Screening for breast cancer-related lymphoedema: self-assessment of symptoms and signs.

INTRODUCTION: In the absence of monitoring programs, those at risk of developing breast cancer-related lymphoedema (BCRL) must detect its development. However, the efficacy of self-assessment for BCRL has not been widely investigated. This study will determine if symptoms and signs of BCRL are associated with lymphoedema detected by bioimpedance spectroscopy (BIS) and whether those with and without BCRL can accurately assess the signs of its presence. METHODS AND RESULTS: Participants with a history of breast cancer (n = 100) reported the presence/absence of symptoms associated with upper limb BCRL and underwent assessment for pitting oedema and differences in tissue texture between their arms (pinch). BIS detected BCRL in 48 women. Women were more likely to have BIS-detected BCRL if they reported swelling (odds ratio (OR), 58.8; 95% CI, 4.9 to 709.4; p = 0.001) or had inter-limb tissue texture differences in their forearm (OR, 73.5; 95% CI, 7.3 to 736.9; p = < 0.001) or upper arm (OR, 23.9; 95% CI, 2.8 to 201.7; p = 0.003). Agreement between therapist and self-assessment of signs of BCRL was almost perfect (kappa, 0.819 to 0.940). A combination of self-reported swelling and/or self-assessed forearm tissue texture difference identified all cases of BIS-detected BCRL. CONCLUSION: Participants accurately identified the presence or absence of physical signs of BCRL in their arm. Perceived swelling and differences in tissue texture in the affected arm were associated with, and sensitive to, BIS-detected BCRL. These findings support the use of self-assessment to determine if BCRL is developing, indicating the need for professional assessment.

The Teamwork Study: enhancing the role of non-GP staff in chronic disease management in general practice.

There is evidence for a team-based approach in the management of chronic disease in primary health care. However, the standard of care is variable, probably reflecting the limited organisational capacity of health services to provide the necessary structured and organised care for this group of patients. This study aimed to evaluate the impact of a structured intervention involving non-GP staff in GP practices on the quality of care for patients with diabetes or cardiovascular disease. A cluster randomised trial was undertaken across 60 GP practices. The intervention was implemented in 30 practices with staff and patients interviewed at baseline and at 12-15 months follow up. The change in team roles was evaluated using a questionnaire completed by practice staff. The quality of care was evaluated using the Patient Assessment of Chronic Illness Care questionnaire. We found that although the team roles of staff improved in the intervention practices and there were significant differences between practices, there was no significant difference between those in the intervention and control groups in patient-assessed quality of care after adjusting for baseline-level score and covariates at the 12-month follow up. Practice team roles were not significantly associated with change in Patient Assessment of Chronic Illness Care scores. Patients with multiple conditions were more likely to assess their quality of care to be better. Thus, although previous research has shown a cross-sectional association between team work and quality of care, we were unable to replicate these findings in the present study. These results may be indicative of insufficient time for organisational change to result in improved patient-assessed quality of care, or because non-GP staff roles were not sufficiently focussed on the aspects of care assessed. The findings provide important information for researchers when designing similar studies.

Capturing nystagmus in the emergency room: posterior circulation stroke versus acute vestibular neuritis.

OBJECTIVES: To compare acute nystagmus characteristics of posterior circulation stroke (PCS) and acute vestibular neuritis (AVN) in the emergency room (ER) within 24 h of presentation. METHODS: ER-based video-nystagmography (VNG) was conducted, recording ictal nystagmus in 101 patients with PCS (on imaging) and 104 patients with AVN, diagnosed on accepted clinical and vestibular test criteria. RESULTS: Patients with stroke in the brainstem (38/101, affecting midbrain (n = 7), pons (n = 19), and medulla (n = 12)), cerebellum (31/101), both (15/101) or other locations (17/101) were recruited. Common PCS territories included posterior-inferior-cerebellar-artery (41/101), pontine perforators (18/101), multiple-territories (17/101) and anterior-inferior-cerebellar-artery (7/101). In PCS, 44/101 patients had no spontaneous nystagmus. Remaining PCS patients had primary position horizontal (44/101), vertical (8/101) and torsional (5/101) nystagmus. Horizontal nystagmus was 50% ipsiversive and 50% contraversive in lateralised PCS. Most PCS patients with horizontal nystagmus (28/44) had unidirectional "peripheral-appearing" nystagmus. 32/101 of PCS patients had gaze-evoked nystagmus. AVN affected the superior, inferior or both divisions of the vestibular nerve in 55/104, 4/104 and 45/104. Most (102/104) had primary position horizontal nystagmus; none had gaze-evoked nystagmus. Two inferior VN patients had contraversive torsional-downbeat nystagmus. Horizontal nystagmus with SPV ≥ 5.8 °/s separated AVN from PCS with sensitivity and specificity of 91.2% and 83.0%. Absent nystagmus, gaze-evoked nystagmus, and vertical-torsional nystagmus were highly specific for PCS (100%, 100% and 98.1%). CONCLUSION: Nystagmus is often absent in PCS and always present in AVN. Unidirectional 'peripheral-appearing' horizontal nystagmus can be seen in PCS. ER-based VNG nystagmus assessment could provide useful diagnostic information when separating PCS from AVN.

