Air pollution and global healthcare use for atopic dermatitis: A systematic review.

Increasing air pollution is common around the world, but the impacts of outdoor air pollution exposure on atopic dermatitis (AD) are unclear. We synthesized the current global epidemiologic evidence for air pollution exposure and associated medical visits for AD among adults and children. This review followed PRISMA guidelines, and searches were conducted on PubMed, MEDLINE, Web of Science and EMBASE databases. The searches yielded 390 studies, and after screening, 18 studies around the world assessing at least 5,197,643 medical visits for AD in total were included for the final analysis. We found that exposure to particulate matter ≤2.5 µm in diameter (PM2.5 ) [(10/11) of studies], particulate matter ≤10 µm in diameter (PM10 ) (11/13), nitrogen dioxide (NO2 ) (12/14) and sulfur dioxide (SO2 ) (10/13) was positively associated with AD visits. Results were equivocal for ozone [(4/8) of studies reported positive association] and limited for carbon monoxide [(1/4) of studies reported positive association]. When stratifying results by patient age, patient sex and season, we found that the associations with particulate matter, NO2 and O3 may be affected by temperature. Exposure to selected air pollutants is associated with AD visits, and increasingly poor worldwide air quality may increase global healthcare use for AD.

Use of gentamicin impregnated POP discs for antibiotic pouch dressing.

Antibiotic pouch technique is commonly used due to the high local antibiotic concentration and moist environment for wound healing. We used locally made gentamicin impregnated Plaster of Paris discs in treating wounds with exposed deep structures like tendons and bones. Out of 22 patients treated with this method, 19 completed treatment. Granulation tissue formed quickly and effectively covered the exposed structures. All wounds either healed by secondary intention or became suitable for split skin grafting. Gentamicin impregnated Plaster of Paris disc pouch dressing is safe, cost saving, and effective for management of deep open wounds.

Necrotizing fasciitis of the lower limb: an outcome study of surgical treatment.

Necrotizing fasciitis is a limb- and life-threatening rapidly spreading infection affecting the deep fascia with secondary necrosis of the subcutaneous tissue. It requires immediate medical attention and emergency surgery to prevent morbidity and death. This study was undertaken to determine its co-morbidity and risk factors affecting the outcome of its surgical treatment. This is a retrospective review of 36 cases of necrotizing fasciitis of the lower limb treated in our center between 1998 and 2002. Only 19% of the cases were correctly diagnosed upon admission and 48.6% were initially diagnosed as 'cellulitis'. Diabetes mellitus was the most common co-morbid. Pseudomonas, Staphylococcus, Streptococcus and Enterobactericae were the common pathogens isolated. Ten patients (27.8%) had major amputation as part of radical debridement. The overall mortality rate was 36% with laboratory parameters: high serum urea and creatinine, and low haemoglobin levels were predictors for higher mortality. Poor white cell response which is common in diabetic patients and a delay in surgical debridement were. notable attributes to a higher mortality. Necrotizing fasciitis is a serious infection associated with significant morbidity and mortality. A poor white blood cell response, high serum urea and creatinine, and low haemoglobin level were the predictors for mortality. Early diagnosis and prompt treatment are of paramount importance in the treatment of this infection.

Body weight as a risk factor in the elderly.

To determine whether body weight is a risk factor for mortality among older persons, we analyzed body mass index (weight [kilogram]/height [square meter]) data for 4710 white, National Health and Nutrition Examination Survey respondents who were aged 55 to 74 years during 1971 through 1975, in relation to their survival over an average of 8.7 years of follow-up. In a multivariate analysis that controlled for elevated blood pressure, smoking, and poverty, we found no additional risk associated with weight among women and a statistically significant, but moderate, additional risk (relative risk, 1.1 to 1.2) among men in the upper decile (body mass index, greater than or equal to 30 kg/m2). In contrast, low weight (body mass index, less than 22 kg/m2) was associated with increased mortality (relative risk, 1.3 to 1.6) except for women aged 55 to 64 years. We conclude that the accepted definition of overweight (body mass index, greater than or equal to 27.8 kg/m2 [men] or greater than or equal to 27.3 kg/m2 [women]) lacks specificity and may be inappropriate for older persons who do not have weight-related medical conditions. The low-weight mortality association, consistently demonstrated, deserves serious scrutiny.

