A qualitative evaluation of hospital versus community-based management of patients on injectable treatments for tuberculosis.

BACKGROUND: Patients being treated for recurrent or multidrug-resistant tuberculosis (TB) require long courses of injectable anti-tuberculous agents. In order to maintain strong TB control programmes, it is vital that the experiences of people who receive long-term injectables for TB are well understood. To investigate the feasibility of a novel model of care delivery, a clinical trial (The TB-RROC Study) was conducted at two central hospitals in Malawi. Hospital-based care was compared to a community-based approach for patients on TB retreatment in which 'guardians' (patient-nominated lay people) were trained to deliver injections to patients at home. This study is the qualitative evaluation of the TB-RROC trial. It examines the experiences of people receiving injectables as part of TB treatment delivered in hospital and community-based settings. METHODS: A qualitative evaluation of the TB-RROC intervention was conducted using phenomenographic methods. Trial participants were purposively sampled, and in-depth interviews were conducted with patients and guardians in both arms of the trial. Key informant interviews and observations in the wards and community were performed. Thematic content analysis was used to derive analytical themes. RESULTS: Fourteen patients, 12 guardians and 9 key informants were interviewed. Three key themes relating to TB retreatment emerged: medical experiences (including symptoms, treatment, and HIV); the effects of the physical environment (conditions on the ward, disruption to daily routines and livelihoods); and trust (in other people, the community and in the health system). Experiences were affected by the nature of a person's prior role in their community and resulted in a range of emotional responses. Patients and guardians in the community benefited from better environment, social interactions and financial stability. Concerns were expressed about the potential for patients' health or relationships to be adversely affected in the community. These potential concerns were rarely realised. CONCLUSIONS: Guardian administered intramuscular injections were safe and well received. Community-based care offered many advantages over hospital-based care for patients receiving long-term injectable treatment for TB and their families.

A systematic review of clinical outcomes on the WHO Category II retreatment regimen for tuberculosis.

OBJECTIVE: To assess the clinical outcomes of patients prescribed the World Health Organization (WHO) Category II retreatment regimen for tuberculosis (TB). DESIGN: A systematic review of the literature was performed by searching Medscape, Embase and Scopus databases for cohort studies and clinical trials reporting outcomes in adult patients on the Category II retreatment regimen. RESULTS: The proportion of patients successfully completing the retreatment regimen varied from 27% to 92% in the 39 studies included in this review. In only 2/39 (5%) studies was the treatment success rate > 85%. There are very few data concerning outcomes in patients categorised as 'other', and outcomes in this subgroup are variable. Of the five studies reporting disaggregated outcomes in human immunodeficiency virus (HIV) positive people, four demonstrated worse outcomes than in HIV-negative people on the retreatment regimen. Only four studies reported disaggregated outcomes in patients with isoniazid (INH) resistance, and treatment success rates varied from 11% to 78%. CONCLUSION: Clinical outcomes on the Category II retreatment regimen are poor across various populations. Improvements in management should consider the holistic treatment of comorbidity and comprehensive approaches to drug resistance in patients with recurrent TB, including a standardised approach for the management of INH resistance in patients who develop recurrent TB in settings without reliable access to comprehensive drug susceptibility testing.

Epidemiology of ventriculostomy in the United States from 1997 to 2001.

Ventriculostomy is a common practice in neurosurgery, but the annual trend of this procedure in the United States has not been reported in the literature. This study evaluates the annual trend during a recent 5-year period. Between 1997 and 2001, a retrospective review was undertaken concerning all patients in the Nationwide Inpatient Sample (NIS) who had undergone ventriculostomy. The population sample represented approximately a 20% stratified sample of nonfederal hospitals in the United States. The annual number of patients who underwent ventriculostomy during the study period ranged from 20,586 to 25,634. Most patients were male (53.4%), with a mean age of 44.8 years, were commercially insured (46.0%) and had a median annual income above $25,000 (84.4%). Most frequent ICD-9-CM diagnoses were subarachnoid haemorrhage, intracerebral haemorrhage and obstructive hydrocephalus, respectively. The majority of ventriculostomies were performed in large, private, not-for-profit, metropolitan, teaching institutions. Mean length of hospital stay was 19.2 days. Regarding discharge status for patients who had undergone ventriculostomy, approximately one-quarter died in the hospital, one-third were discharged home and one-third were transferred to another institution. No demographic variables changed during the study with the exception of location of ventriculostomy in a teaching hospital, which increased from 64.4% in 1997 to 77.4% in 2001. Patient and hospital demographic characteristics were consistent during the study period. By extrapolation of the data, the prevalence of ventriculostomy in the United States averaged 24,380 per year. This study is the first to comprehensively document data concerning the epidemiology of this common procedure.

Analysis of the risk factors for the development of post-operative spinal epidural haematoma.

