Interpreting the real-time dynamic 'sliding sign' and predicting pouch of Douglas obliteration: an interobserver, intraobserver, diagnostic-accuracy and learning-curve study.

OBJECTIVE: To determine inter- and intraobserver agreement, diagnostic accuracy and the learning curve required for interpreting the 'sliding sign' and predicting pouch of Douglas (POD) obliteration. METHODS: This was an inter-/intraobserver, diagnostic-accuracy and learning-curve study involving six observers with different medical backgrounds, clinical skill sets and prior gynecological ultrasound experience: five non-specialist observers who had performed 0-750 previous gynecological scans and an expert sonologist who had performed > 15 000. Following a formal theoretical and practical training session, they each viewed 64 offline transvaginal ultrasound (TVS) 'sliding-sign' videos from two anatomical locations (retrocervix and posterior uterine fundus (PUF)) in 32 women presenting with chronic pelvic pain, interpreting the videos as positive or negative for sliding sign and predicting, on that basis, the POD status. For intraobserver agreement analysis they re-analyzed the same video sets, in a different order, at least 7 days later. The expert sonologist was the reference standard for interpreting the sliding sign and the gold standard, laparoscopy, was used for the POD analysis. Learning-curve cumulative summation (LC-CUSUM) tests were conducted to assess if observer performance reached acceptable levels, using LC-CUSUM score < -2.45 as a cut-off. RESULTS: With respect to interpretation of the sliding sign, the overall multiple-rater agreement was moderate (Fleiss' kappa, K = 0.499). Observers were more consistent in their interpretation of the second compared with the first observation set (K = 0.547 vs 0.453) and for the retrocervical compared with the PUF region (K = 0.556 vs 0.346). Regarding prediction of POD status, the accuracy, sensitivity, specificity and positive and negative predictive values for individual observers ranged from 65.4 to 96.2%, 80.0 to 100%, 64.7 to 100%, 50.0 to 100% and 94.7 to 100%, respectively. Using LC-CUSUM score < -2.45, the observer with experience of 200 previous gynecological scans reached acceptable levels for predicting POD obliteration and interpreting the sliding sign at each region (retrocervix and PUF) at 39, 54 and 28 videos and the observer with experience of 750 scans at 56, 53 and 53 videos. CONCLUSIONS: Performance of a minimum number of gynecological ultrasound examinations is necessary for interpreting offline videos of the real-time dynamic sliding sign and predicting POD obliteration. Non-specialist observers with prior experience of 200 or more gynecological scans were more consistent in interpreting the sliding sign at the retrocervix vs PUF. Copyright © 2015 ISUOG. Published by John Wiley & Sons Ltd.

[Experience with mathematical analysis of regional arterial pressure in occupational pathology of the hypothalamus]. / Opyt matematicheskogo analiza pokazatelei regionarnogo arterial'nogo davleniia pri professional'noi patologii gipotalamusa.

The authors performed a mathematical analysis of systemic and regional (temporal and retinal) arterial pressure in 193 patients with lesions of the hypothalamic are of professional etiology and in the control group of 280 individuals. There was dissociation between the figures of sytemic and cerebral arterial pressure a high degree of variability in the bronchial, temporal, retinal arteries. A correlation between the character of disturbances and clinical forms of pathology was established. Any connection between the indices of AD and the form of professional factor, service with noxious factors and duration of the disease was not found. The authors discuss questions of pathogenesis in the changes of arterial pressure and possible approaches in therapy.

[Kant and medicine of enlightenment]. / Kant und die Medizin der Aufklärung.

Immanuel Kants "Critique of Judgment" (1970) reflects the medicine of the second part of the eighteenth century. Both parts of the "Critique of Judgment" (as well the "Critique of Aesthetic Judgment" as the "Critique of Teleological Judgment") refer to problems of medicine.

A family doctor's work with adolescent patients.