The impact of nocturnal symptoms associated with gastroesophageal reflux disease on health-related quality of life.

BACKGROUND: Two types of reflux episodes have been identified: upright or daytime and supine or nocturnal. The population-based prevalence of symptoms of nocturnal gastroesophageal reflux disease (GERD) and the impact of those symptoms on health-related quality of life (HRQL) have not been established. METHODS: A national random-sample telephone survey was conducted to estimate the prevalence of frequent GERD and nocturnal GERD-like symptoms and to assess the relationship between HRQL, GERD, and nocturnal GERD symptoms. Respondents were classified as controls, subjects with symptomatic nonnocturnal GERD, and subjects with symptomatic nocturnal GERD. The HRQL was assessed using the Medical Outcomes Study Short-Form 36 Health Survey (SF-36). RESULTS: The prevalence of frequent GERD was 14%, with an overall prevalence of nocturnal GERD of 10%. Seventy-four percent of those with frequent GERD symptoms reported nocturnal GERD symptoms. Subjects with nonnocturnal GERD had significant decrements on the SF-36 physical and mental component summary scores compared with the US general population. Subjects reporting nocturnal GERD symptoms were significantly more impaired than subjects reporting nonnocturnal GERD symptoms on both the physical component summary (38.94 vs 41. 52; P<.001) and mental component summary (46.78 vs 49.51; P<.001) and all 8 subscales of the SF-36 (P<.001). Subjects with nocturnal GERD demonstrated considerable impairment compared with the US general population and chronic disease populations. Subjects with nocturnal GERD had significantly more pain than those with hypertension and diabetes (P<.001) and similar pain compared with those with angina and congestive heart failure. CONCLUSIONS: Nocturnal symptoms are commonly experienced by individuals who report frequent GERD symptoms. In addition, HRQL is significantly impaired in those persons who report frequent GERD symptoms, and HRQL impairment is exacerbated in those who report nocturnal GERD symptoms.

Menstrual cycle and headache in a population sample of migraineurs.

BACKGROUND: Migraine is three times more common in women than men. There is a clinical impression that migraines are more common and severe around the time of menses. OBJECTIVES: To determine 1) the distribution of headache attacks by day of the menstrual cycle in women with migraine, 2) if the excess occurrence varies by headache type, and 3) if headache features differ by time in the menstrual cycle. METHODS: In a population-based sample, 81 menstruating women with clinically diagnosed migraine were enrolled in a 98-day diary study and completed a total of 7219 diary days. The daily diary was used to record the occurrence of menses, headache days, and, on days with headache, associated headache features (i.e., symptoms, quality-of-pain, attack duration, pain intensity, and disability at work, household work, and nonwork activities). RESULTS: An excess risk of headache occurred perimenstrually and was highest on days 0 and 1 of the cycle (day 0 being the first day of menses). A significantly elevated risk of headache on days 0 and 1 was observed for migraine without aura (OR 2.04; 95% CI 1.49, 2.81) and for tension-type headache (OR 1.67; 95% CI 1.24, 2.25). Elevated risks were also observed in the 2 days before onset of menses for migraine without aura (OR 1.80; 95% CI 1.40, 2.30). A significantly lower risk was observed around the time of ovulation for all headaches (OR 0.44; 95% CI 0.27, 0.72). Few significant differences were observed in headache features (i.e., pain intensity, disability score, symptom score, headache duration) by day of the cycle overall or by headache type. Pain intensity was slightly greater for migraine headaches during the first 2 days of menses. CONCLUSIONS: Attacks of migraine without aura, but not migraine with aura, were more likely to occur 2 days before onset of menses and on the first 2 days of menses. This study does not support the clinical notion that headaches, regardless of type, are more severe during the perimenstrual period compared to other times in the cycle. Although migraine headaches are significantly more painful during the first 2 days of menses, differences are small.

Volumetric MRI changes in basal ganglia of children with Tourette's syndrome.

