Socioeconomic status and lifestyle behaviours in cancer survivors: smoking and physical activity.

PURPOSE: Smoking cessation and increased physical activity (pa) have been linked to better outcomes in cancer survivors. We assessed whether socioeconomic factors influence changes in those behaviours after a cancer diagnosis. METHODS: As part of a cross-sectional study, a diverse group of cancer survivors at the Princess Margaret Cancer Centre (Toronto, ON), completed a questionnaire about past and current lifestyle behaviours and perceptions about the importance of those behaviours with respect to their health. The influence of socioeconomic indicators on smoking status and physical inactivity at 1 year before and after diagnosis were assessed using multivariable logistic regression with adjustment for clinico-demographic factors. RESULTS: Of 1222 participants, 1192 completed the smoking component. Of those respondents, 15% smoked before diagnosis, and 43% of those smokers continued to smoke after. The proportion of survivors who continued to smoke increased with lower education level (p = 0.03). Of the 1106 participants answering pa questions, 39% reported being physically inactive before diagnosis, of whom 82% remained inactive afterward. Survivors with a lower education level were most likely to remain inactive after diagnosis (p = 0.003). Lower education level, household income, and occupation were associated with the perception that pa had no effect or could worsen fatigue and quality of life (p ≤ 0.0001). CONCLUSIONS: In cancer survivors, education level was a major modifier of smoking and pa behaviours. Lower socioeconomic status was associated with incorrect perceptions about pa. Targeting at-risk survivors by education level should be evaluated as a strategy in cancer survivorship programs.

Predictors for affected stroke territory and outcome of acute stroke treatments are different for posterior versus anterior circulation stroke.

Distinct patient characteristics have been proposed for ischaemic stroke in the anterior versus posterior circulation. However, data on functional outcome according to stroke territory in patients with acute stroke treatment are conflicting and information on outcome predictors is scarce. In this retrospective study, we analysed functional outcome in 517 patients with stroke and thrombolysis and/or thrombectomy treated at the University Hospital Zurich. We compared clinical factors and performed multivariate logistic regression analyses investigating the effect of outcome predictors according to stroke territory. Of the 517 patients included, 80 (15.5%) suffered a posterior circulation stroke (PCS). PCS patients were less often female (32.5% vs. 45.5%, p = 0.031), received thrombectomy less often (28.7% vs. 48.3%, p = 0.001), and had lower median admission NIHSS scores (5 vs. 10, p < 0.001) as well as a better median three months functional outcome (mRS 1 vs. 2, p = 0.010). Predictors for functional outcome were admission NIHSS (OR 0.864, 95% CI 0.790-0.944, p = 0.001) in PCS and age (OR 0.952, 95% CI 0.935-0.970, p < 0.001), known symptom onset (OR 1.869, 95% CI 1.111-3.144, p = 0.018) and admission NIHSS (OR 0.840, 95% CI 0.806-0.876, p < 0.001) in ACS. Acutely treated PCS and ACS patients differed in their baseline and treatment characteristics. We identified specific functional outcome predictors of thrombolysis and/or thrombectomy success for each stroke territory.

Comparative effectiveness of antitumour necrosis factor agents, biologics with an alternative mode of action and tofacitinib in an observational cohort of patients with rheumatoid arthritis in Switzerland.

