factor replacement products. The median age and the life expectancy of patients with hemophilia have risen markedly, as has the median age at death.

Thrombocytopenia in the newborn.

Infants with platelet counts below 100,000/mm3 should be evaluated for the cause of the thrombocytopenia. A maternal history to determine previous illnesses and particularly thrombocytopenia, drugs taken, and perinatal complications is important, and a maternal platelet count must be obtained. Physical examination of the infant is revealing in the TAR and giant cavernous hemangioma syndromes and may suggest intrauterine infection. A complete blood cell count (CBC) should be done to look for associated anemia and neutropenia or for polycythemia. Red cell morphology may be helpful. A bone marrow examination may be necessary if the etiology is unclear after the initial studies are done. Investigation of the well child will usually find an etiology for the thrombocytopenia. It is important to consider and test for isoimmune thrombocytopenia and intrauterine infection. In the ill infant multiple factors may contribute to a low platelet count, and a single, precise etiology often cannot be established. Thrombocytopenia with or without DIC may be an important indicator of sepsis. Platelet transfusions are helpful if the thrombocytopenia is due to decreased production or intrinsic platelet defects. In disorders with increased platelet destruction, donor platelets may survive long enough to be of some benefit. In ill infants treatment of the underlying problem often results in resolution of the thrombocytopenia. Transfusions should be used for the bleeding child and for the infant with severe thrombocytopenia who is the product of a vaginal delivery. In addition to being therapeutic, platelet transfusions may also assist in diagnosis.

Precision error of fan-beam dual X-ray absorptiometry scans at the spine, hip, and forearm.

The current study investigated short-term precision of fan-beam dual X-ray absorptiometry scans using a sample of subjects typically seen in a routine practice. Seventy-two women were scanned twice each in array fan-beam mode at the lumbar spine and 71 at the hip on a Hologic QDR 2000. Sixty-five were scanned at the forearm on a Hologic QDR 4500A in array mode. Each of the two scans was analysed without reference to its companion scan (independent analysis). The second assessment was also reanalyzed using the manufacturer's "Compare" function (compared analysis). Coefficients of variation (CVs) were calculated for the two forms of analysis at all the sites measured. Paired t-tests were performed to see whether the "Compare" function improved precision. The CV at the lumbar spine was 1.1% in both forms of analysis. The "Compare" function did not improve precision significantly at this site. The highest precision at the hip was found at the (Total) site of the hip (1.2-1.0%, independent and compared analyses, respectively) and the lowest at Ward's triangle. The Compare function significantly improved precision at Ward's triangle. The forearm had the best precision of all the sites measured with the Total site of the forearm being highest (0.5-0.7%) and the ultradistal site lowest (1.6-1.8%). The Compare function significantly decreased precision at the mid-distal and Total sites of the forearm. In conclusion, the highest precision was found at the Total site of the hip, the Total site of the forearm, and the spine. The Compare function did not significantly improve precision at the spine or hip (with the exception of Ward's triangle) and decreased precision at the forearm.