To define the site of pathology in Tourette's syndrome (TS), we performed a volumetric MRI study of basal ganglia structures and lateral ventricles on 37 children with this disorder and 18 controls. There were no statistically significant differences in the size of the right or left caudate, putamen, globus pallidus, or ventricles in these populations. In contrast, there were significant differences for measures of symmetry in the putamen and the lenticular region. Virtually all controls (17 right- and one left-handed) had a left-sided predominance of the putamen, whereas in 13 of 37 TS subjects, a right predominance exceeded that of any control. Statistical comparisons among TS patients, with (n = 18) or without (n = 19) attention-deficit hyperactivity disorder (ADHD), and controls showed significant differences for the volume of the left globus pallidus and for lenticular asymmetry. Post hoc evaluations showed that in the TS + ADHD group, the volume of the left globus pallidus was significantly smaller than the volume of the right and that lenticular asymmetry was due to a greater right-sided predominance in the TS+ADHD group. This study lends further support to proposals that claim the basal ganglia is involved in the pathogenesis of TS and also suggests that the comorbid problem of ADHD is related to regional changes that differ from those primarily associated with tics.

Genetic-epidemiologic study of omphalocele and gastroschisis: evidence for heterogeneity.

On the basis of clinical manifestations, epidemiologic characteristics, and the presence of additional malformations, omphalocele (OM) and gastroschisis (GA) are considered casually and pathogenetically distinct abdominal wall defects. More than 50% of infants with OM have additional defects, but only about 15% of those with GA do. To evaluate whether there is heterogeneity between isolated and multiply affected cases of OM and GA, we analyzed epidemiologic characteristics and familial risks of major defects for 82 OM and 81 GA cases drawn from a population-based study in the Maryland-Washington, DC-Northern Virginia area and born from 1980 through June 1987. We examined year of birth, sex, race, and maternal age distributions after stratifying the infants into isolated and multiple defect groups. We found significant differences in maternal age between cases with isolated OM and GA, but not between cases with GA or OM who had other defects. Using regressive logistic models, we analyzed familial aggregation of birth defects among relatives of infants with OM and GA. An autosomal recessive model of inheritance was found to be the most parsimonious explanation for the families of infants with isolated OM or GA. However, for families of infants with multiple defects, a sporadic or nongenetic model fit best. These findings are not only useful for estimating familial risk of major birth defects, but they also suggest further heterogeneity of infants with OM and GA according to the presence of other malformations.

Functional decline in older adults: expanding methods of ascertainment.

BACKGROUND: There is substantial interest in the prevention of physical disability associated with aging. However, little is known about how to screen for declining function at sufficiently early stages to prevent frank disability. This work provides an initial description and assessment of a new self-report method for measuring function in older adults which complements standard methods and may be sensitive to subtler degrees of disablement than currently employed methods. We operationalize the method and demonstrate that it identifies a meaningful number of people as potentially disabled who are not identified by standard methods; also, we evaluate the method's reliability and validity for identifying subtle functional decline relative to existing methods. METHODS: This is a cross-sectional, observational study of a volunteer population of 231 adults 59 years and older, evaluated in a multidisciplinary laboratory. Self-reported difficulty and dependency in each of 27 tasks of daily life were assessed as the measure of disability. Those without difficulty were evaluated for other functional change, by self-report, defined as either: (a) modification of method, or (b) decreased frequency of task performance, when due to health rather than change in social circumstances. Prevalence, test-retest reliability, construct, and criterion validity were evaluated. RESULTS: In a study population in which from 1% to 50% of participants reported difficulty with each of 27 tasks, from 2% to 33% reported modification of task performance while not having difficulty. Few participants reported decreased frequency without modification. Persons with task modifications, particularly in mobility tasks, showed intermediate levels of performance on objectively measured tests and an intermediate number of chronic diseases, compared to those reporting difficulty and those reporting neither difficulty nor modification. CONCLUSIONS: Cross-sectional evidence supports the ability of the proposed method to identify meaningful numbers of people with functional decline who were not identified by standard self-report methods. In some cases, these were individuals with functional losses comparable to those who did report difficulty. In other cases, these may have been individuals with earlier functional loss, perhaps representing a preclinical stage of disability. Prospective evaluation will identify whether this method predicts the onset of difficulty or disability, and whether it predicts decline with sufficient precision to identify at-risk individuals in a clinical setting.

Treatment of cerebrotendinous xanthomatosis with chenodeoxycholic acid in three siblings.

