Photon scattering measurement of calcaneal bone density: result of in vivo cross-sectional studies.

The density of trabecular bone in the os calcis has been measured in 321 subjects using a gamma ray scattering technique. In normal subjects it was shown that density could be predicted from body weight and age with a standard error of 5.6%. It was also shown that the dependence of density upon weight and age was the same for both sexes. When the os calcis had been subjected to a greater than normal mechanical stress by either increased physical activity or excessive body weight, trabecular bone density was increased. Density was measured in 128 patients in whom the incidence of skeletal demineralization was expected to be greater than that in control subjects. Some significant reductions in density were observed. It is projected that density measurements might be of value in those situations where, in response to metabolic stress, the rate of loss of mineral from trabecular bone is greater than that from cortical bone.

The Patient Care Travelling Record in palliative care: effectiveness and efficiency.

The Patient Care Travelling Record (PCTR) is a passport-like health-care summary that, in previous research by the authors, has been found to be a feasible and acceptable tool to convey important clinical information about the palliative care patient. This randomized controlled trial was conducted to determine the effectiveness and efficiency of this Record in improving patient mood, decreasing uncertainty, improving satisfaction with health care, reducing use of health-care services, and maximizing pain control. Eligible patients were randomized to receive or not receive the PCTR (completed by nurse or physician and reviewed jointly with the patient). As baseline entry into the study and then at 1 and 2 months, patients completed measures on level of certainty, mood states, satisfaction with care, levels of pain, and health-care services utilization. During the 2-year study period, only 20% (N = 61) of the patients enrolled in a palliative care program in Southern Ontario were eligible for the trial. Of these patients, 18 died, 15 declined to participate, and 7 were emotionally unable to complete the questionnaires. Thus 21 patients completed the trial. With the exception of those age 65 years and over, the patients using the Record reported decreased levels of uncertainty on follow-up. There was no additional use of health-care services, no differences in mood states, pain relief, or satisfaction with health care. It is significant that 80% of palliative patients were not eligible because their physical and psychological status rendered them insufficiently stable to participate in a research study. Because of their vulnerable status, these patients may be ideal for the utilization of the Record in clinical care. Although research in this palliative care population is challenging due to difficulties with recruitment and high dropout rates due to death, the PCTR, which was previously shown to be acceptable and feasible, has now been shown to be effective in reducing patient uncertainty, specifically for adults under 65 years. Indications for future research are described.

Comparison of questionnaires determining patient satisfaction with medical care.

This study compares the results of previously developed patient satisfaction questionnaires which quantitatively assessed the personal attitudes of 59 patients toward their medical care. These patients, hospitalized for acute myocardial infarction, were admitted to the intensive care unit of a community hospital in southern Ontario, Canada. The questionnaires were completed by these patients at four and six months post-myocardial infarction. This quantitative assessment of patient satisfaction, as indicated by Hulka and Ware questionnaires, provided data to compare the relative effectiveness of these questionnaires in measuring satisfaction. Generally, these questionnaires were reliable (r = .64, r = .59) and evidence of criterion concurrent validity was noted (r = .75-.81). Both questionnaires have comparable results concerning the prevalence of dissatisfaction (0-7 percent).

Effects of 2 years of hormone replacement upon bone mass, serum lipids and lipoproteins.

The objective of this study was to measure the effects on postmenopausal women of 2 years of either a low dose or a moderate dose regimen of hormone replacement upon bone mass and serum cardiovascular risk factors. After 6 months of calcium supplementation, 75 women chose to add hormone replacement or to remain on calcium. Those choosing hormones were randomised to either 0.3 mg/day equine estrogen and 2.5 mg/day medroxyprogesterone or 0.625 mg/day equine estrogen, days 1-25, and 5 mg/day medroxyprogesterone, days 16-25. On calcium only, lumbar spine bone mineral content and radius bone mass fell. Serum concentrations of cholesterol and triglycerides increased while HDL concentration fell. The low dose continuous regime reduced whole body bone turnover and prevented the age related reductions in bone mass and serum cardiovascular risk profile. The moderate dose regimen reduced whole body bone turnover and increased lumbar spine bone mass. Total serum cholesterol was unchanged while HDL levels increased, LDL levels fell and triglyceride concentration increased.