TB risk by time since U.S. entry among non-U.S.-born residents of Washington State, USA.

BACKGROUND: Progress towards TB elimination in the United States will require improved detection and treatment of latent TB infection among non-U.S.-born residents who remain at disproportionate risk of TB disease. To inform targeted testing efforts, we evaluated risk of TB disease among non-U.S.-born residents of Washington State, USA, by region of origin and time from U.S. entry.METHODS: We conducted a retrospective cohort study among non-U.S.-born residents diagnosed with TB disease in Washington State from 2005 to 2014, for which country-specific population estimates were also available. The risk of TB disease among non-U.S.-born residents was estimated by time since U.S. entry, World Bank region of origin, and WHO TB incidence category.RESULTS: Risk of TB disease for non-U.S.-born residents was highest within the first year after U.S. entry. Among persons from countries with high TB incidence who had resided in the United States for more than 20 years, risk for TB remained elevated.CONCLUSION: Elevated risk of developing TB disease among individuals not born in the United States persisted long after U.S. entry, particularly among persons originating from certain regions and from high-burden countries. These findings contribute to evidence supporting a refinement of existing screening guidelines.

Oxypurine cycle in human erythrocytes regulated by pH, inorganic phosphate, and oxygen.

The effect of pH, PO2, and inorganic phosphate on the uptake and metabolism of hypoxanthine by erythrocytes has been studied. Uptake of hypoxanthine and accumulation of inosine 5'-monophosphate (IMP) were markedly increased at acid pH, high external phosphate concentrations, and low PO2. Release of accumulated IMP as hypoxanthine occurred at alkaline pH values and low external phosphate concentrations. Conditions favoring IMP accumulation gave rise, in the absence of hypoxanthine, to a corresponding increase in 5'-phosphoribosyl-1-pyrophosphate. Intracellular phosphate concentrations were markedly pH dependent and a model is presented whereby hypoxanthine uptake and release are controlled by intracellular concentrations of inorganic phosphate and 2,3-bisphosphoglycerate. These allosteric effectors influence, in opposing ways, two enzymes governing IMP accumulation, namely 5'-phosphoribosyl-1-pyrophosphate synthetase and 5'-nucleotidase. These metabolic properties suggest that the erythrocyte could play a role in the removal of hypoxanthine from anoxic tissue.

Current knowledge of scoliosis in physiotherapy students trained in the United Kingdom.

BACKGROUND: It has been highlighted in both Poland and the United States of America (USA) that knowledge of idiopathic scoliosis (IS) among physiotherapy students is limited with respect to the 2011 International Society on Scoliosis Orthopaedic and Rehabilitation Treatment (SOSORT) guidelines. Early detection of scoliosis and correct initial management is essential in effective care, and thus physiotherapists should be aware of the basic criteria for diagnosis and indications for treatment. The aim of this study was to evaluate the basic knowledge of IS in physiotherapy students trained in the United Kingdom (UK). METHODS: A previously designed and tested 10-question survey, including knowledge of the 2011 SOSORT guidelines, was transcribed onto an online-survey platform. Questions were designed to analyse knowledge of definition, cause, development, prevalence, diagnosis, treatment and bracing of scoliosis. All UK universities offering physiotherapy degrees were invited to participate, with the programme lead of each institution asked to distribute the questionnaire to all penultimate and final year physiotherapy students (bachelor's and master's degrees). The final number of students who received the study invitation is unknown. The survey link closed after 8 weeks of data collection. RESULTS: Two hundred and six students, split over 12 institutions, successfully completed the questionnaire. Analysis showed that 79% of students recognised when IS is likely to develop, yet only 52% recognised that IS's aetiology is unknown. Eighty-eight percent of students incorrectly defined IS as a 2-dimensional deformity, with only 24% successfully recognising the prevalence of IS within the scoliosis population. Just 12% knew the criteria for diagnosis; however, 93% were unable to recognise the appropriate treatment approach through therapeutic exercise. Finally, 54% of students managed to identify correctly when bracing is recommended for IS. In comparison to previous studies within the USA, students in the UK performed worse in relation to all questions except treatment (7% answered correctly vs 3% in the American study). CONCLUSION: With only 7% of students able to answer > 50% of the survey questions correctly, there is a clear lack of knowledge of appropriate IS diagnosis and care which could directly impact the information these patients are given within the first contact primary care in the UK.