In order to identify the risk factors and the incidence of post-operative spinal epidural haematoma, we analysed the records of 14 932 patients undergoing spinal surgery between 1984 and 2002. Of these, 32 (0.2%) required re-operation within one week of the initial procedure and had an International Classification of Diseases (ICD)-9 code for haematoma complicating a procedure (998.12). As controls, we selected those who had undergone a procedure of equal complexity by the same surgeon but who had not developed this complication. Risks identified before operation were older than 60 years of age, the use of pre-operative non-steroidal anti-inflammatories and Rh-positive blood type. Those during the procedure were involvement of more than five operative levels, a haemoglobin < 10 g/dL, and blood loss > 1 L, and after operation an international normalised ratio > 2.0 within the first 48 hours. All these were identified as significant (p < 0.03). Well-controlled anticoagulation and the use of drains were not associated with an increased risk of post-operative spinal epidural haematoma.

Approaches and informatics tools to assist in the integration of similar clinical research questionnaires.

OBJECTIVE: The integration of similar clinical research questionnaires is a complex process that can benefit from informatics approaches and tools that provide a systematic structure for performing mapping and integration. This systematic approach is necessary to address complex issues in integration such as data heterogeneity, differing levels of granularity of questions and responses, and other issues involving semantic differences. Informatics tools and approaches have been successfully applied to various standard clinical vocabulary integration processes but not for questionnaire integration or mapping. METHODS: A systematic approach to questionnaire integration was developed in the context of a collaboration of researchers using Trial/DB, a database designed to support clinical research. This approach was applied to the integration of questionnaires involving breast cancer risk factors from each of three research sites. RESULTS: From 375 questions on the three original questionnaires, we identified 65 concepts that were measured by two or three of the sites. An algorithm was developed and used to formalize the process of mapping questions and answers across the questionnaires. The approach was applied to previously collected data and prospective data in disparate data-base systems to import and merge the data from these three sites into Trial/DB. CONCLUSION: Informatics tools that support a systematic approach to mapping questionnaires can be used throughout the research process from questionnaire integration and creation, legacy data integration to data library maintenance and curation.

Postoperative morbidity, mortality, costs, and long-term survival in severely obese patients undergoing orthotopic liver transplantation.

OBJECTIVE: Severely obese patients who undergo orthotopic liver transplantation are likely to have higher morbidity, mortality, costs, and a lower long-term survival. METHODS: This case-control study was done at a university hospital. One hundred twenty-one consecutive patients who underwent liver transplantation between 1994 and 1996 were studied. Severe obesity was defined as body mass index (BMI) more than 95th percentile (>32.3 for women and >31.1 for men), and moderate obesity was defined as BMI between 27.3 and 32.3 for women and 27.8 and 31.1 for men. The outcome measures were intraoperative complications, postoperative complications (wound infections, bile leak, vascular complications), length of hospital stay, costs of transplantation, and long-term survival RESULTS: The baseline characteristics, UNOS status, and cause of liver disease at the time of transplantation were similar in severely obese (n = 21, BMI = 37.4+/-4.8 kg/m2), obese (n = 36, BMI 28.7+/-0.9 kg/m2), and nonobese patients (n = 64, BMI 23.8+/-2.5 kg/m2). The intraoperative complications and transfusion requirements were similar in all three groups. The postoperative complications such as respiratory failure (p = 0.009) and systemic vascular complications (p = 0.04) were significantly higher in severely obese patients. The overall perioperative complication rate was 0.61 (39 of 64 patients) in nonobese patients, 0.77 (28 of 36 patients) in obese patients, and 1.43 (30 of 21 patients) in severely obese patients (p = 0.01). Infections were the leading cause of death in all groups accounting for 57-66% of deaths. The length of hospital stay was significantly higher in obese patients. The hospital costs of transplantation were higher ($30,000-$40,000) in severely obese patients than in nonobese patients. The long-term patient survival was similar between the groups (Kaplan-Meier analysis). CONCLUSIONS: Despite higher postoperative complications, severely obese patients have an acceptable long-term survival, which is comparable to nonobese patients. The cost of transplantation is higher among severely obese patients. There was no increased incidence of cardiovascular mortality among severely obese patients during the follow-up period.

The effect of neuromuscular blockade on pedicle screw stimulation thresholds.

STUDY DESIGN: Nerve root stimulation thresholds were studied relative to the level of neuromuscular blockade in patients undergoing lumbar decompression surgery. OBJECTIVES: To determine what levels of intraoperative neuromuscular blockade can be used during pedicle screw stimulation. BACKGROUND DATA: Previous studies of intraoperative pedicle screw stimulation thresholds have failed to determine the effect of neuromuscular blockade on the stimulation threshold. METHODS: Twenty-one roots in 10 patients undergoing lumbar decompression surgery were studied at different levels of neuromuscular blockade. Ninety-five nerve root thresholds were determined relative to level of blockade. RESULTS: Neuromuscular blockade below 80% provides nerve root thresholds similar to thresholds without blockade. CONCLUSIONS: Neuromuscular blockade should be less than 80% when using pedicle screw electrical stimulation testing.