Prediction of human spleen size by computer analysis of splenic scintigrams.

A method of assessing spleen size from splenic scintigraphs obtained using autologous heat damaged 99Tcm labelled red cells is described. The method depends on a "computed volume" estimate. The method has a correlation coefficient of 989 with the exsanguinated weight ofthe spleen after splenectomy and has been shown to have an accuracysuperior to methods previously described.

Understanding newborn infant readmission: findings of the Ontario Mother and Infant Survey.

The Ontario Mother and Infant Survey examined health and social service utilization of postpartum women and newborn infants from five hospital sites. A cross-sectional multilanguage survey design with longitudinal follow-up was used: 1,250 eligible, consenting women completed a self-report questionnaire in hospital and 875 women participated in a structured telephone interview at four weeks post-discharge. Rates of newborn infant readmission ranged from 2.4% to 6.7%. The best predictors of readmission were: main source of household income was other than employment; maternal self-rating of health was poor; mother anticipated inadequate help and support at home following discharge; mother received help from friends/neighbours following discharge; and mother had concern about infant care and behaviour. Readmission was not associated with length of postpartum hospital stay. The study findings suggest that there is a complex relationship between infant health care needs, family resources and provider practices that produces clinically important, site-specific readmission patterns.

A patient care travelling record for palliative care: a feasibility study.

The provision of palliative care can be a complex process. Patients are treated in a variety of settings, by multiple persons, thus risking loss of continuity of care. These patients take numerous medications and require many complex treatment decisions in the course of their illness, making the ready availability of current and accurate information a vital component of effective care. The use of a patient care travelling health record, while requiring time and commitment from all parties to be effective, has been shown to be both feasible and helpful to patients, families, and health professionals. Considerable education and commitment is necessary to ensure compliance by all involved parties.

Cancer of the oesophagus--how should tumour biology affect treatment?

An analysis of the biology of cancer of the oesophagus suggests that significant dissemination may not have taken place at the time of diagnosis in approximately one-third of cases. Positive nodal histology in the mediastinum or abdomen is the best available evidence of disseminated disease. Patients without such nodal involvement therefore represent a group in whom the disease is most likely to be localized. It is suggested that only these patients be subjected to aggressive local therapy. The effects of no treatment, orth- and megavoltage radiotherapy, surgery and combinations of surgery and radiotherapy are reviewed. The need for cooperative randomized clinical trials to test the biological hypothesis outlined is discussed. Megavoltage radiotherapy as a primary treatment for oesophageal cancer followed by radical surgery in those patients without evidence of dissemination from nodal histology is proposed as a basis for such clinical trials.

Percutaneous resection of renal transitional carcinoma: venous injury and its conservative management.

An interesting observation encountered at percutaneous resection of a renal transitional cell carcinoma and its conservative management is described. During resection of the tumour sudden heavy haematuria was encountered. Nephroscopic inspection revealed the blood to be coming from behind a loop-generated flap, the raising of which allowed entry of the endoscope into a sizeable vein and thence upwards into the renal vein and inferior vena cava (IVC). On table nephrostogram confirmed contrast outlining the renal vein and IVC. Placement and clamping of a nephrostomy tube was followed by stabilization of the patient and the bleeding stopped. The urine became clear within 24 h. Later on repeat nephrostogram showed an intact pelvicalyceal system with an acceptable tumour clearance. This case highlights the importance of a trial of conservative management in the treatment of bleeding complications during nephroscopy.

Dynamic rectus abdominis tendon colposuspension for female stress urinary incontinence: a new procedure and its follow-up.

