Utilization of the validated Psoriasis Epidemiology Screening Tool to identify signs and symptoms of psoriatic arthritis among those with psoriasis: a cross-sectional analysis from the US-based Corrona Psoriasis Registry.

BACKGROUND: Despite increasing awareness of the disease, rates of undiagnosed psoriatic arthritis (PsA) are high in patients with psoriasis (PsO). The validated Psoriasis Epidemiology Screening Tool (PEST) is a five-item questionnaire developed to help identify PsA at an early stage. OBJECTIVES: To assess the risk of possible undiagnosed PsA among patients with PsO and characterize patients based on PEST scores. METHODS: This study included all patients enrolled in the Corrona PsO Registry with data on all five PEST questions. Demographics, clinical characteristics and patient-reported outcomes were compared in Corrona PsO Registry patients with PEST scores ≥3 and <3 using t-tests for continuous variables and chi-squared tests for categorical variables; scores ≥3 may indicate PsA. RESULTS: Of 1516 patients with PsO, 904 did not have dermatologist-reported PsA; 112 of these 904 patients (12.4%) scored ≥3 and were significantly older, female, less likely to be working, and had higher BMI than patients with scores <3. They also had significantly longer PsO duration, were more likely to have nail PsO and had worse health status, pain, fatigue, Dermatology Life Quality Index and activity impairment. CONCLUSIONS: Improved PsA screening is needed in patients with PsO because the validated PEST identified over one-tenth of registry patients who were not noted to have PsA as having scores ≥3, who could have had undiagnosed PsA. Appropriate, earlier care is important because these patients were more likely to have nail PsO, worse health-related quality of life and worse activity impairment.

Further clues to recognition of patients with fibromyalgia from a simple 2-page patient multidimensional health assessment questionnaire (MDHAQ).

OBJECTIVE: To analyze quantitative scores for pain, fatigue, functional disability, and the number of symptoms on a review of systems on a multidimensional health assessment questionnaire (MDHAQ), including the ratios of scores for pain to physical function and fatigue to physical function, and to further study how these scores can help to identify patients with fibromyalgia. METHODS: All consecutive patients seen at a rheumatology clinic completed a 2-sided, 1-page MDHAQ at each visit to assess physical function, pain, fatigue, global status, helplessness and review of systems, and had their erythrocyte sedimentation rate (ESR) measured. Scores for these variables were analyzed in 78 consecutive patients with fibromyalgia over a two-year period, and in 149 patients with rheumatoid arthritis (RA) as a "control" group. A subset analysis was conducted in patients with RA who were classified independently according to clinical criteria as having or not having coexistent fibromyalgia. Descriptive statistics, logistic regression, and receiver-operating-characteristic curves were computed for patients with fibromyalgia and compared to patients with RA. RESULTS: Patients with fibromyalgia had high ratios of pain:physical function and fatigue:physical function scores, and a high number of reported symptoms. These quantitative data differed significantly from patients with RA. Patients with fibromyalgia also had a lower ESR than patients with RA, whose scores were similar whether or not there was coexistent fibromyalgia. Patients with fibromyalgia were distinguished equally well from patients with RA by patient questionnaire data as by the ESR. CONCLUSION: A simple 1-page, 2-sided patient questionnaire provides quantitative information which may contribute to identify patients with fibromyalgia, including patients with RA who may also have coexistent fibromyalgia.

Can diet in conjunction with stress reduction affect the rate of increase in prostate specific antigen after biochemical recurrence of prostate cancer?