Pseudarthrosis repair. Autogenous iliac crest versus femoral ring allograft.

Pseudarthrosis repair in the lumbar spine is one of the most challenging problems faced by spine surgeons. Historically high failure rates with posterior repair have led to the use of anterior lumbar interbody fusion with tricortical iliac crest autograft in these difficult cases. More recently, femoral ring allografts packed with autograft bone have been advocated as another method that would decrease donor site morbidity. Two series of patients underwent anterior lumbar interbody fusion with anterior instrumentation to repair pseudarthrosis (Group I, 33 patients with tricortical autogenous iliac crest and Group II, 20 patients with femoral ring allografts). At minimum 2-year followup, there was no difference in fusion rates (Group I, 32 of 33 versus Group II, 20 of 20). Patients in Group I had radiographic fusion develop more rapidly than patients in Group II (12 months versus 18 months), but a significant proportion of patients in Group I (35%) had an average of 2 mm of graft subsidence. Despite excellent fusion rates in both groups, functional outcomes were not as good with only 28% of patients in Group I and 36% of patients in Group II returning to work. Using anterior instrumentation, anterior interbody fusion offers an excellent method to repair pseudarthrosis using femoral ring allografts or autogenous iliac crest. However, femoral ring allografts offer the potential to decrease donor site morbidity, allowing the surgeon to treat multiple spine levels.

Vasoactive effects of potassium in kidneys of hypertensive rats fed a high-potassium diet.

DESIGN AND METHODS: Levels of dietary and serum potassium are thought to correlate inversely with vascular resistance and blood pressure. This study examined renal vascular resistance in perfused rat kidneys partially preconstricted with 10 micromol/ phenylephrine, quantifying changes in the resistance when levels of potassium in the perfusate ([K+]o) were varied between 2 and 80 mmol/l. RESULTS: In kidneys from 17-week-old Wistar-Kyoto rats (WKY strain) fed a normal diet (American Institute of Nutrition AIN-76 diet), the resistance decreased when [K+]o was raised from 4 to 6-20 mmol/l, whereas resistance increased when [K+]o was either lowered to 2 mmol/l or raised above 25 mmol/l. The vasodilation that occurred at 13 mmol/l [K+]o was blocked by 100 micromol/l BaCl2 and 10 micromol/l ouabain in an additive manner, suggesting that both the inward rectifier K+ channel and the Na-K-ATPase underlie the dilation. Kidneys from spontaneously hypertensive rats (SHR strain) fed the AIN-76 diet displayed modestly enhanced vasodilations and vasoconstrictions as compared to WKY. A high-potassium diet (AIN-76 supplemented with 3.5% potassium citrate, provided for 8 weeks) led to exaggerated vasoconstrictive effects of [K+]o, and modestly enhanced vasodilations, in WKY rats. In contrast, the diet led to attenuated vasoconstrictions, and dramatically enhanced vasodilations, in the SHR strain. The diet did not affect the blood pressure increase or weight gain of either strain. CONCLUSIONS: Changes in the responsiveness of blood vessels to extracellular potassium might underlie some beneficial effects of high-potassium diets in hypertensive individuals.

Spine epidural steroids for patients with lumbar spinal stenosis.

The use of epidural steroid injections to relieve sciatic pain from spinal stenosis is extremely variable and controversial. Drs. Cohen and Kostuik take the position that most studies do not support their use and highlight the potential complications. Dr. Rydevik believes that epidural steroids might be considered as a nonsurgical alternative, especially in elderly patients where surgery carries greater risk.

Upper extremity physical factors affecting tennis serve velocity.

Forty tournament-level tennis players with expert serve technique volunteered to have their serve evaluated to determine relationships between anthropometric data, extremity strength, and functional serve velocity. All players underwent a complete physical examination, a video taped serve analysis, a radar measurement of serve velocity, and a series of upper extremity strength measurements. Statistical analysis was performed to determine which factors were related to serve velocity. Statistically significant relationships were found between serve velocity and several flexibility measurements including increased dominant wrist flexion (P < 0.05), increased dominant shoulder flexion (P < 0.05), and increased dominant shoulder internal rotation at 0 degrees of abduction (P < 0.05). Several strength measurements were also related to serve velocity including elbow extension torque production (P < 0.01) and the ratios of internal to external rotational torque production for both low- and high-speed measurements (P < 0.01 concentrically and P < 0.05 eccentrically). These findings relate strength and flexibility to serve velocity, suggesting that it may be possible to increase a tennis player's serve velocity through specifically directed muscular strengthening or stretching regimens. However, prospective studies must be undertaken to demonstrate these possibilities.

