Cognitive decline in the middle-aged after surgery and anaesthesia: results from the Wisconsin Registry for Alzheimer's Prevention cohort.

Surgery and anaesthesia might affect cognition in middle-aged people without existing cognitive dysfunction. We measured memory and executive function in 964 participants, mean age 54 years, and again four years later, by when 312 participants had had surgery and 652 participants had not. Surgery between tests was associated with a decline in immediate memory by one point (out of a maximum of 30), p = 0.013: memory became abnormal in 77 out of 670 participants with initially normal memory, 21 out of 114 (18%) of whom had had surgery compared with 56 out of 556 (10%) of those who had not, p = 0.02. The number of operations was associated with a reduction in immediate memory on retesting, beta coefficient (SE) 0.08 (0.03), p = 0.012. Working memory decline was also associated with longer cumulative operations, beta coefficient (SE) -0.01 (0.00), p = 0.028. A reduction in cognitive speed and flexibility was associated with worse ASA physical status, beta coefficient (SE) 0.55 (0.22) and 0.37 (0.17) for ASA 1 and 2 vs. 3, p = 0.035. However, a decline in working memory was associated with better ASA physical status, beta coefficient (SE) -0.48 (0.21) for ASA 1 vs. 3, p = 0.01.

The Room Where It Happens: Clinician Reflections on Returning Preclinical Alzheimer's Biomarker Results to Research Participants.

Disclosing Alzheimer's disease (AD) biomarkers to research participants is a growing practice. Here, we aim to synthesize the experiences of clinicians leading preclinical AD biomarker disclosure. Semi-structured interviews were conducted individually with each of the four clinicians conducting biomarker disclosure as a part of a longitudinal, observational AD cohort study. Study clinicians emphasized the importance of participant education, having adequate time available for the disclosure visit, and forms to facilitate disclosure. To train and support future clinicians conducting AD biomarker disclosure, our study clinicians highlighted providing information about AD and biomarkers, shadowing a disclosure visit, having team debriefing sessions, and collating a frequently asked questions document. To date, this is the first characterization of clinician reflections on disclosing AD biomarker result to cognitively unimpaired research participants. As more clinicians in research or clinical settings seek to disclose AD biomarker results, best practices for training clinicians to lead disclosure are necessary.

Enhanced pancreatic CT imaging utilizing a geometric magnification technique.

Computed tomography (CT) using a geometric magnification technique was found to improve spatial resolution in phantom studies when compared with conventional third-generation geometry images. The clinical feasibility of using geometric magnification, small focal spot size, and dynamic contrast enhancement was studied in 143 patients referred to CT for clinically suspected pancreatic disease. This population included 46 patients with a normal pancreas and 36 patients subsequently proven to have primary pancreatic carcinoma. Using this new technique in conjunction with dynamic contrast enhancement resulted in high quality pancreatic images. Despite the limitations in tube current associated with a small focal spot size and low total heat capacity of the system, clinical imaging was not adversely affected. Use of the geometric magnification technique is recommended in departments where it is technically feasible.

Effect of HIV counseling and testing on sexually transmitted diseases and condom use in an urban adolescent population.

OBJECTIVE: To determine whether human immunodeficiency virus (HIV) counseling and testing has an effect on reducing subsequent risk behaviors in those tested, to evaluate stability in condom use over time, and to determine whether self-reported frequency of condom use relates to the incidence of sexually transmitted diseases (STDs). DESIGN: Cohort study with 2-year follow-up. SETTING: An urban adolescent-medicine clinic. PARTICIPANTS: A random sample of 149 patients (118 female and 31 male adolescents) with a mean (+/- SD) age of 16.4 +/- 1.51 years were selected from a cohort of 500 patients at high risk for HIV infection. The patients had received a risk behavior questionnaire during pretest counseling for HIV testing. They were divided into 3 groups, identified by the letter F, S, or R, based on their self-report of frequency of condom use at enrollment: 24% used condoms frequently/always (F); 40%, sometimes (S); and 36%, rarely/never (R). One hundred twenty-six patients (85%) made return visits. INTERVENTION: HIV counseling and testing. MAIN OUTCOME MEASURES: Medical record documentation of STDs before and after HIV testing, and self-reported condom use frequency. RESULTS: Before HIV testing, all 3 condom use groups had a similar frequency of STD visits per month. The number of STD visits per month did not decrease significantly in the posttest period for either the total group or each of the 3 subgroups. Also, most patients (F, 67%; S, 44%; R, 53%) in each of the 3 subgroups had shifted unfavorably to rarely/never (R) condom use within the month before their follow-up visit. Only 24% (8 patients) of those in the initial frequently/always (F) group reported continued frequent condom use. CONCLUSIONS: As has been found in adult studies, single-dose interventions such as HIV counseling and testing did not seem to reduce HIV risk behaviors in our sample of high-risk adolescent patients. None of the 3 groups showed a significant decrease in STDs after HIV testing and counseling. Also, our adolescent patients reported widely varying condom use frequency over time, yet the incidence of STDs did not correlate with self-reported condom use.