PURPOSE: Epidemiological and laboratory evidence indicates that a Western diet is associated with an increased incidence of prostate cancer. Specific components of the diet, such as high saturated fat, low fiber and high meat content, may have greatest clinical significance in the later stages of tumor promotion and progression. However, departure from the conventional diet is difficult to initiate and maintain. Therefore, we combined the well-known Mindfulness-Based Stress Reduction (MBSR) program with a low saturated fat, high-fiber, plant-based diet to determine the effect on the rate of change in prostate specific antigen (PSA) in patients with biochemical recurrence after prostatectomy. MATERIALS AND METHODS: We enrolled 10 men and their partners in a 4-month group-based diet and MBSR intervention. A pre-study post-study design in which each subject served as his own control was used to compare the rate of increase in and doubling time of PSA before and after intervention. RESULTS: The rate of PSA increase decreased in 8 of 10 men, while 3 had a decrease in absolute PSA. Results of the signed rank test indicated a significant decrease in the rate of increase in the intervention period (p = 0.01). Estimated median doubling time increased from 6.5 months (95% confidence interval 3.7 to 10.1) before to 17.7 months (95% confidence interval 7.8 to infinity) after the intervention. CONCLUSIONS: Our small study provides evidence that a plant-based diet delivered in the context of MBSR decreases the rate of PSA increase and may slow the rate of tumor progression in cases of biochemically recurrent prostate cancer. Larger-scale randomized studies are warranted to explore further the preventive and therapeutic potential of diet and lifestyle modification in men with prostate cancer.

Fetal surgery for myelomeningocele and the incidence of shunt-dependent hydrocephalus.

CONTEXT: Intrauterine closure of exposed spinal cord tissue prevents secondary neurologic injury in animals with a surgically created spinal defect; however, whether in utero repair of myelomeningocele improves neurologic outcome in infants with spina bifida is not known. OBJECTIVE: To determine whether intrauterine repair of myelomeningocele improves patient outcomes compared with standard care. DESIGN: Single-institution, nonrandomized observational study conducted between January 1990 and February 1999. SETTING: Tertiary care medical center. PARTICIPANTS: A sample of 29 study patients with isolated fetal myelomeningocele referred for intrauterine repair that was performed between 24 and 30 gestational weeks and 23 controls matched to cases for diagnosis, level of lesion, practice parameters, and calendar time. All infants were followed up for a minimum of 6 months after delivery. MAIN OUTCOME MEASURES: Requirement for ventriculoperitoneal shunt placement, obstetrical complications, gestational age at delivery, and birth weight for study vs control subjects. RESULTS: The requirement for ventriculoperitoneal shunt placement for decompression of hydrocephalus was significantly decreased among study infants (59% vs 91%; P = .01). The median age at shunt placement was also older among study infants (50 vs 5 days; P = .006). This may be explained by the reduced incidence of hindbrain herniation among study infants (38% vs 95%; P<.001). Following hysterotomy, study patients had an increased risk of oligohydramnios (48% vs 4%; P = .001) and admission to the hospital for preterm uterine contractions (50% vs 9%; P = .002). The estimated gestational age at delivery was earlier for study patients (33.2 vs 37.0 weeks; P<.001), and the birth weight of study neonates was less (2171 vs 3075 g; P<.001). CONCLUSIONS: Our study suggests that intrauterine repair of myelomeningocele decreases the incidence of hindbrain herniation and shunt-dependent hydrocephalus in infants with spina bifida, but increases the incidence of premature delivery.

Prevention of preterm birth. Role of daily telephone contact.

OBJECTIVE: To compare the effectiveness of routine management of patients at high risk for preterm delivery to the effectiveness of routine management in combination with daily telephone nursing contact. STUDY DESIGN: The control group, 1 (n = 21), had education and frequent prenatal visits and cervical examinations. The study group, 2 (n = 21), had education, frequent prenatal visits and cervical examination, and daily telephone contact. Group 3 (n = 22) received education but refused to participate. RESULTS: There were no significant differences (SD) between groups in race, smoking, age, multiple gestation, visits, diagnosis of premature labor, mean days gained after diagnosis of premature labor, tocolytic use or bed rest. There was also no SD in preterm birth rate, mode of delivery, number of maternal or neonatal hospital days, mean neonatal weight or gestational age at delivery between groups. While not reducing the overall incidence of preterm birth, this management for all groups resulted in a more advanced gestational age at the time of delivery (mean change = 7.5 weeks, P < .0001) when compared to the patient's first preterm birth. CONCLUSION: This study indicated that daily contact, while providing reassurance and support, did not change the outcome when the study group was compared to women managed similarly but without daily contact.

Fat and carbohydrate overfeeding in humans: different effects on energy storage.