We investigated the therapeutic effect of chenodeoxycholic acid (750 mg/day) in three siblings with cerebrotendinous xanthomatosis. All three siblings had characteristic clinical manifestations, abnormal findings of magnetic resonance imaging and electroencephalogram, and high serum levels of cholestanol, cholesterol precursor (lathosterol), and plant sterols (campesterol, sitosterol). After treatment for one year, the serum levels of these sterols were decreased and some neurologic improvements in the pyramidal tract signs and cerebellar signs were noted. The electroencephalographic findings were markedly changed and normalized. However, mental defects and sensorimotor polyneuropathy still remained. No changes of neuroradiologic features could be detected. A longer period of treatment is required to estimate the overall effects of chenodeoxycholic acid in patients with cerebrotendinous xanthomatosis.

Congenital mirror movement: report of a case.

We report the case of a 27-year-old woman who has had mirror movements in both hands since childhood. These synkinetic involuntary movements impair her performance in bimanual activities such as buttoning clothes, tying shoes, and washing dishes. Cranial magnetic resonance imaging disclosed only mild diffuse cortical atrophy. Although congenital mirror movements have been well-documented in the English literature, we herein report the first case of a Chinese patient in Taiwan.

Cerebrotendinous xanthomatosis in three siblings from a Taiwanese family.

We present and discuss the clinical and biochemical findings of three siblings with cerebrotendinous xanthomatosis, which has not been previously reported in Taiwan. Clinical features consisted of tendinous xanthomas, cataracts, mental defects, pyramidal signs, cerebellar ataxia, peripheral neuropathy and renal stones. Biochemical findings included normal serum cholesterol levels, high serum cholestanol levels and elevated serum cholestanol to cholesterol ratios. The serum levels of cholesterol precursor (lathosterol) and plant sterols (campesterol, sitosterol) were also elevated.

Four year experience with cholangiocarcinoma: a survey of patients, clinical presentation, management and prognosis in two hospitals.

Seventeen patients with cholangiocarcinoma diagnosed in Toa Payoh and Tan Tock Seng Hospitals from 1986-90 were studied retrospectively. There was a male preponderance (male:female = 12:5) with a mean age of 58 years (range 28-82 years). All presented with obstructive jaundice. Three had cholangitis. Biliary stones were associated in 3 (18%). Two patients (12%) had choledochal cysts. The level of obstruction was identified at the hilum in 12 (70.5%), lower third in 4 (23.5%) and at a choledochojejunostomy anastomosis in 1 (6%). Ultrasound and percutaneous cholangiography (PTC) were the commonest investigations used. Endoscopic retrograde cholangio-pancreatography (ERCP) was performed in 7 (41%) and computer tomography (CT) of abdomen in 6 (35%). Biochemically, a raised alkaline phosphatase (1.5-9 x normal) was typical. Biliary bypass surgery was performed in 7 (41%); Whipple's procedure in 2 (12%) and drainage only in 6 (35%). Nine operated upon survived an average of 6 months (range 2-11 months) and six by drainage survived an average of 62 days (range 13-155 days). Three (of which two declined treatment) were lost to follow up. Cholangiocarcinoma is an uncommon cancer occurring in the older age group. In younger patients, choledochal cyst seems to be an association. Survival is dismal with palliative treatment.

Hepatitis B virus infection in patients with systemic lupus erythematosus.

Sera from 76 patients with systemic lupus erythematosus (SLE) were examined for HBsAg, anti-HBsAb and total anti-HBcAB by radioimmunoassay. Fifteen patients (19.7%) had one or more of these serological markers of HBV infection. This is comparable to the sero-prevalence in 100 sex- and age-matched healthy individuals (19%). There was no significant difference in the prevalence of HBV infection in patients who had received immunosuppressants compared with those who had not. Patients who had received transfusion of blood or blood products had a higher prevalence of serological markers but this was not statistically significant.

Clotest (rapid urease test) in the diagnosis of Helicobacter pylori infection.

Over a period of 3 months, 85 patients who underwent gastroscopy had antral biopsy taken for Clotest, histology and/or culture for Helicobacter pylori (HP). The sensitivity and specificity of Clotest were found to be 77% and 96% respectively with negative predictive value of 63% and positive predictive value of 98%. Ninety-two percent of the positive Clotests were positive within 20 minutes, thus giving rapid result. Therefore, Clotest is a rapid, sensitive and highly specific test for HP infection. A high correlation between HP infection and chronic gastritis was noted and the prevalence of HP infection in patients with duodenal ulcer (90%) was higher than that of gastric ulcer (64%) or non-ulcer group (65%).