BACKGROUND: Multiple biologic and targeted synthetic disease-modifying rheumatic drugs (b/tsDMARDs) are approved for the management of rheumatoid arthritis (RA), including TNF inhibitors (TNFi), bDMARDs with other modes of action (bDMARD-OMA) and Janus kinase inhibitors (JAKi). Combination of b/tsDMARDs with conventional synthetic DMARDs (csDMARDs) is recommended, yet monotherapy is common in practice. OBJECTIVE: To compare drug maintenance and clinical effectiveness of three alternative treatment options for RA management. METHODS: This observational cohort study was nested within the Swiss RA Registry. TNFi, bDMARD-OMA (abatacept or anti-IL6 agents) or the JAKi tofacitinib (Tofa) initiated in adult RA patients were included. The primary outcome was overall drug retention. We further analysed secondary effectiveness outcomes and whether concomitant csDMARDs modified effectiveness, adjusting for potential confounding factors. RESULTS: 4023 treatment courses of 2600 patients were included, 1862 on TNFi, 1355 on bDMARD-OMA and 806 on Tofa. TNFi was more frequently used as a first b/tsDMARDs, at a younger age and with shorter disease duration. Overall drug maintenance was significantly lower with TNFi compared with Tofa [HR 1.29 (95% CI 1.14 to 1.47)], but similar between bDMARD-OMA and Tofa [HR 1.09 (95% CI 0.96 to 1.24)]. TNFi maintenance was decreased when prescribed without concomitant csDMARDs [HR: 1.27 (95% CI 1.08 to 1.49)], while no difference was observed for bDMARD-OMA or Tofa maintenance with respect to concomitant csDMARDs. CONCLUSION: Tofa drug maintenance was comparable with bDMARDs-OMA and somewhat higher than TNFi. Concomitant csDMARDs appear to be required for optimal effectiveness of TNFi, but not for bDMARD-OMA or Tofa.

Open reduction and palmar plate-osteosynthesis in combination with a nanocrystalline hydroxyapatite spacer in the treatment of comminuted fractures of the distal radius.

In a prospective study, we used the nanocrystalline hydroxyapatite paste Ostim (Osartis, Obernburg, Germany) in combination with a palmar plate to treat comminuted radius fractures with a metaphyseal and articular component in order to examine the clinical use of Ostim as a bone substitute. Twenty-one patients with 22 radius fractures of AO types C2 and C3 were included in the study. The measurements, taken 10.2+/-1.3 months after the initial treatment, revealed a dorsopalmar tilt of 8.8+/-3.7 degrees , a radioulnar inclination of 18.8+/-2.8 degrees and an ulnar variance of 0.8+/-1.8mm. According to the Gartland and Werley evaluation, eight of the treated fractures attained an excellent, 11 a good and the remaining three a fair result. The study demonstrates that Ostim, in combination with angularly stable osteosynthesis, can be used as an acceptable bone substitute for the treatment of type C2 and C3 radial fractures.

Can early computed tomography angiography after endovascular aortic aneurysm repair predict the need for reintervention in patients with type II endoleak?

PURPOSE: This study was designed to identify parameters on CT angiography (CTA) of type II endoleaks following endovascular aortic aneurysm repair (EVAR) for abdominal aortic aneurysm (AAA), which can be used to predict the subsequent need for reinterventions. METHODS: We retrospectively identified 62 patients with type II endoleak who underwent early CTA in mean 3.7 ± 1.9 days after EVAR. On the basis of follow-up examinations (mean follow-up period 911 days; range, 373-1,987 days), patients were stratified into two groups: those who did (n = 18) and those who did not (n = 44) require reintervention. CTA characteristics, such as AAA, endoleak, as well as nidus dimensions, patency of the inferior mesenteric artery, number of aortic branch vessels, and the pattern of endoleak appearance, were recorded and correlated with the clinical outcome. RESULTS: Univariate and receiver operating characteristic curve regression analyses revealed significant differences between the two groups for the endoleak volume (surveillance group: 1391.6 ± 1427.9 mm(3); reintervention group: 3227.7 ± 2693.8 mm(3); cutoff value of 2,386 mm(3); p = 0.002), the endoleak diameter (13.6 ± 4.3 mm compared with 25.9 ± 9.6 mm; cutoff value of 19 mm; p < 0.0001), the number of aortic branch vessels (2.9 ± 1.2 compared with 4.2 ± 1.4 vessels; p = 0.001), as well as a "complex type" endoleak pattern (13.6 %, n = 6 compared with 44.4 %, n = 8; p = 0.02). CONCLUSIONS: Early CTA can predict the future need for reintervention in patients with type II endoleak. Therefore, treatment decision should be based not only on aneurysm enlargement alone but also on other imaging characteristics.

Identification of predictive CT angiographic factors in the development of high-risk type 2 endoleaks after endovascular aneurysm repair in patients with infrarenal aortic aneurysms.