Both the amount and composition of food eaten influence body-weight regulation. The purpose of this study was to determine whether and by what mechanism excess dietary fat leads to greater fat accumulation than does excess dietary carbohydrate. We overfed isoenergetic amounts (50% above energy requirements) of fat and carbohydrate (for 14 d each) to nine lean and seven obese men. A whole-room calorimeter was used to measure energy expenditure and nutrient oxidation on days 0, 1, 7, and 14 of each overfeeding period. From energy and nutrient balances (intake-expenditure) we estimated the amount and composition of energy stored. Carbohydrate overfeeding produced progressive increases in carbohydrate oxidation and total energy expenditure resulting in 75-85% of excess energy being stored. Alternatively, fat overfeeding had minimal effects on fat oxidation and total energy expenditure, leading to storage of 90-95% of excess energy. Excess dietary fat leads to greater fat accumulation than does excess dietary carbohydrate, and the difference was greatest early in the overfeeding period.

The white blood cell response to splenectomy and bacteraemia.

The aim of this study was to determine the relationship of the white blood cell (WBC) count to bacteraemia, and the risk of bacteraemia after splenectomy. The case series study was carried out at the Vanderbilt University Level I Trauma Center, and included 11,870 consecutive trauma admissions: 258 required a splenectomy (191) or splenorrhaphy (67). Bacteraemia was defined as the presence of a positive blood culture. Statistical analysis included ANOVA, the non-parametric Kruskal-Wallis test and logistical regression. Forty-two (22 per cent) of the splenectomy patients had positive blood cultures, while only six (9 per cent) of the splenorrhaphy patients had positive cultures. For the group of patients requiring a splenectomy, the mean WBC count was higher and more persistent in patients with bacteraemia. Logistical regression demonstrated that the type of surgery does not significantly correlate with bacteraemia after accounting for severity of injury (TRISS). The study conclusions were as follows (1) for the group of patients with bacteraemia after splenectomy, the peak WBC count was higher and more persistent than that which occurred in the group of patients without bacteraemia after splenectomy; (2) the WBC count cannot be used to predict bacteraemia for an individual patient, but a WBC count greater than 20,000 after 10 days should initiate a vigorous search for infection; (3) the severity of injury (and not splenectomy/splenorrhaphy) accounted for the increased risk of bacteraemia in population studied.

Safety of the blood supply. Surrogate testing and transmission of hepatitis C in patients after massive transfusion.

OBJECTIVE: To define a risk profile for post-transfusion hepatitis C in patients receiving massive transfusion. SUMMARY BACKGROUND DATA: Hepatitis C accounts for more than 90% of post-transfusion hepatitis. METHODS: Two-hundred twenty-one of 8,765 consecutive trauma admissions to a Level I trauma center received more than 20 units of erythrocytes. Sixty-nine survivors had positive viral serologic tests at least 1 year after transfusion. Surrogate testing for hepatitis C using alanine aminotransferase (ALT) levels and antibodies to hepatitis B core antigen (Core) began in October 1986 and January 1987, respectively. Donor blood for group 1 (pre-ALT/Core) was transfused before surrogate screening was introduced. Donor blood for group 2 (post-ALT/Core) was transfused after surrogate screening. RESULTS: Sixty-nine patients received blood products from 4,987 donors (mean, 72.3 units of exposure). No patient tested positive for antibodies to hepatitis B surface antigen, human immunodeficiency virus, or human T-lymphotrophic virus type 1. However 23.2% tested positive for hepatitis C virus (HCV) as measured by a second-generation enzyme immunoassay (HCV 2.0) and a recombinant immunoblot assay (RIBA), and 21.7% tested positive by HCV 1.0. Antibodies to Core were found in 8.7% of patients. The risk for post-transfusion hepatitis C per unit of exposure is estimated to be 1.52% group 1 (pre-ALT/Core) and 0.239% for group 2 (post-ALT/Core). CONCLUSIONS: The introduction of ALT/Core donor screening by a blood bank reduced the incidence of post-transfusion hepatitis C by 84%. The risk for post-transfusion hepatitis C depends on units of exposure, screening techniques, and prevalence of hepatitis C in the donor population. In our community, the risk for post-transfusion hepatitis C is less than 0.2% per unit of exposure. The population of massively transfused patients may serve as our effective resource for monitoring the safety of the blood supply.

