Digital thermal hyperaemia impairment does not relate to skin fibrosis or macrovascular disease in systemic sclerosis.

OBJECTIVES: Thermal hyperaemia is impaired in patients with systemic sclerosis (SSc). The objective of these studies was to determine whether this was consecutive to skin fibrosis, microangiopathy or macroangiopathy. METHODS: Using laser Doppler flowmetry, we first compared the thermal hyperaemia on the third left finger pad and on the left forearm in 21 patients with non-diffuse systemic sclerosis (SSc), in comparison with primary Raynaud's phenomenon and healthy volunteers. Second, we tested whether the altered thermal hyperaemia correlated to the digital pressure index at baseline, and following the thermal challenge. RESULTS: In the first study, thermal hyperaemia of the finger pad was impaired in terms of both amplitude and kinetics, but not on the forearm in patients with SSc. In the seven SSc patients without cutaneous fibrosis, the response was similarly altered in terms of amplitude and kinetics. In the second study, we observed a weak correlation between the digital systolic blood pressure index. However, in the 15 SSc patients tested at 44 degrees C, the median digital systolic blood pressure index was 1.04 (0.84-1.24) at baseline vs 1.08 (0.87-1.29) at 44 degrees C (NS), while seven of them had an abnormal response in terms of kinetic. Furthermore, only one patient showed a clear-cut decrease in digital systolic blood pressure at 44 degrees C. CONCLUSION: In patients with SSc, digital thermal hyperaemia is impaired, but does not relate to the skin fibrosis or to an associated macroangiopathy in most cases. Further studies are required to determine whether its impairment reflects a functional or structural microvascular damage.

Intra-aortic balloon pump complications: A five-year retrospective study of 283 patients.

OBJECTIVE: To determine the type, incidence, and risk factors for complication with the intra-aortic balloon pump. DESIGN: Descriptive, chart review. SETTING: Midwestern community teaching hospital. PATIENTS: Two hundred eighty-three patients with 287 intra-aortic balloon pump insertions from January 1, 1990, to December 31, 1994. OUTCOME MEASURES: Complications of therapy. RESULTS: Seventeen percent of balloon insertions resulted in minor complications, and 14 patients had major complications. Polychotomous logistic regression was used to determine which study risk factors were predictive of the development of minor or major complications in patients. Patients with longer balloon duration had an increased risk of a major complication; whereas smokers and patients with lower body mass index had an increased probability of the development of a minor complication.

Detection of cancerous masses for screening mammography using discrete wavelet transform-based multiresolution Markov random field.

When cancerous masses are embedded in and camouflaged by varying densities of parenchymal tissue structures, they are difficult to visually detect on mammograms. We present a novel algorithm based on the discrete wavelet transform (DWT) and multiresolution markov random field (MMRF) that will single out the suspicious masses to assist the attending radiologist in making decisions.

The consultation and referral process. A report from NEON. Northeastern Ohio Network Research Group.

BACKGROUND: Consultation and referral are essential components of the practice of primary care. Despite this, little is known about the factors that contribute to the success of a referral. We examined the short-term outcomes of communication between family physicians and consultants during the referral process. METHODS: The study setting was six family practice centers in northeastern Ohio. All eligible physicians at each center participated in data collection by means of a card study. Data was recorded on any patient who received a referral to a physician or nonphysician provider during the month of July 1994. One year later, referrals were followed up by physician questionnaire. RESULTS: Three hundred nine of 5172 total patients were referred (5.97 referrals per 100 office visits). At follow-up, the family physicians reported that 63% of patients had visited the consultant, 14% had not, and the physician had no knowledge of the actions taken by the other 23%. The referring physician received feedback from the consultant regarding 55% of the patients referred. Receipt of feedback was strongly related to communication by the family physician to the consultant at the time of referral. Physicians who received feedback were the most satisfied with communication from the consultant and the care their patient had received. CONCLUSIONS: Primary care physicians can influence the likelihood of receiving feedback from a consultant by initiating communication with the consultant. A referral wherein the physicians involved do not communicate with one another results in physician dissatisfaction. Primary care physicians must practice strategies to improve the referral process.

