Determinants of masked hypertension in hypertensive patients treated in a primary care setting.

BACKGROUND: Recent data suggest that masked hypertension (MH) carries a cardiovascular risk similar to that of uncontrolled hypertension. AIMS: The objective of this study was to determine the prevalence and determinants of MH in patients treated for hypertension in a Canadian primary care setting. METHODS: Office blood pressure (OBP) was measured at baseline and after 3 months of valsartan-based therapy in 5636 hypertensive patients who had recorded their home blood pressure monitoring (HBPM) for seven consecutive days at month 3 using an Omron HEM-711 apparatus. MH was defined in nondiabetic patients as an OBP <140/90 mmHg and an HBPM ≥135/85 mmHg, and in those with diabetes as an OBP <130/80 mmHg and an HBPM ≥125/75 mmHg. RESULTS: Of the 5636 patients, 1025 had diabetes. OBP was controlled at 3 months in 268 (26.1%) of them, but 167 (62.3%) had MH. OBP was controlled in 2728 (59.1%) of the 4611 patients without diabetes, and 935 (34.3%) of them had MH. Overall, 1102 patients had MH, representing 36.8% of patients with controlled OBP and 19.6% of the entire hypertensive study population. Stepwise multiple logistic regression analysis in nondiabetic patients with controlled OBP at 3 months revealed that older age, male sex, higher body mass index and higher office systolic blood pressure were determinants of MH. CONCLUSION: Our results indicate that one of five hypertensive patients and more than one of three with controlled OBP will have MH. MH is associated with other cardiovascular risk factors, such as diabetes, and in nondiabetics, with male sex, older age and obesity.

Prognostic factors in the recurrence of stage I and II squamous cell cancer of the oral cavity.

Stage I and II squamous cell cancers of the oral cavity have a high recurrence rate given their size and relative amenability to surgical resection. It has been suggested that one way to decrease this recurrence rate is to augment the surgical resection of these tumors with either elective neck dissection or radiation therapy. However, this would expose a significant number of patients to the unnecessary morbidity associated with either of these modalities. In an attempt to identify those patients most at risk for recurrence, we retrospectively determined the clinical and histologic factors that were associated with recurrence in 49 patients with stage I and II oral cavity cancer. Multiple regression analysis revealed that when various interactions between variables were controlled for, only the presence of a positive surgical margin or a tumor depth greater than 5 mm was significantly associated with recurrence. Each individually increased the likelihood of recurrence almost threefold.

Hypersegmentation of neutrophils in the cerebrospinal fluid: report of a case with hematologic correlation and review of the literature.

Hypersegmented neutrophils can occasionally be seen in the cerebrospinal fluid (CSF) of patients with acute pyogenic meningitis, and rarely as an artifact of cytocentrifugation. We report a case of florid neutrophil hypersegmentation in cytocentrifuged CSF specimens from a patient presenting with anemia and mental status changes. Megaloblastic anemia was excluded by a thorough hematologic evaluation, and the patient was later found to have an epidural abscess. The striking hypersegmentation is attributed to the combined effects of meningeal infection and cytocentrifugation, and a review of the available limited literature on cytomorphologic alterations in CSF cells, specifically neutrophils, is presented.

Right-left orientation, mental rotation, and perspective-taking: when can children imagine what people see from their own viewpoint?

Right-left orientation, mental rotation, and perspective-taking were examined in a group of 406 subjects ranging from 5 to 11 yr. of age with equal numbers of children in each age group. Immediate recognition was not a difficult task as even young children succeeded adequately on the three tasks involving different images. Right-left identification, where right and left terms are used, was harder even for the oldest subjects when associated with mental rotation. When children had to identify which image a person would see from another viewpoint, they succeeded when the person was looking away in the same direction as they were looking. When the person was facing the children (in the opposite direction of "forward"), three different behaviors emerged which indicated absence or presence of mental rotation in perspective-taking. Young subjects chose images as if the figures in the image were seeing from the subject's viewpoint; this percentage diminished slowly across increased ages. As subjects' ages increased, more chose the correct image. Even at 11 years of age, however, only half of the subjects chose correctly. Finally, an equal percentage of subjects among the different age groups understood that the person was seeing a different orientation of the persons but did not associate this with the correct right-left position of the persons on the image. This transition most probably reflects the slow evolution of cognitive processes which determine the way the child will use references to internal or external frameworks. It illustrates as well the passage from egocentrism to geocentrism with the ability to consider viewpoints other than one's own.