A partial agonist at the anticonvulsant benzodiazepine receptor: reversal of the anticonvulsant effects of Ro 15-1788 with CGS-8216.

A benzodiazepine antagonist (Ro 15-1788) prevents the development of kindled seizures. CGS-8216, another benzodiazepine antagonist, prevents DMCM-induced seizures (indicating that CGS-8216 acts at a benzodiazepine receptor) but has no effect on kindling or kindled seizures. CGS-8216 prevents the anticonvulsant actions of Ro 15-1788 suggesting that Ro 15-1788 is a partial agonist at an anticonvulsant benzodiazepine receptor. These results support that idea of of distinct, separate receptors for anticonvulsant and sedative effects of benzodiazepines.

Sleep cycle control and cholinergic mechanisms: differential effects of carbachol injections at pontine brain stem sites.

Muscular atonia and cortical desynchronization, two signs of desynchronized sleep, can be enhanced or suppressed by direct injection of carbachol into the pontine brain stem of cats. The positive effects are graded, being maximal in the gigantocellular tegmental field and less marked in adjacent nuclei. These positive effects are dose-dependent. Suppressive effects of carbachol are maximal in the region of the locus coeruleus and are dose-dependent but do not exceed those of the vehicle alone. The results support the hypothesis that cholinergic mechanisms of the pontine tegmentum are involved in desynchronized sleep generation.

Iron deficiency anaemia and aspirin use in old age.

Aspirin is being increasingly prescribed for cardiovascular protection, but is also recognized to have significant gastrointestinal side-effects. Whether chronic aspirin consumption causes iron deficiency is undetermined, and there is little information available regarding iron deficiency and aspirin use in old age. We studied the relationship between iron deficiency anaemia and regular aspirin prescription in old age.

Analysis of urinary benzodiazepines using solid-phase extraction and gas chromatography-mass spectrometry.

A solid-phase extraction and GC-MS confirmation method was developed for certain urinary diazolo- and triazolobenzodiazepines, including the metabolites of lorazepam, clonazepam, alprazolam, and triazolam. The latter two do not form benzophenones, and the others are not readily confirmed by conventional thin-layer chromatography or GC-MS techniques. Samples were hydrolyzed with glucuronidase at 37 degrees C, adjusted to pH 4.5, extracted with Bond Elut Certify columns, dried, and derivatized using BSTFA with 1% TMCS. Sample preparation time averaged 4 hours. A GC-MS selected-ion-monitoring acquisition method targeting retention time, molecular ion abundances, and qualifier ion ratios was used to determine positive results. The recovery of 7-NH2-clonazepam was 95%, and recoveries of alpha-hydroxyalprazolam, alpha-hydroxytriazolam, and lorazepam were greater than 66%. Linearity was demonstrated from 0.1 to 1.0 microgram/mL for each drug. Within-run CVs were less than 11%, and between-run CVs were less than 16%. Using this technique, we have been able to confirm suspected cases of abuse that had not been confirmed by previous techniques.

Malabsorption: common causes and their practical diagnosis.

Malabsorption may present as non-specific ill health and malnutrition in the elderly. Outside major medical centers, however, investigation is often thought to be difficult and unrewarding, and screening tests unreliable. Therefore, a direct approach is suggested to identify treatable small bowel disease in those elderly patients with a clinical possibility of malabsorption. It is based on the use of plain abdominal x-ray, endoscopy with duodenal biopsy, and small bowel meal.

The modern geriatric day hospital.

Geriatric day hospitals have played a major role in the rehabilitation of older people, although the evidence base has proved thin. As the provision of geriatric medicine changes, they need to develop new roles such as responding to subacute crises, providing specialist services and ensuring comprehensive geriatric assessment before long-term care.

Education for health services management: a graduate student survey of an Australian program.

This article reports the results of a study which was designed to evaluate a revised Master's of Health Administration program in the School of Health Services Management at the University of New South Wales, Australia. The original program was established in 1956; during the 1970s, humanities-based subjects such as sociology and quality assurance were added to the traditional financial and management subjects. During 1987-88, health-oriented subjects such as public health and epidemiology were included as compulsory subjects. To assess the program, a cross-sectional study of 1990 to 1992 graduates was undertaken. The study revealed that students found that the traditional financial and management subjects and the health-related subjects were useful to their jobs. The study also demonstrated significant career advancement for a majority of graduates. Two-thirds of the respondents stated that their initial objectives for enrolling in the course had been met.

Mental state and presentation of myocardial infarction in the elderly.

Atypical presentations of myocardial infarction are more common in the elderly. Fifty-three cases of myocardial infarction were found by prospectively screening all acute medical admissions aged over 75 years. The presenting symptom was compared with an assessment of mental state using a simple scoring system. Atypical presentations were found to be significantly (P = less than 0.001) associated with an impaired mental score.