To stay or not to stay: factors influencing family practice residents' choice of initial practice location.

BACKGROUND AND OBJECTIVES: This study examined what factors influence US third-year family practice residents' choice of location of their first practice. METHODS: A survey was developed by the members of Northeastern Ohio Network to assess the influence of factors related to family, education, geography, finances, the medical community, and others on the selection of practice location. Surveys were sent to all program directors listed in the American Academy of Family Physicians 1994 Directory of Family Practice Residency Programs to be distributed to all third-year family practice residents. The program directors indicated the type of residency program, the number of surveys distributed, and the number returned, then forwarded completed surveys to the investigators. RESULTS: Two hundred fifty-nine of the 380 programs (68%) with PGY-3 residents responded. Of the programs that responded, 1,012 residents (64%) of a possible 1,578 completed surveys. Estimated from the directory, 812 residents from non-responding programs did not complete the survey for an overall response rate among residents of 42% (1,012/[1,578+812]). Family-related items seem to have the most influence on choice of practice location and are more important to married people. More than 50% of residents want to practice in the same size community in which they grew up. Money-related factors were not rated as highly as expected. CONCLUSIONS: Several factors appear to be important to family practice residents when selecting their first practice location. Hospitals interested in retaining their graduates can maximize their success by concentrating on these areas.

Predictive factors for early mortality after percutaneous endoscopic gastrostomy.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a safe access procedure for enteral nutrition. The purpose of this investigation is to identify predictive factors for early mortality after PEG. METHODS: A retrospective review of the hospital records of 416 patients undergoing PEG from June 1, 1989, through December 31, 1991, was conducted. Patient demographics, admitting diagnosis, indication for PEG, risk factors for early mortality, and cause and date of death were reviewed. Logistic regression analysis was used to develop a model to predict early mortality after PEG. The follow-up period ranged from 1 to 30 months. RESULTS: The overall mortality rate in this review was 227 of 416 patients (54.6%). The 7- and 30-day case fatality rates were 39 of 416 (9.4%) and 97 of 416 (23.3%), respectively. Logistic regression analysis showed that urinary tract infection (odds ratio (OR) = 3.05; 95% confidence interval (CI) = 1.45-6.43) and previous aspiration (OR = 6.86; 95% CI = 3.27-14.4) were predictive factors for death at 1 week after PEG. Patients who had both risk factors had a 48.4% probability of dying within 7 days after PEG insertion, whereas those who had no risk factors had a 4.3% probability of death. Urinary tract infection (OR = 2.00; 95% CI = 1.17-3.41), previous aspiration (OR = 3.62; 95% CI = 2.00-6.55), and age greater than 75 years (OR = 2.49; 95% CI = 1.47-4.21) were predictive factors for death at 1 month after PEG. Patients who had all three risk factors had a 67.1% probability of death at 1 month while those who had no risk factors had a 10% probability of death. CONCLUSIONS: A subgroup of patients exists that has a very high mortality rate after PEG. Less invasive ways of nutritionally supporting these high-risk patients should be evaluated.

Rotation of dissecting groups among different cadavers provides students of anatomy with increased opportunity to observe human variations.

One way to increase medical students' awareness of anatomical variability is the dissection of different cadavers throughout laboratory coursework. This report covers such a procedure successfully instituted in a human gross anatomy course.

The morphology of the developing canine conducting system: bundle branch and Purkinje cell architecture from birth to week 12 of life.