Comparison of live attenuated and inactivated influenza vaccines in cystic fibrosis patients and their families: results of a 3-year study.

Forty-one cystic fibrosis (CF) patients and 89 family members were immunized in a double-blind randomized 3-year trial with either intranasal live cold-adapted (ca) influenza A vaccine or the recommended intramuscular trivalent inactivated (triv) influenza vaccine. Local, respiratory, and systemic symptoms after vaccine were infrequent and did not differ between vaccine groups. CF patients did not differ from family members in immune response to either vaccine. Although antibody responses tended to be higher after triv vaccine, > or = 85% of subjects had mean hemagglutination inhibition antibody titers > or = 1:32 to influenza H1N1 and H3N2 after the first dose of either vaccine. Infection with influenza H3N2 viruses circulating during this study occurred with comparable low frequency in CF patients after ca (14 infections/100 subject-years of observation) or triv vaccine (10 infections/100 subject-years of observation). Influenza A ca vaccines appear to be safe, immunogenic alternatives to influenza A inactivated vaccines for CF patients and their families.

A review of the results of laparoscopic versus open appendectomy.

Proponents of laparoscopic appendectomy emphasize the advantages of laparoscopic operation--decreased hospitalization, paralytic ileus, postoperative pain and wound complications, including infection. This study compared open laparoscopic appendectomy with laparoscopic appendectomy. To compare the two techniques, patients undergoing laparoscopic appendectomy at four hospitals were compared with patients undergoing open appendectomy during a six month period. Excluded were incidental appendectomies and patients with perforated appendicitis. An equal number of pediatric patients undergoing laparoscopic and open procedures were included in the analysis to avoid bias, because most of the laparoscopic appendectomies were performed in the adult patient population (age of more than 16 years). A University Medical Center, a Veterans Administration and two community hospitals were the settings. Patients undergoing laparoscopic appendectomy (n = 54) had an average age of 25.7 +/- 1.5 (range of six to 59 years). These patients were compared with 121 patients undergoing open appendectomy whose average age was 23.7 +/- 1.8 (range of three to 83 years). The race and gender distribution were similar in the two groups. Traditional open appendectomy was compared with a group of patients undergoing laparoscopic appendectomy. Variables evaluated were operating room time, number of patients who reported nausea, days until patient tolerated a regular diet, days of hospitalization, postoperative pain medication and wound infection rate. Results are expressed as the mean plus or minus standard error of the mean. Analysis of variance was used to compute continuous variables and Fischer's exact test was used for discrete variables. The laparoscopic approach was attempted in 61 patients and completed in 54 patients. Open appendectomy was performed upon 121 patients. Nineteen patients (18 who underwent open operation and one patient who underwent laparoscopic operation) were excluded from further analysis because of perforated appendicitis. The open procedure took less time (p < 0.05). However, there were more wound infections than in the laparoscopic group (seven of 103 versus zero of 53; p = 0.09). Patients with acute appendicitis recuperated more quickly from the laparoscopic procedure, as evidenced by the time until eating regular diet, period of hospitalization, incidence of nausea and pain medications on postoperative day one (p < 0.05). The absence of wound infections after laparoscopic appendectomy can be attributed to the practice of placing the appendix in a sterile bag or into the trocar sleeve before removal from the abdomen. Laparoscopic appendectomy reduces the period of hospitalization, postoperative ileus, nausea and postoperative pain in patients with acute appendicitis.(ABSTRACT TRUNCATED AT 400 WORDS)

Long-term visual results and complications in children with aphakia. A function of cataract type.