Right-left orientation: development of correct use of right and left terms.

Right-left orientation includes discrimination and recognition as well as identification, the former two differentiating between symmetrical cues and the latter using the words right and left. In the present experiment involving 406 children, the evolution of the knowledge and use of the concepts of right and left were assessed. Discrimination and recognition on all tasks used in this study are mastered much earlier than verbal identification, and, at even 11 years of age, half of the subjects of the present study still did not apply the words right and left properly onto other persons in the milieu. Children use the words right and left correctly first on their own bodies as early as seven years of age, then on people facing away, and finally on people facing them around eight to nine years of age. This transition most probably reflects the slow evolution of cognitive processes which determine the way the child will use internal or external frameworks as well as the passage from egocentrism to "alteregocentrism" with ability to consider other viewpoints than one's own.

Which handedness: preference or performance?

Two ways of measuring handedness, questionnaires and hand-efficiency tests, are compared. A method for combining performance scores of 128 children from different hand-efficiency tests to obtain a single handedness score based on efficiency is presented. Handedness classifications according to different thresholds of preference as well as of performance are shown. To select pure right- or left-handers, it is argued that handedness should be established simultaneously through preference questionnaires and performance tests and that only subjects falling simultaneously into the same category on both measures be kept. Advantages and disadvantages of each classification are discussed as well as the relations between efficiency and motor control of upper limb and hand.

A community-based clinical trial of Intra-Venous zOledRonic acid once Yearly in comparison to oral bisphosphonates in postmenopausal women with osteoporosis: the IVORY trial Methodological considerations.

BACKGROUND: Zoledronic acid is an intravenous once yearly bisphosphonate that has been shown to be effective and safe in improving BMD (bone mineral density) and reducing fracture risk in controlled clinical trials. IVORY is a Canadian post marketing study aiming at assessing real-life effectiveness, health care resource utilization, safety and compliance to treatment with zoledronic acid in comparison to orally administered bisphosphonates (OBP). METHODS: IVORY is a prospective two cohort observational study of patients treated with zoledronic acid or OBP. Eligible patients are postmenopausal females, >45 years old with osteoporosis for whom initiation of treatment with OBP or zoledronic acid is indicated. Subjects will be followed for four years. Outcomes are the change in lumbar spine, femoral neck and total hip BMD and the incidence of fractures. The study cohort will consist of 920 patients treated with zoledronic acid and 460 treated with OBP. Additional comparisons will be based on external standardization to the population of Quebec patients treated with OBP. DISCUSSION: Post Marketing Observational Studies (PMOS) are essential for the assessment of real-life effectiveness and population based benefit-risk ratios. The effect of access to care, compliance, adherence to guidelines, patient comorbidity and concomitant medication use could only be assessed with observational studies. IVORY will provide information about true life effectiveness, benefit-risk ratios, cost-effectiveness and barriers to the process-outcome optimization. The results will have implications for decision makers and health care stakeholders regarding the management of osteoporosis in Canada.

An acceptable yearly screening device for endometrial carcinoma.