PURPOSE: An extensive analysis of the value of computed tomography (CT) parameters as potential predictors of the clinical outcome of type 2 endoleaks after endovascular aortic aneurysm repair (EVAR). MATERIALS AND METHODS: Initial CT scans of 130 patients with abdominal aortic aneurysms (AAAs) were retrospectively reviewed. On the basis of postoperative CT scans and angiographies, patients were stratified into a low-risk group (LRG; without or transient type 2 endoleak; n = 80) and a high-risk group (HRG, persistent type 2 endoleak or need for reintervention; n = 50). Statistical analysis comprised a univariate and multivariate analysis. RESULTS: Anatomical, thrombus-specific, as well as aortic side branch parameters were assessed on the initial CT scan. Of all anatomical parameters, the diameter of the immediate infrarenal aorta was significantly different in the univariate analysis (LRG 22.4 ±â€Š3.8 mm; HRG 23.6 ±â€Š2.5 mm; p = 0.03). The investigation of the thrombus-specific parameters showed a trend towards statistical significance for the relative thrombus load (LRG 31.7 ±â€Š18.0%; HRG 25.3 ±â€Š17.5%; p = 0.09). Assessment of aortic side branches revealed only for the univariate analysis significant differences in the patency of the inferior mesenteric artery (LRG 71.3%; HRG 92.0%; p = 0.003) and their diameter (LRG 3.3 ±â€Š0.7 mm; HRG 3.8 ±â€Š0.9 mm; p = 0.004). In contrast, the number of lumbar arteries (LAs; LRG 2.7 ±â€Š1.4; HRG 3.6 ±â€Š1.2; univariate: p = 0.01; multivariate: p = 0.006) as well as their diameter (LRG 2.1 ±â€Š0.4 mm; HRG 2.4 ±â€Š0.4 mm; univariate: p < 0.001; multivariate: p = 0.006) were highly significantly associated with the development of type 2 endoleaks of the HRG. CONCLUSION: The most important predictive factors for the development of high-risk type 2 endoleaks were mainly the number and the diameter of the LAs which perfused the AAA. KEY POINTS: • This study is a very detailed and comprehensive analysis of the value of various CT parameters as potential predictors of the clinical outcome of type 2 endoleaks after EVAR. • Anatomical as well as thrombus-specific parameters were unsuitable as predictors. • The most important predictive factors were mainly the number and the diameter of the LAs which perfused the AAA.

Possible role of atrial natriuretic hormone in pituitary-adrenocortical unresponsiveness in lactate-induced panic.

OBJECTIVE: This study investigated whether lactate-induced panic attacks in patients with panic disorder would activate atrial natriuretic hormone, which could explain the missing ACTH and cortisol response found in this kind of experimentally induced panic. METHOD: Sodium lactate and placebo infusions were administered to 10 patients with panic disorder and to 10 healthy comparison subjects, and the atrial natriuretic hormone responses of the two groups were compared. RESULTS: During lactate infusion both the seven patients who had panic attacks and the eight comparison subjects who did not responded with increased plasma concentrations of atrial natriuretic hormone, but the patients had more pronounced surges of the hormone. CONCLUSIONS: Because atrial natriuretic hormone suppresses both pituitary ACTH and adrenal cortisol release, the authors suggest that the immediate rise of atrial natriuretic hormone explains the reported lack of pituitary-adrenocortical activation during lactate-induced panic.

Congenital insensitivity to pain with anhidrosis (CIPA) in Israeli-Bedouins: genetic heterogeneity, novel mutations in the TRKA/NGF receptor gene, clinical findings, and results of nerve conduction studies.

Congenital insensitivity to pain with anhidrosis (CIPA), a rare and severe disorder, comprises absence of sensation to noxious stimuli, inability to sweat, and recurrent episodes of hyperthermia. It has a relatively high prevalence in the consanguineous Israeli-Bedouins. Clinical studies of 28 patients are reported here. Using the linkage analysis approach, we linked the disease in 9 of 10 unrelated Israeli-Bedouin families with CIPA to the TrkA gene, which encodes the receptor for nerve growth factor. In one family, linkage was excluded, implying that another gene, yet unidentified, is involved. Two new mutations in the tyrosine kinase domain of the TrkA gene were identified in our CIPA patients: a 1926-ins-T in most of the southern Israeli-Negev CIPA patients, and a Pro- 689-Leu mutation in a different isolate of Bedouins in northern Israel. Eight prenatal diagnoses were made in the southern Israeli-Negev Bedouins, two by linkage analysis and six by checking directly for the 1926-ins-T mutation. Three polymorphisms in the TrkA protein kinase encoding domain were also observed.