This is a qualitative and quantitative study of dog bundle branch and Purkinje cell development from day 0 to week 12 of life; we correlate the morphologic data with changes observed in the functional properties of developing dog Purkinje tissue. The bundle branch itself has a roughly cylindrical shape and is surrounded by a collagen sheath covered with endocardium. Within the bundle, Purkinje cells are packed closely together in fascicles distributed evenly around a central artery. Cross-sectional area doubles in the right bundle and increases 5-fold in the left bundle system between day 0 and week 12 of life. About one third of the bundle by volume is Purkinje tissue; the rest is extracellular space containing an increasing amount of collagen as the animal ages. Purkinje cell cross-sectional area is constant during the first week of life, but its length doubles and the cell changes from a relatively round to a more cylindrical shape. Between day 7 and week 12, cell diameter doubles; Purkinje cell surface area increases 5-fold and its volume almost 10-fold. As a consequence, the surface to volume ratio halves and approaches the value reported for adult dogs by week 12 of life. The percent of the intercalated disc occupied by nexal junctions virtually doubles by week 12, the same period over which Purkinje fiber conduction velocity increases. The disc itself becomes less dominant as the cell enlarges; the total percent of sarcolemma involved in its formation decreases by a fourth and has achieved the adult value by week 12 of life. As this happens, the percent of cell membrane facing on clefts increases almost 6-fold, so that the total percent of sarcolemma facing on small spaces (approximately 340A wide) is constant over the age period studied. The paucity of clefts in newborn tissue compared with the value reported for the adult dog may help explain the relative lack of responsiveness to extracellular potassium concentration of the resting membrane potential described for fetal Purkinje tissue. Within the Purkinje cell itself, the percent by volume occupied by mitochondria remains relatively constant over the age span studied, while sarcomeric mass increases 3-fold over the same period of time; these data are consonant with the relative resistance of this tissue to hypoxia.

Clinical correlates of abnormal sensitivity to intraesophageal balloon distension.

Sixty-five patients with esophageal complaints were studied to determine clinical associations with abnormal sensitivity to intraesophageal balloon distension (esophageal sensory dysfunction). Associations were examined in four categories: motility, esophageal symptoms, recent psychological symptoms, and general clinical features. A positive response to balloon distension (pain with less than or equal to 8 ml volume) was found in 29 (45%) of the subjects. This response was associated with specific findings in each category except recent psychological symptoms. A multiple logistic regression analysis indicated that an increased frequency of multipeaked waves on motility testing, presence of dysphagia, and shorter height of the subject each had an independent association with positive response to balloon distension (P less than or equal to 0.05 for each). Further comparison of subjects with sensory dysfunction, motor dysfunction, or both (sensorimotor dysfunction) indicated that subjects with the combined disorder appeared more symptomatic than those with either finding alone. These observations indicate that: (1) esophageal motor and sensory dysfunction are partially associated, but both contribute to the symptomatic state; (2) dysphagia may be representative of sensory dysfunction in some cases; and (3) subject height should be taken into consideration when interpreting balloon distension results.

Achalasia, diffuse spasm and non-specific motor disorders.

Achalasia is the best understood of the motor disorders described in this chapter. The pathogenesis involves loss of intramural neurones, a process that subsequently results in poor lower sphincter relaxation and atony of the oesophageal body. Treatment is appropriately focused on mechanical or pharmacological alleviation of LOS obstruction. In contrast, the pathophysiology of DOS and the non-specific disorders remains poorly understood. Some of the non-specific disorders, such as the vigorous contraction wave abnormalities (including 'nutcracker oesophagus'), appear closely related to DOS. Treatment for patients with these findings has been based on assumptions about mechanisms of symptom production. The non-specific disorders are common in referred patients with oesophageal symptoms, and the importance of these findings deserves further study. We use a method for categorization of these manometric abnormalities which aids understanding of this difficult area and recommend its more widespread use.

Pill-induced esophageal strictures: clinical features and risk factors for development.

Clinical data from five subjects with pill-induced esophageal strictures and from the English-language literature on pill-induced esophageal damage were reviewed to determine risk factors for stricture development and to characterize this complication. Including our five cases, 195 patients with pill-induced damage and 39 patients with pill-induced strictures have been reported to date. Seventy-eight percent of the strictures were located in the proximal or mid-esophagus. Potassium chloride or quinidine preparations were incriminated in 60% of cases and were more likely to produce stricture than other medications commonly associated with esophageal damage (e.g., tetracycline). Older age, male gender, left atrial enlargement, ingestion of sustained-release formulations, and prior esophageal structural abnormality were all more commonly present in the subset with strictures (p less than 0.05 for each), even after appropriately controlling for medication. A logistic regression analysis revealed that older age and ingestion of sustained-release formulations were the most significant independent factors associated with stricture development (p less than 0.0001 for each). These findings indicate that stricture formation from pill-induced esophageal damage is dependent upon host-related factors as well as the caustic nature of the pill.