PIP: Endometrial carcinoma is a disease of menopausal and postmenopausal women with 74% of cases occurring between the ages of 50-69 years and 16% at age 70 or older. Recent reports suggest an increase in the frequency of the lesion and occurrence at an earlier age. Any single test by most of the conventional methods will miss about 50% of the carcinomas of the endometrium. To obtain greater accuracy in diagnosis, it is necessary to obtain large numbers of well-preserved cells directly from the endometrial cavity. Cervical patency should be proved in the examination of all postmenopausal women. The device described uses a silicone rubber tube 33.5 cm in length and 2 mm in diameter. A wire stylet for stiffness and a rounded plastic tip facilitate passage through the sometimes stenotic cervical canal. Near the tip many small holes permit aspiration of endocervical secretions. A plastic collar around the tubing facilitates the aspiration. An aspirating syringe adapter is needed. After conventional Pap smears are obtained the aspirating tube is passed into the uterus. Little or no pain is produced. Negative pressure for aspiration is obtained with a syringe. The contents of the aspirating tube are expelled onto a slide. The slide preparations are immediately fixed in a bottle of absolute alcohol containing 3% glacial acetic acid. The acid lyses most red blood cells. This method was used in 983 outpatients and 500 hospitalized patients. There were only 5 patients in whom the endometrial aspirator could not be passed, due to previous cervical trauma in 3 and vaginal atrophy and distortion in 2. No uterine perforations or infections occurred. There were no positive tests for carcinoma in the 983 outpatients. Endometrial carcinoma was diagnosed histologically in 32 of the 500 hospitalized patients. IN 27 of these 32 cases the endometrial carcinoma had been detected by cytological examination of the aspirate. There were 5 carcinoma cases in which the aspirate did not show malignant cells. In 3 of them external radiation had been given prior to surgery and some residual cancer was found in the hysterectomy specimen. Excessive blood on the slide had prevented adequate cytologic evaluation in the other 2. In 6 cases adenocarcinoma was suspected from the examination of the aspirate but not found histologically. 4 of them showed abnormal endometrial curettings. Polyps were found in 3 and hyperplasia in 1. 8 cases of in situ or early invasive carcinoma of the cervix were discovered. Results show that the method is safe and accurate to an 84.4% degree for detecting endometrial adenocarcinoma. In an accompanying discussion, better fixation of material on slides was suggested. Annual mass population screening by this method was not considered practical. Others have depended on a jet wash of the endometrium and on endometrial biopsies to obtain material for histologic study, but many patients do not like having the needed dilatation and fail to return for reexaminations.^ieng

The changing trends of uterine cancer and cytology: a study of morbidity and mortality trends over a twenty year period.

Data on squamous carcinoma of the cervix from a 20 year study period (1955 to 1974) in metropolitan Toledo revealed a 66% reduction of the average annual age-adjusted incidence rate and a 61% reduction in death rate of cervical squamous carcinoma when the first time period (1955 to 1958) was compared with the last time period (1971 to 1974). The decrease for both morbidity and mortality rates was more pronounced in women age 50 years and younger. The age-adjusted death rate during this study period revealed 15.5/100,000 for black women and 8.7/100,000 for white women. The reduction in death rate of 83% in black women is more prominent than 54.5% in white women. The decrease in both morbidity and mortality for cervical squamous carcinoma has a close relation to cytologic screening activity. The factors of age and race, probably related to socioeconomic status, are two known determinants of risk for cervical squamous carcinoma. Data for endometrial carcinoma during this study period revealed 15.5/100,000 women in the average age-adjusted incidence and an increase of 13.8% in average yearly rates when the first time period (1955 to 1958) were compared with the last time period (1971 to 1974). The peak age was 60 to 64 years old in the first time period and shifted to 70 to 74 years old in the last time period. The trend in metropolitan Toledo is comparable to that of Louisville, Kentucky. The mass cytologic screening program which contributed to a remarkable reduction in morbidity and mortality for the cervical squamous carcinoma, did not have any beneficial effect on endometrial carcinoma.

Localized in situ amplification (LISA): a novel approach to in situ PCR.

Amplification of specific gene target sequences has become a routine molecular procedure in a variety of laboratories. When coupled with either a direct or indirect method of detecting amplified product, in situ amplification offers an extremely powerful investigative tool. We describe a protocol for a localized in situ amplification (LISA) reaction that includes tissue-culture cloning rings and allows for the amplification of gene target sequences in specific regions of paraffin-embedded tissue sections. Digoxigenin-11-dUTP was added to the amplification reaction and thus incorporated into the amplified products, providing a mechanism by which direct nonisotopic detection could be performed. To demonstrate the approach, LISA was performed on known positive Pneumocystis carinii rat lung tissues, with primers specific for the P. carinii rRNA gene sequence.