The use of relaxation for the promotion of comfort and pain relief in persons with advanced cancer.

The efficacy of a relaxation technique involving deep breathing, muscle relaxation, and imagery was tested as a nursing intervention for the promotion of comfort and pain relief in hospitalized oncology patients. The intervention was implemented in accordance with Orem's self-care approach to nursing practice. Sixty-seven new admissions to an oncology ward were randomly assigned to receive relaxation training by audio tapes, live relaxation training by nurses, or no relaxation training. Relaxation training was conducted twice weekly over a period of three weeks. All subjects were pretested and post-tested with the McGill Pain Questionnaire and Visual Analogue Scale for pain. Analgesic medication was monitored throughout the study. Data analysis showed significant reductions in subjective pain ratings by subjects receiving relaxation training. There was also a significant reduction in non-opiate p.r.n. analgesic intake which suggested a reduced incidence of breakthrough pain.

Subconjunctival injection of triamcinolone in the treatment of lid retraction of patients with thyroid eye disease: a case series.

PURPOSE: To report the results of subconjunctival injection of triamcinolone in the treatment of thyroid eye disease-related lid retraction. INTERVENTION: Patients with either unilateral or bilateral upper lid retraction, secondary to thyroid eye disease, diagnosed during the period of February 2004 to June 2005 were recruited. An injection of 0.5 ml of triamcinolone acetonide (40 mg/ml kenalog) with 0.1 ml of 2% lignocaine was injected into the subconjunctival region of the lid between the conjunctiva and Muller's muscle under topical anaesthesia on upper lid eversion. Pre- and post-procedure measurements included lid aperture, marginal reflex distance, the amount of lagophthalmos, and intraocular pressure measurements. Photographs were also obtained before the procedure and at subsequent visits. Follow-up was done at 2 weeks, 1, 3, 6 months and at 1 year. RESULTS: Three of the four patients had resolution of their upper lid retraction within 1 month of treatment, with one patient requiring a repeat triamcinolone injection. The patient who had fibrotic muscles did not respond to triamcinolone injections and required surgical correction. CONCLUSION: Upper lid subconjunctival triamcinolone appears to be an effective treatment option in reducing lid retraction in patients with recent onset of thyroid eye disease.

Treatment of trigger points with microamperage transcutaneous electrical nerve stimulation (TENS)--(the Electro-Acuscope 80).

One-half of the students taking part in a double-blind study received a microamperage electrical stimulation of trigger points in the neck and shoulder region with the Electro-Acuscope 80. All the subjects were evaluated by digital palpatory physical examination for the presence of trigger points before each of their treatments. Results indicate that the subjects who received treatment had a higher change of trigger-point indicators compared to those receiving the placebo treatment. A two-tailed t-test indicated significant results (P less than 0.001). It appears that microamperage electrical stimulation is effective in the treatment of trigger points.

Risk factors for secondary amenorrhea and galactorrhea.

OBJECTIVE: Analyses were undertaken to identify factors that may predispose women to secondary amenorrhea or galactorrhea, frequent sources of abnormal reproductive function. METHODS: Data were gathered from interviews with 252 women with secondary amenorrhea or galactorrhea from four clinical centers, along with neighborhood controls matched to each case. Univariate comparisons were made for clinical and demographic factors of the study subjects. RESULTS: Patients with amenorrhea and normal prolactin (PRL) levels and their matched controls tended to be younger than those with amenorrhea and elevated PRL or than menstruating patients with galactorrhea alone and their matched controls. Patients with amenorrhea and normal PRL also were significantly more educated and were older at menarche than their controls, while amenorrhea patients with elevated PRL or patients with galactorrhea alone did not differ significantly from their controls in age at menarche or educational level. More patients with galactorrhea alone had reported menstrual pain to their physicians and had significantly longer menstrual periods than their matched controls. Patients with galactorrhea alone also weighed more than their controls 2 years prior to diagnosis, a difference that remained after stratification by parity, although only statistically significant among women who had had one or two pregnancies. Finally, significantly fewer patients with amenorrhea than controls were smokers. Thus, these disorders may not be due to anti-estrogenic effect or to low estrogen levels which have been associated with smoking.