AIMS AND OBJECTIVE: To describe the technique, results and follow-up of dynamic rectus abdominis tendon colposuspension (DRTC) in the management of female stress urinary incontinence (SUI). PATIENTS AND METHODS: Eighteen patients with SUI were studied prospectively from 1998 to 1999 who underwent DRTC. Type I and type II SUI patients with or without mild to moderate cystocoele were included in the study. A complete preoperative work-up was done as described in detail in this article. Follow-up assessment was done at 6 weeks, 3 and 6 months and then annually involving a SEAPI quality-of-life score, a satisfaction questionnaire, urge symptoms and assessment of dryness. RESULTS: Mean follow-up of these 18 patients was 20 +/- 6 months. Cure of symptoms and dryness was achieved in 16/18 (89%) of the patients. Four of 9 patients had residual urge symptoms and 2 developed de novo urge, which settled by 3 months; no patient required long-term anticholinergics. Three patients required clean self-intermittent catheterization (CSIC) immediately postoperatively but only 1 patient continued to perform CSIC after 3 months. Mean operating time was 41 +/- 10 min and mean hospital stay was 3.5 +/- 1 days. There were two failures, one in a patient with a neurogenic bladder and one in a patient with multiple previous pelvic operations. One so-called failure uses <2 pads/day postoperatively with an improvement in both symptom and dryness score. Postoperative complications include blood transfusion in 1, urinary tract infection in 1 and wound infection in 1 patient. All the patients with initial good results showed persistent results over follow-up. CONCLUSIONS: DRTC is a simple procedure with minimal morbidity showing good results, which are consistent on follow-up.

An important factor in drug usage......and the adoption of a positive role.

How can drug use be controlled and what is the most effective way of organising pharmaceutical services? In these two articles P.I. Harrison, BSc, MPhil, MPS, APO, Ealing Hammersmith and Hounslow AHA and J.G. Roberts, FPS, OBE, RPO, Mersey RHA, discuss the answers to these questions.

Information searching in health care: a pilot study.

Although many academic institutions have attempted to incorporate formal instruction in library skills into their curricula, the question as to the best method of conveying the necessary information has been a continual challenge to health care educators. A library skills workshop, which included the distribution of a workbook, was offered to physical therapy and occupational therapy students in a Bachelor of Health Science program with the aim of assisting students to develop skills in library searches and to perform critical appraisals of the literature. Thirty-three students agreed to participate in a study designed to determine its effectiveness: 24 who had volunteered to attend the workshop formed the experimental group, and 9 who did not attend acted as controls. A Library Skills Questionnaire that attempted to measure cognitive and psychomotor skills in retrieving and appraising health care literature was given to all participants prior to, and at the completion of, the two-session workshop. Nine students in the experimental group did not attend the second session and were then termed "drop-outs" for the purpose of the study. The results show that the drop-outs had statistically significant higher knowledge scores (p = less than 0.05) in their post-test scores in comparison with both the students who attended the two sessions and the students in the control group. One explanation for this finding is that the drop-outs may be better self-directed learners who used the workbook to teach themselves.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum alpha-1-acid glycoprotein as an index of dissemination in breast cancer.

Assay of the serum alpha-1-acid glycoprotein (SAGP) produced by the liver in response to many disease states is shown to reflect prognosis and monitor progress in patients with early, recurrent and disseminated breast cancer. Eighteen of 26 patients with localized breast cancer and positive bone scans had elevated SAGP when first seen, but within 5 months of treatment 5 further patients with positive bone scans developed an elevated SAGP. Furthermore, an initially abnormal SAGP level became normal within 5 months in 5 of 6 patients with negative bone scans. While elevated SAGP in breast cancer correlates with positive bone scans, a series of normal values may indicate patients without early haematogenous dissemination of their disease.

Infusion thrombophlebitis: a prospective comparison of 645 Vialon and Teflon cannulae in anaesthetic and postoperative use.

A prospective study of the incidence and severity of infusion thrombophlebitis in peripheral intravenous infusions used for anaesthetic and postoperative purposes in 645 patients was conducted over a four-month period. Conditions of insertion were carefully controlled while ward management was according to standard practice. A total of 330 polyurethane Vialon and 315 FEP-A Teflon cannulae were used. The results show that the nature of the cannula was the single most important factor in the incidence and severity of infusion thrombophlebitis, Vialon cannulae being associated with a 46% lower incidence than the Teflon type. Less important but significant factors included intravenous antibiotics, duration of infusion, cannula tip damage and caesarean section. Factors not associated with infusion thrombophlebitis included potassium therapy, blood transfusion or site of insertion in the upper limb. Heparinisation increased duration of infusion without affecting the incidence of infusion thrombophlebitis.