Imaging of the liver, biliary tract, and pancreas.

The interaction between the various noninvasive and invasive imaging modalities used to evaluate the liver, biliary tract, and pancreas is demonstrated in this article. By understanding this interaction and correlating noninvasive studies, the clinician will avoid diagnostic redundancy and the need for invasive testing may be reduced.

Pancreatic imaging.

In this article, the pancreas is evaluated with regard to the controversies surrounding this organ from a clinical standpoint, and an approach to imaging modalities is examined. The roles of computed tomography, ultrasound, endoscopic retrograde cholangiopancreatography, and magnetic resonance imaging are put into proper perspective.

Imaging approach to the suspected renal mass.

The authors present their algorithmic approach to the detection, characterization, and staging of renal masses. Based on classification of urographic findings, the patient may be triaged to the appropriate cross-sectional or invasive imaging modality that will result in the most cost-effective management.

Hepatic imaging: current status.

The radiologist needs to be aware of the varied appearance of hepatic mass lesions and be prepared to recommend the most cost-effective imaging approach. In this article, the authors discuss their hepatic imaging experience, common pitfalls, and current recommendations.

Controversies in the radiologic diagnosis of pelvic malignancies.

Although vast differences exist among the many pelvic malignancies, several unifying concepts emerge from this discussion. First, there is a different role for diagnostic imaging for each type of pelvic malignancy. The radiologist should be aware that although the radiographic findings may be similar, the clinical impact varies greatly with a particular tumor. Second, although clinical staging is notoriously inaccurate, nevertheless diagnostic imaging techniques only improve upon but do not replace it because of false-positive and false-negative results. Third, because of the high false-negative rates of most of the modalities in use, negative studies do not in fact rule out the presence of disease. A surgical procedure may still be needed. Finally, several new techniques, including MRI and transrectal or transurethral ultrasound, may improve the accuracy rates. These developments will probably further enliven the controversies surrounding the radiologic evaluation of pelvic malignancies.

Are adolescents accurate in self-report of frequencies of sexually transmitted diseases and pregnancies?

PURPOSE: Many surveys of adolescent behavior are dependent on self-reported data. We sought to assess the accuracy of adolescent self-report of sexually transmitted diseases (STDs) and pregnancies. METHODS: We randomly selected 149 (118 females, 31 males) adolescents to participate in this accuracy study. Follow-up questionnaires were administered to the 126 patients (99 females, 27 males) who returned after enrollment. Patients were asked about STDs and pregnancies during the follow-up period which ranged from 6 months to 1 year. All patient charts were reviewed to validate post-testing history. RESULTS: Return visits were made by 126 patients (84%). Fifty-one (40%) denied having had an STD at all during the follow-up period but were found to have had at least one STD. Another 11 (9%) admitted having had an STD but had multiple STDs in excess of what they reported. Only 46% of the patients provided accurate information on the follow-up questionnaire. Of the 99 girls who returned for follow-up, the inaccurate patients (10%) consisted of 9 who reported no visits for a pregnancy but had a pregnancy documented in their charts and 1 who underreported her number of pregnancies. Reliability analysis of the accuracy of STD and pregnancy self-report for our patients showed kappas ranging from 0.185 to 0.413 (slight and fair to moderate, respectively). Pearson correlation coefficients were 0.3107 and 0.4364 for STD and pregnancy, respectively. CONCLUSIONS: Our patients' histories of visits for STDs and pregnancies are often not substantiated by review of their medical records. The reason for the inaccuracies in self-report of sexual behaviors is unclear. Further research in this area should be done. Physicians must confirm patient history concerning sexual practices through appropriate record review and medical evaluation.