Risk of imbalance in elderly people with impaired hearing or vision.

We evaluated the effect of impaired hearing and vision on balance in a sample of 977 elderly people residing in the community. Of the sample, 21% reported balance problems, 27% vision problems, and 30% hearing problems. The increased relative risk for balance problems was 1.7 for each 10-year age increment. Women were 1.7 times more likely to report balance problems than were men. The relative risk of imbalance with impaired vision decreased with age from 2.8 in those aged 65-69 years to 1.0 in those over 85 years. There was no age-hearing interaction, the relative risk for impaired hearing is 1.6. It appears that impaired vision and hearing are important risk factors for imbalance and perhaps falls and injury.

Urinary tract infections in childhood: a current imaging approach.

The authors present their approach to the evaluation of urinary tract infection in childhood based on real time sonography, 99m-Tc-DTPA scintigraphy and voiding cystourethography.

A strategy to increase appointment keeping in a pediatric clinic.

This paper reports the results of two related studies. The first, a prospective study, investigated the relationship between appointment keeping at a pediatric clinic and parents' self-perceived time utilization skills as measured by a subscale of Wessman's Temporal Experience Questionnaire (TEQ). Using a logistic regression analysis to adjust for the effect of telephone reminders, low scorers on the time utilization subscale were twice as likely as high scorers to miss their appointments. The second study was a test of the value of using knowledge of parents' subjective time perspectives as part of a strategy to increase appointment keeping. The goal of this study was to achieve equivalent missed appointment rates between high and low scorers on the TEQ. Parents attending the clinic were asked to complete the questionnaire, and they were then stratified into two groups. High scorers, those who initially had a low probability of missing appointments, received a single reminder. Low scorers, those who initially had a high probability of missing appointments, received two reminders. Two alternate forms of reminders were randomly allocated within each scoring strata. Equivalent missed appointment rates were observed between parents who scored low and those who scored high on the TEQ. The study also investigated two other questions. Information on the importance of the visit had no effect. Postcard reminders were as effective as telephone reminders and were more cost efficient.

Interpretation of moderately elevated MMPI scores for normal subjects.

Two opposing views concerning the interpretation of moderately elevated MMPI scores of normal subjects have appeared in the literature. Whereas some authors have suggested that such scores indicate negative characteristics less severe than those suggested by more extremely elevated scores for psychiatric patients, other authors have suggested that such scores may be indicative of more positive characteristics. The present study attempted to determine the relative validity of these two opposing views. Correlates of MMPI clinical scales were determined for 101 male and 101 female college students who had no clinical T-score greater than 75. Subjects described themselves using the Adjective Check List (ACL), and they were also described by peers using the ACL. Point-biserial correlations between MMPI scores and self and peer endorsements on the ACL were computed. For both self and peer data more significant correlations were found than expected by chance. Most of the correlates involved negative characteristics, offering some support for the interpretive approach based on an attenuation of negative descriptors derived for psychiatric patient samples.

Developmental and reading ability differences in accessing information from semantic memory.

A categorical judgment task was utilized to investigate the relationships between word recognition skills and reading achievement at several grade levels. In the first experiment skilled and unskilled readers from Grades 2, 4, and 6 made cognitive decisions about pairs of words using either graphemic, lexical, or semantic information. In Experiment 2 skilled, average, and unskilled readers from Grades 1, 3, and 5 made semantic decisions about word or picture pairs. The speed and accuracy of word encoding, lexical access, and semantic memory access processes varied as a function of reading ability. These results suggest that inefficient word recognition skills can contribute to reading deficiencies as can deficiencies in semantic memory organization.

The effect of contrast media on patient motion during cerebral angiography.

Conray, Renografin-60, and Reno-M-60 were compared in 40 patients undergoing cerebral angiography. Pain during injection, as evidenced by head motion, was documented using subtraction. Conray produced less had head motion and therefore a superior subtraction study than either Renografin-60 or Reno-M-60 and was also subjectively the least painful of the three.