PURPOSE: Previous studies of outcome in children with aphakia have approached the data by grouping patients according to features such as age at surgery, type of procedure, or some other common attribute. The purpose of this study is to identify factors predictive for visual outcome and complications in pediatric patients with cataracts. METHOD: One hundred seventy-four eyes in 118 patients underwent lensectomy and anterior vitrectomy for congenital or juvenile cataracts. All received early optical correction, occlusion therapy when necessary, and follow-up for at least 6 months. Visual outcome and complications were analyzed statistically to determine predictive factors. Features analyzed included cataract type, laterality, age at onset, follow-up, and corneal size. RESULTS: Statistical analysis showed that the most important predictor of long-term visual outcome and complications is cataract type. Visual outcome differed significantly by cataract type, with best results in the lamellar and posterior lentiglobus groups. Unilateral cases had a mean acuity lower than bilateral cases. Other factors, such as age at surgery and corneal size, were less predictive but closely linked to cataract type. Complications, such as aphakic glaucoma, also were more closely linked to the type of cataract than to other variables. CONCLUSION: The results indicate that an important determinant of long-term outcome and complications in aphakic children is cataract type. Other features were found to be closely correlated to cataract type and were not independently significant.

Chorionic villus sampling: quality control--a continuous improvement model.

OBJECTIVE: Our purpose was to describe Vanderbilt University Medical Center's experience in establishing a chorionic villus sampling program and the importance of quality control along with a continuous improvement model on the first 1000 cases. STUDY DESIGN: A continuous improvement model was established with emphasis on a multidisciplinary team approach and quality assurance process. A computerized data base was used for continuing analysis of complications and for allowing facile access to pertinent information. RESULTS: A continuous improvement model allowed for an improved process and outcome for patients, personnel, and referring health care providers. Follow-up for initial symptoms after chorionic villus sampling was obtained on 98.5% of patients. Pregnancy follow-up, including birth data, was obtained on 93%. CONCLUSION: A continuous improvement mode from the project's onset resulted in an improved process and outcome, information helpful for accessing spontaneous abortion rates and pregnancy outcomes (including the incidence of limb abnormalities and factors associated with abortions) and recommendations for training personnel.

Human papillomavirus in women. A three-year experience in a county hospital colposcopy clinic.

The human papillomavirus (HPV) has been associated with cervical dysplasia and carcinoma. This report summarizes the authors' experience with HPV-related problems over three years, 1987-89, while managing 1,644 women at a county hospital colposcopy clinic. Probes for HPV DNA were not used, and the diagnoses were made with cytologic and histologic criteria alone. The percentage of patients referred to the clinic with HPV found on routine Papanicolaou smears rose significantly, from 3 in 1987 to 18 in 1989. Fifteen percent of those referred because of HPV on a Papanicolaou smear were found to have cervical intraepithelial neoplasia (CIN) grade II or III after they were evaluated at the clinic. Of the 367 cases of biopsy-proven cervical HPV, only 33 (9%) were recorded on Papanicolaou smears performed immediately before the biopsy, and 140 (38%) also had concomitant, biopsy-proven CIN, grade II or III. Of the 195 instances in which the colposcopic impression was simple HPV without CIN, 46 (24%) had high-grade CIN on biopsy. We conclude that the proportion of patients with HPV-associated problems is increasing, that the Papanicolaou smear is not sensitive in detecting cervical HPV infections, that patients with HPV changes found on Papanicolaou smears should be evaluated with colposcopy and that lesions that appear colposcopically to be simple HPV should undergo biopsy to rule out the presence of high-grade CIN.

Depth of myometrial invasion in endometrial cancer: preoperative assessment by transvaginal ultrasonography.

Twenty-five patients with cancer of the uterus underwent transvaginal sonography (TVS) to assess depth of myometrial invasion. All scans were performed with a 5.0-MHz curvilinear array probe (Toshiba, Inc., Tustin, CA) within 1 week of hysterectomy. In 21 cases (84%) sonography correctly predicted the depth of invasion (within 15% of actual). Only one of three cases with cervical involvement was detected. Transvaginal sonography can accurately detect depth of myometrial invasion and is well suited as a screening test to detect high-risk patients for consultation or referral.

Bone and soft tissue changes in paraplegic patients.

The loss of bone mineral in 66 paraplegic patients has been measured in the lower femoral shaft by scanning the leg with a beam of mono-energetic radiation from 241Am. The profile of the transmitted radiation was used to determine a parameter which was related to bone mass. The bone mass of paraplegic patients was significantly lower than normal. Persistent paralysis does not lead to a continued fall in bone mass, but once it has fallen, bone mass remains constant. Soft tissues also showed a muscle/fat ratio was lower than normal.