PIP: Many studies of adolescent sexual behavior are based on self-reported data. The present study sought to assess the accuracy of adolescents' self-reports of pregnancies and sexually transmitted diseases (STDs). Enrolled were 149 predominantly African-American adolescents (118 females and 31 males) who visited the Children's National Medical Center (Washington, DC) for outpatient care; 126 respondents (99 females and 27 males) completed a follow-up questionnaire 6-12 months later. The medical charts of these 126 adolescents were reviewed to validate post-testing history. Only 46% of adolescents provided accurate information on STDs in the follow-up questionnaire. 51 adolescents denied they had an STD during the follow-up period but, in fact, had at least 1 STD recorded. Another 11 acknowledged having had 1 STD but, in fact, had multiple STDs. In terms of pregnancies, 76% of female participants were accurate responders. 9 females who had a pregnancy recorded in their charts denied a pregnancy in the follow-up questionnaire and 1 underreported the number of pregnancies. Reliability analysis of the accuracy of STD and pregnancy self-reports showed kappas of 0.185 and 0.413, respectively, while the Pearson correlation coefficients were 0.317 and 0.4364, respectively. These findings indicate that adolescents frequently provide inaccurate information regarding their sexual histories. The contribution of factors such as discomfort with the interviewer, a lack of privacy in the interview, and a misunderstanding of information conveyed by health staff about STDs to this phenomenon is unknown, however.

Effectiveness of self-instruction for arthritis patient education.

Self-instruction is one means of providing patient education, allowing the health professional to teach a larger number of persons than with one-to-one or group instruction and at a lower cost. The purpose of this study was to examine the effects of self-instruction on learning, satisfaction with the teaching approach, and health status of persons with rheumatoid arthritis (RA). A control-group pretest-posttest design was used. Thirty subjects receiving care at a rheumatology clinic who met study criteria were randomly assigned to two groups: self-instruction and control. One-way analysis of covariance on posttest Rheumatoid Arthritis Knowledge Inventory (RAKI) scores, with the pretest as covariate, was used to examine the difference in learning between the self-instruction and control groups. There was a significant difference between the groups (P = 0.01). Participants who completed the self-instructional program had improved scores on the posttest as compared to the control. Subjects rated self-instruction as an effective teaching strategy in terms of promoting learning about RA and patient acceptability. t-Test demonstrated no significant difference between the groups in health status. Significant correlations were found between subjects' test scores and selected variables.

Will the pill make me sterile? Addressing reproductive health concerns and strategies to improve adherence to hormonal contraceptive regimens in adolescent girls.

UNLABELLED: PAPER OBJECTIVE: This paper is designed to help clinicians understand the relationship between hormonal contraceptive side effects and the potential development of general and reproductive health concerns that can impact on adherence to hormonal contraception. By understanding the concerns raised by young women, we can then make our counseling more specific to the factors that affect compliance in this population. DESIGN: Studies that specifically addressed hormonal contraceptive compliance, side effects, and method selection in adolescents and young women were chosen for this paper. All articles were from peer-reviewed journals. Medline-Ovid articles from 1980-2000 were used with the following search keywords: Contraception, Patient Compliance, Hormonal Contraception, Oral Contraceptive Pills, Norplant, Depo Provera, and Adolescents. DATA SYNTHESIS: The general public has many concerns about the safety of hormonal contraception. The development of side effects, especially those that are menstrual-related, seem to cause adolescents and young women to feel that their general and reproductive health is being threatened. CONCLUSIONS: Hormonal contraceptive counseling should include 1) explaining, in a nontechnical manner, how these methods work; 2) addressing negative information the patient has heard about the methods; 3) providing factual information about cancer risks, blood clots, and other general health concerns; 4) discussing the potential side effects and what each means to her health; 5) asking specifically about possible reproductive health worries, especially in light of the menstrual irregularities that may occur; and 6) assuring the patient that she should always feel free to share her concerns and worries with you, the provider.