Circadian changes in the sensitivity of the corticotropin-releasing hormone-stimulated HPA system after arginine vasopressin and atrial natriuretic hormone in human male controls.

In order to investigate whether modulation of the effects of corticotropin-releasing hormone (CRH) by arginine vasopressin (AVP) and atrial natriuretic hormone (ANH) is sensitive to circadian fluctuations, 12 healthy male volunteers were administered 100 micrograms hCRH during 30 min infusion of placebo, 3 IU AVP, or 150 micrograms ANH, the experiment being carried out in the morning (0800h) or in the evening (1900h). Compared with placebo, AVP significantly amplified the CRH-induced adrenocorticotropin hormone (ACTH) surge both in the morning and in the evening, whereas it enhanced cortisol secretion only in the evening. In contrast, ANH significantly reduced the ACTH surge, but only in the evening, and it reduced the cortisol surge in the morning compared to the evening. During ANH infusion plasma AVP levels were suppressed both in the morning and in the evening, pointing to a hypothalamic site of action in addition to the pituitary and adrenocortical effects. The ACTH secretion profiles were indistinguishable between morning and evening in all three experimental conditions, whereas cortisol profiles differed significantly depending on the time of day in the AVP and ANH condition, but not for placebo.

Atrial natriuretic hormone inhibits corticotropin-releasing hormone-induced prolactin release in man.

Atrial natriuretic hormone (ANH) is found in heart myocytes, and also in the CNS. The inhibitory action of ANH on the hypothalamic-pituitary-adrenocortical (HPA) system has been established by in vivo and in vitro experiments, and could be of considerable importance: whereas several synergists to corticotropin-releasing hormone (CRH), the key hormone of the HPA system, are characterized in the past, until now ANH seems to be the only peptide which counterbalances the effects of CRH at the pituitary. As well as at the corticotroph, CRH has a stimulatory influence upon the lactotroph in vivo, and like ACTH and corticosteroids prolactin (PRL) is released in response to physical and cognitive challenges. To test the hypothesis of whether ANH also inhibits the CRH-mediated prolactin release a randomized, placebo-controlled, double-blind study in 12 males aged from 25 to 30 years was conducted. With regard to the diurnal variation of the HPA system activity we compared the prolactin release by 100 micrograms hCRH during a 30 min infusion of placebo, 150 micrograms ANH or 3 IU arginine vasopressin in the morning (08:00 h) and evening (19:00 h). Evaluation of morning and evening effects revealed that administration of hCRH led to a prompt rise of plasma PRL concentration. Infusion of ANH resulted in a significantly reduced maximum increment of PRL compared to placebo (0.83 +/- 0.87 vs 2.85 +/- 1.57 ng/ml, mean +/- SD, n = 12, p < .001). In addition, the AUC values were significantly lower under ANH than in the placebo condition. Infusion of AVP did not significantly change the PRL response to CRH vs placebo.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of enzyme immunoassay with radioimmunoassay for the detection of hepatitis B surface antigen.

A direct solid-phase enzyme immunoassay (Auszyme I) and a direct solid-phase radioimmunoassay (Austria II) for detection of hepatitis B surface antigen (HBsAg) were compared in tests with a panel of 347 human sera. Compared with RIA, EIA showed a sensitivity of 98% with 153 HBsAg-positive sera and a specificity of 99% with 194 HBsAg-negative sera. Sera that gave false negative and false positive results by EIA were re-examined by both RIA and EIA to confirm the initial result. Use of less than the recommended volume of serum for EIA produced results inconsistent with RIA in four of 27 sera examined. Quantitative correlation between RIA and EIA was low (r = 0.691). Positive controls used for EIA showed considerable variation from day to day, although intra-assay variation was much less. The sensitivity of the EIA method examined compares favourably with previously published EIA studies and with the RIA used in this study. Auszyme I EIA is a sensitive and specific third generation test for HBsAg that offers several advantages over currently used RIA techniques.

Prevalence of lymphadenopathy of the head and neck in infants and children.