Isokinetic concentric versus eccentric training of shoulder rotators with functional evaluation of performance enhancement in elite tennis players.

Thirty elite tennis players were randomly assigned to three groups to evaluate shoulder isokinetic internal and external rotation training: an isokinetic concentric group, an isokinetic eccentric group, and a control group with no training. Subjects were tested before and after training both concentrically and eccentrically using an isokinetic dynamometer. Functional output before and after training was assessed by the average and peak velocity of six maximal serves. The effect of training on serve velocity endurance was also assessed. Statistically significant concentric and eccentric strength gains (11%) were obtained in both training groups when compared with controls (decreased total average strain of 2%) (P < 0.0004). Serve velocity increased by greater than 11% in both training groups, which was a significant increase from the average of 1% in the control group (P < 0.0001). In the endurance study, training group subjects displayed a tendency to maintain their serve velocity (loss of approximately 2%) greater than controls (loss of 6.4%) (P < 0.05). Isokinetic training led to increases in objective and functional output in elite tennis players. This training regimen may have significance in the final stages of the rehabilitation of injured shoulders as well as in improved performance and reduced injury risk.

Bilateral optic nerve cryptococcosis in sudden blindness in patients with acquired immune deficiency syndrome.

PURPOSE: A neuroanatomic study was undertaken to search for the cause of sudden, simultaneously bilateral blindness in a patient with acquired immune deficiency syndrome who had cryptococcal meningitis. METHODS: Careful gross examination was performed, and microscopic sections were cut at 50- to 100-microns intervals of the entire visual pathway. RESULTS: Focal cryptococcosis destroyed segments of the right intracanalicular optic nerve and the left intraorbital optic nerve adjacent to the optic canal. The meninges were heavily infiltrated by Cryptococcus organisms around the optic tracts, optic nerves, and optic chiasm; however, only a few scattered cryptococcal organisms were found in the periphery of the chiasm contiguous with heavy meningeal infection. Blood vessels supplying the chiasm appeared normal. Generalized cerebral edema and focal vacuolization of periventricular white matter were evident. CONCLUSION: The authors believe that sudden, simultaneously bilateral visual loss in this patient was caused by focal but fulminant necrosis of both optic nerves. However, the presence of cryptococcal organisms throughout the basal meninges and in the sheaths of both optic nerves suggests that cryptococcosis may produce visual loss by damaging multiple areas of the anterior visual pathway.

Comparative histopathologic study of various lens biomaterials in primates after Nd:YAG laser treatment.

A Nd:YAG laser was used to perform posterior capsulotomies on primates in whom one-piece silicone or three-piece polymethylmethacrylate intraocular lenses were in place for more than one year. The eyes were followed for eight weeks after treatment before enucleation. Histologically, no toxic effects caused by the dispersion of any of the biomaterial within the eyes and no significant inflammatory reactions were seen. The silicone lenses used in this study compared favorably with traditional polymethylmethacrylate lenses when posterior capsulotomies with a Nd:YAG laser were performed.

Familial sinistrality and sex differences in cognitive abilities.

The performance of right-handed males and females, with and without a family history of sinistrality (FS+ and FS-, respectively) were examined for three cognitive abilities: spatial ability, verbal fluency, and perceptual speed. FS+ subjects, especially females, showed performance decrements in spatial ability. Also, FS+ subjects, especially males, showed performance decrements in perceptual speed, with no differences being observed in verbal fluency.

Chloroplast DNA evolution and the origin of amphidiploid Brassica species.

The origin and evolution of a hybrid species complex in the genus Brassica (cabbage, turnip, mustard, rapeseed oil) has been explored through mutational analysis of the maternally inherited chloroplast genome. A detailed chloroplast DNA phylogeny enables identification of the maternal parent for most of the amphidiploids examined and permits quantitative resolution of the relative time of hybridization as well as the relative divergence of the diploid parents. Contradictory chloroplast and nuclear phylogenies obtained for two accessions of the amphidiploid B. napus (rapeseed oil) lead to the hypothesis that introgressive hybridization has also figured in their recent evolution.

Transcatheter therapy in angiography: indications, techniques, and illustrations.

This paper reports the history, methods,and indications currently accepted for transcatheter management of two distinct pathologic states. Reported are numerous cases from available literature and five cases from our own experience, supported by illustrations from angiography performed in this institution. It is hoped that the technologist has gained an understanding of the indications and methods for performing transcatheter therapies and that the growing interest in this adaptation of radiologic capabilities will serve to enhance the technologist's scope of operation as a member of the health-care team. The future of diagnostic angiography cannot be predicted, pending full evaluation and implementation of the rapid advances in other diagnostic modalities. The future of transcatheter therapeutic measures, however, appears worthy of continued vigorous investigation.