Alternative nursing environments: do they affect hospital outcomes?

1. A dayroom program focused intensively on functional needs and was implemented for confused geriatric inpatients who otherwise might have been restrained or required sitters. 2. There were fewer complications from hospitalization documented for dayroom patients. 3. There was an increase in family satisfaction regarding the nursing care provided for patients in the alternative environment.

Esophageal malignancy: imaging results and complications of combined endoscopic-radiologic palliation.

Fifty-one patients with advanced cancer of the esophagus underwent 191 endoscopic palliative procedures, including bouginage, laser therapy, bipolar electrocoagulation, and stent placement. In three patients free perforations developed; these were treated immediately and no sequelae developed. Perforations confined within the tumor mass were diagnosed with CT in two patients and did not require treatment. Methods of endoscopic palliation are discussed with reference to the radiologic studies and techniques. The radiologist must evaluate tumor topography and esophageal wall thickness with computed tomography and esophagography to aid in the choice of palliative therapy. Knowledge of each technique and its risks by the radiologist is essential for useful consultation with the endoscopist before, during, and after the procedure.

Renal metastases: clinicopathologic and radiologic correlation.

The clinical and radiologic features of 27 patients with renal metastases arising from eight different types of nonlymphomatous primary malignancies are presented. Renal metastases were generally detected late in the course of the malignancy. In 23 patients there were no symptoms referable to the kidney. Urinalysis was normal in nine patients and showed microscopic hematuria in nine, gross hematuria in four, and proteinuria in four. Radiologically, metastases were usually multifocal; however, metastases arising from colon, lung, and breast carcinoma were sometimes large, solitary, and otherwise indistinguishable from primary renal cell carcinoma. Three of four melanoma metastases and three of seven lung metastases infiltrated the perinephric space. Computed tomography was the most sensitive modality, depicting renal metastases in all 24 cases in which it was employed, followed by ultrasound and intravenous urography. In patients with a history of malignancy, renal metastases outnumbered renal cell carcinomas by approximately 4:1. This study indicates that a new renal lesion in a patient with advanced, noncurable cancer is more likely metastatic than primary and that biopsy in this setting is unlikely to be of aid.

Renal cell carcinoma: dynamic thin-section CT assessment of vascular invasion and tumor vascularity.

Dynamic thin-section computed tomography (CT) was used to evaluate renal cell carcinoma in 80 patients. The lesion was correctly staged with CT in 90% of patients. With use of the dynamic technique, the ipsilateral renal vein was depicted in 99% of patients. Extension of the tumor to the renal vein or the inferior vena cava was correctly detected in 18 of 19 patients. Actual depiction of tumor thrombus was a far more accurate indicator of renal vein invasion than was the identification of isolated renal vein enlargement. Dynamic thin-section CT of the kidney should be considered the routine method for comparison studies with other newer cross-sectional techniques in the evaluation of renal cell carcinoma.

CT evaluation of suspected hepatic metastases: comparison of techniques for i.v. contrast enhancement.

Although IV injection of contrast material is widely used for detection and follow-up of hepatic metastases on CT, the optimal method of contrast enhancement has not yet been defined. A prospective study was performed in 50 consecutive patients with suspected hepatic metastases. Lesion size and detectability were compared on unenhanced CT scans, scans obtained during a bolus injection of contrast material (early bolus phase), and scans obtained during a rapid infusion after the loading bolus. A total of 60 hepatic lesions were evaluated in 26 patients, 19 with histologic confirmation of metastases and seven with strong supportive evidence. The bolus phase allowed detection of 15% more lesions than did examination during the rapid-infusion phase. Lesion size varied, depending on the timing and method of contrast administration; the largest measurements were obtained during bolus injection of contrast material. In addition, bolus administration of contrast material subjectively resulted in the best lesion detection. Because the three techniques of IV contrast enhancement may produce different size measurements, sequential examinations must be tailored appropriately. Scanning during the bolus phase is technically possible with current CT equipment and is recommended as the primary CT screening examination for hepatic metastases.

Perirenal cobwebs: the expanding CT differential diagnosis.

Although initially described as representing collateral venous structures, perirenal cobwebs may be due to a variety of benign and malignant conditions. Six representative cases illustrating the broad differential diagnosis are presented.