Dr A Model describes his experience in general practice with adolescent patients. He describes their problems and shows how these differ according to age and sex, and considers the role of the general practitioner in their eyes.Dr Faith Spicer describes the sexual problems of adolescence and shows how these differ between the sexes. She enquires into the emotional and mental processes which contribute to early sex experience in the young.Dr A Ryle contrasts working in a student health service with his experience of adolescents in general practice. He concludes that there should be a range of alternative sources of help for adolescents.

A randomized double-blind pilot study comparing Doloteffin and Vioxx in the treatment of low back pain.

OBJECTIVE: This randomized, double-dummy, double-blind pilot study of acutely exacerbated low back pain was aimed to inform a definitive comparison between Doloteffin, a proprietary extract of Harpagophytum, and rofecoxib, a selective inhibitor of cyclo-oxygenase-2 (COX-2). METHODS: Forty-four patients (phyto-anti-inflammatory drug-PAID-group) received a daily dose of Doloteffin containing, inter alia, 60 mg of harpagoside for 6 weeks and 44 (non-steroidal anti-inflammatory drug-NSAID-group) received 12.5 mg/day of rofecoxib. All were allowed rescue medication of up to 400 mg/day of tramadol. Several outcome measures were examined at various intervals to obtain estimates of effect size and variability that might be used to decide the most suitable principal outcome measure and corresponding numbers required for a definitive study. RESULTS: Forty-three PAID and 36 NSAID patients completed the study. Ten PAID and 5 NSAID patients reported no pain without rescue medication for at least 5 days of the 6th week of treatment. Eighteen PAID and 12 NSAID patients had more than a 50% reduction in the week's average of their pain scores between the 1st and 6th weeks. The mean percentage decrease from baseline in the pain component of the Arhus Index was 23 (S.D. 52) in PAID and 26 (S.D. 43) in NSAID. The corresponding measures for the overall Arhus Index were 11 (31) and 16 (24) and, for the Health Assessment Questionnaire, 7 (8) and 6 (7). Tramadol was used by 21 PAID patients and 13 NSAID patients. Fourteen patients in each group experienced 39 adverse effects, of which 28 (13 in PAID) were judged to some degree attributable to the study medications. CONCLUSION: Though no significant intergroup differences were demonstrable, large numbers will be needed to show equivalence.

Treatment of low back pain with a herbal or synthetic anti-rheumatic: a randomized controlled study. Willow bark extract for low back pain.

OBJECTIVES: To compare the effects of a proprietary extract of willow bark (Assalix) and a selective inhibitor (rofecoxib) of the enzyme cyclo-oxygenase-2 (COX-2). METHODS: An open, randomized, post-marketing study was carried out in an out-patients clinic on two groups of patients aged 18 to 80 yr presenting over a 6-month period with acute exacerbations of low back pain. Using computer-generated random list, 114 patients were allocated to receive a daily dose of herbal extract containing 240 mg of salicin [PAID (phyto-anti-inflammatory drug) group] and 114 were allocated to receive 12.5 mg of the synthetic COX-2 inhibitor rofecoxib [NSAID (non-steroidal anti-inflammatory drug) group]. The doses were chosen according to existing recommendations. All patients were free to use whatever additional conventional treatments were thought necessary. The outcome measures were a modified Arhus index, its pain component and the Total Pain Index. RESULTS: Groups were well matched. After 4 weeks of treatment, the Arhus index had improved by about 20%, its pain component by about 30% and the Total Pain Index by about 35%. The number of pain-free patients (visual analogue scale score <2) was about 20 in each group. About 60% of the patients in each group responded well to the treatment (as judged by an improvement of >/=30% in the Total Pain Index relative to its baseline). The improvement was also reflected reasonably well in the physicians' and patients' judgements of the effectiveness of treatment, which were largely concordant. Few patients of either group resorted to the additional conventional treatment options. The incidence of adverse events was similar in the two groups. Treatment with rofecoxib was about 40% more expensive than that with Assalix. CONCLUSION: There was no significant difference in effectiveness between the two treatments at the doses chosen. Treatment with Assalix was less expensive.