This study demonstrates the widespread prevalence of "normal" adenopathy in children; i.e., not associated with infectious adenitis or serious system illness. The knowledge of this distribution is helpful in determining when adenopathy may be pathologic. Occipital and postauricular adenopathy is a common nonspecific finding in infancy; but, over the age of 2 years, it is sufficiently rare that it can be a useful diagnostic finding. Cervical and submandibular nodes are rare in infants under 12 months but are common in older children. Supraclavicular nodes are probably pathologic at any age.

What is fever? Normal temperature in infants less than 3 months old.

To determine the normal temperature of healthy infants, we studied 691 infants less than 3 months of age being seen for regularly scheduled well-baby visits. All temperatures were taken rectally with an electronic thermometer. The mean temperature was 37.5 degrees C +/- 0.3 degrees C. Using a cutoff of 2 standard deviations (SD) above the mean, fever would be defined as a temperature > or = 38.1 degrees C. The 95th percentile was 38.0 degrees C, and > or = 38.1 degrees C would correspond to values above the 95th percentile. The most widely used definition of fever at present is a temperature > or = 38.0 degrees C; by this definition, 6.5% of these well infants would be considered to have a fever. A significant rise in temperature with age was noted. For infants from birth to 30 days old, 2 SD above the mean was 38.0 degrees C; for those 31 to 60 days old, it was 38.1 degrees C; and for those 61 to 91 days old, it was 38.2 degrees C. Similarly, the 95th percentile was 37.9 degrees C, 38.0 degrees C, and 38.1 degrees C, respectively. Temperature also varied significantly with the season of the year, being higher in the summer (2 SD above a mean = 38.3 degrees C) than in the winter (2 SD above a mean = 38.0 degrees C). Fever should be defined as a temperature > or = 38.0 degrees C in infants less than 30 days of age, > or = 38.1 degrees C in 1-month-olds, and > or = 38.2 degrees C in 2-month-olds.

Learning by teaching. A resident-taught oral therapy program for acute diarrhea.

An educational program on oral rehydration therapy (ORT) for diarrhea was instituted in our residents' continuity clinics to evaluate the impact that residents teaching parents would have on the knowledge and practices of both groups. Sixty-one residents and 287 parents answered the initial written questionnaire before the teaching program began, and 48 residents and 147 parents completed a second questionnaire at the end of the program. Nineteen residents in two clinics were told to participate frequently in teaching the parents, while 29 residents in three other clinics were given no such instructions. The parents were divided into three groups: 58 received teaching and an instructional handout on the management of diarrhea; 73 received only the instructional handout; and 16 received neither intervention. The 19 "teaching" residents had a significantly improved overall score compared with the "nonteaching" residents (p < .03). No improvement was found in the scores of the 58 parents who received teaching compared with those of the 89 parents who received either a handout or no educational intervention. We conclude that active teaching of ORT may improve the knowledge and practices of residents, but that single teaching encounters, whether or not accompanied by written instructions, may have little impact on parents.

[Angle- and rotation-stable internal fixation of proximal humerus fractures with the humerus fixator plate. Early clinical experience with a newly developed implant]. / Die winkel- und rotationsstabile Osteosynthese proximaler Humerusfrakturen mit der Humerus-Fixateurplatte. Erste klinische Erfahrungen mit einem neu entwickelten Spezialimplantat.

INTRODUCTION: The Humerus Fixator Plate is presented as a new implant for angle- and rotation-stable internal fixation for the operative treatment of proximal humerus fractures at the surgical neck. METHODS: In an ongoing two-centre study, 47 patients were treated with the new implant. To date, 31 patients had clinical and radiological postoperative follow-up examinations with a mean interval of 10 months (range: 6-14 months). RESULTS: In 46 patients (97.9%), complete angle and rotational stability was achieved without limiting the range of motion or requiring immobilization. Good pain relief was obtained in 43 patients (91.5 %), and 3 patients (6.4%) showed moderate pain relief following surgery. There was one implant failure. Utilizing the Constant-Raw score (without any correction factors), a mean result of 82.8 points (range: 46-100 points) was ascertained. The majority of the patients (87.1%) achieved "excellent" or "good" clinical results. X-ray analysis revealed no non-union nor humerus head necrosis. In 4 cases (12.9%), protrusion of a humerus head screw was observed which mandated removal of the implant. CONCLUSION: The first clinical investigations of the novel Humerus Fixator Plate are encouraging and provide essential advances in the treatment of unstable proximal humerus fractures.

Laser doppler flow imaging of open lower leg fractures in an animal experimental model.

PURPOSE: Open lower leg fractures are frequently associated with severe soft tissue damage, followed by osteomyelitis. Using an animal experimental model, we investigated the effect of timing of coverage of a tibial fracture with a local muscle flap. METHODS: 80 rabbits had a tibial fracture induced in a standardised fashion, which was stabilised by screw osteosynthesis. After 3 (group A; n=40) and 7 days (group B; n=40), respectively, the tissue defect was covered by a local gastrocnemius flap. In increasing intervals from 1 to 2, 4, 8, and 16 weeks, the rabbits from each group were killed and the bone fracture was analysed histomorphologically. Cortical microcirculation was measured by 2-channel laser doppler flowmetry. RESULTS: Muscle flaps after 3 days improved perfusion significantly as compared with 7 days (24 Flux [standard error, 5 Flux] versus 10 Flux [3 Flux]; baseline, 1.4 Flux). Group A animals also displayed a lower rate of necrosis (0 versus 38). The incidence of osteomyelitis was higher in group B than in group A (24% versus 0%). CONCLUSION: Laser doppler flowmetry was proven to be a reliable, minimally invasive means for identifying avital tissue, leading to reduction in the loss of vital bone tissue in experimental settings.

Detection of high-energy phosphates in cortical bone as an indicator of bone healing and remodelling: use of a rabbit model.

UNLABELLED: PURPOSE; To study high-energy phosphates in cortical bone through experiments on inbred white New Zealand rabbits. METHODS: Tibial fractures were induced in 80 rabbits and then stabilised by screw osteosynthesis. After 3 (group A; n=40) or 7 days (groups B; n=40), the defective tissue was covered by local muscle flaps. At increasing intervals (from 1 to 16 weeks), the screws were removed and the animals were euthanised (n=8 per group). The bone was removed and analysed histomorphologically; adenosine triphosphate (ATP) levels were determined by high-performance liquid chromatography. RESULTS: The mean ATP concentration in healthy cortical bone at 16 weeks was 0.092 (standard error, 0.009) nmol/mg dry mass, which was significantly higher than that in the group with delayed healing: 0.081 (0.011) nmol/mg in group A and 0.005 (0.001) nmol/mg in group B (paired t test, p<0.05). Earlier healing led to lower rates of necrosis (0 vs 38; groups A vs B) and osteomyelitis. CONCLUSION: Early muscle-flap coverage can revascularise the cortical bone, which is reflected in the higher ATP content in the cortical bone measured by high-performance liquid chromatography. Measuring changes of ATP levels can help investigate the metabolism of the pathological bone.

[Prevention and treatment of procedural pain in pediatric wards: collected guidelines].

Present knowledge and available pharmacological agents allow for adequate prevention and treatment of pain in children. We present guidelines we prepared for the prevention and treatment of procedural pain in children in our general pediatric ward. This followed extensive review of the literature, participation in scientific meetings, discussions with experts and consultation with interested clinicians. Successful implementation of the guidelines requires increased appreciation of the importance of pain prevention, participation of the nursing, as well as medical staff, and ability to evaluate pain in children of various ages.

[Oral rehydration in acute gastroenteritis in infants and children--advantages of a standardized protocol].

Oral rehydration (OR) for acute gastroenteritis in infants and children has been shown to be as effective as IV therapy, with less discomfort and lower costs. In this retrospective study we compared 2 pediatric wards, in 1 of which only a standardized, simplified, bedside protocol, based on American Academy of Pediatrics guidelines, was used. There were no significant clinical characteristics in the 208 patients. In the ward which used the above protocol, OR utilization was significantly more frequent than in the other ward (48% versus 15%), thus saving equipment costs of nearly $1,000/3 months. There were no significant differences in outcome between the wards. We conclude that introducing a standardized management protocol may increase OR utilization in hospitalized children with acute diarrhea.