Percutaneous management of renal pelvic urothelial tumors: long-term followup.

PURPOSE: We present the long-term outcome of percutaneous resection of renal urothelial tumor. MATERIALS AND METHODS: A total of 24 patients underwent primary percutaneous resection of renal urothelial tumor. Patients with low stage pT0-1 disease were treated primarily with percutaneous surgery. All pelvicaliceal tumors were taken for biopsy and treated with percutaneous resection. Patients with multi-segmental pelvicaliceal system involvement, stage greater than pT1, high grade histology or additional ureteral tumors were considered for nephroureterectomy. Topical chemotherapy (mitomycin C or epirubicin) was administered via nephrostomy tube or intravesical instillation after Double-J stent (Medical Engineering Corp., New York, New York) insertion. Surveillance included upper tract cytology, nephroscopy or fiberoptic ureterorenoscopy. Long-term followup was correlated with histopathology. RESULTS: Of the 24 cases 2 had squamous cell carcinoma, 5 had grade III transitional cell carcinoma, 15 had grade I to II transitional cell carcinoma and 2 had no tumor. Control was established with initial percutaneous resection in 18 (75%) cases and second look nephroscopy in 4. Early recurrences were detected by excretory urography (IVP) in 3 cases, small pelvic recurrences by IVP in 2, fiberoptic ureterorenoscopy in 2 and bladder tumors by flexible cystoscopy in 3 after 1 year. A total of 10 nephroscopies were performed in 5 cases, 24 flexible uretereorenoscopies in 9 and IVP in 6. Three synchronous, grade I bladder tumors were managed conventionally. All patients with high grade disease died of malignancy except one (with no further treatment) and 6 of the 15 patients with low grade noninvasive transitional cell carcinoma underwent nephroureterectomy during followup either due to progression of disease, concomitant tumor or complications. Two patients with solitary kidneys died of renal failure unrelated to malignancy. High grade tumors or tumors greater than T1 were treated with nephroureterectomy early during management. There was no perioperative mortality and 9 (60%) of the low grade cases the kidneys were preserved at a mean followup +/- SD of 64 +/- 15 months. All excised tracks from patients who underwent nephroureterectomy and the renal fossae were free of tumor on histopathological examination. CONCLUSIONS: Percutaneous resection of transitional cell tumor should be considered primarily in patients with early stage disease excluding tumors crossing caliceal infundibula, ureteropelvic junction tumor, tumor extending over multiple calices and synchronous ureteral tumors. The long-term outcome of low grade tumors is good and they should be managed by either form of minimally invasive surgery. Nephron sparing is possible in a large percentage of low grade disease but high grade tumors should be treated with nephroureterectomy.

An integrated study of pharmacokinetics and pharmacodynamics of chlormethiazole in healthy young volunteers.

Chlormethiazole ethanedisulphonate (0.8%) (Hemineurin, Astra) was administered to 10 healthy unpremedicated volunteers at a constant-rate infusion of 2.5 ml/min for 60 min (Phase 1, n = 5) and 113 min (Phase 2, n = 5). With one exception, chlormethiazole blood concentration-time data were described by a two-compartment open model. Total body clearance was the same in both phases (1.151 . min-1, SD 0.49; and 1.051 . min-1, SD 0.49; and 1.051 . min-1, SD 0.36 respectively) and was similar to the clearance of indocyanine green. No correlation was found between clearance, initial dilution volume (1371, SD 62; and 1251, SD 33 in 1 and 2 phases respectively) or volume of distribution at steady-state equilibrium (3081, SD 91; and 2241, SD 59) with either body weight or estimated lean tissue mass. Slow half-life was 289 min (SD 169) in Phase 1 and 253 min (SD 172) in Phase 2. Moderately heavy sedation associated with amnesia while retaining the ability to readily obey verbal commands was achieved in one subject of Phase 1 and 4 subjects of Phase 2 and occurred at a mean chlormethiazole ethanedisulphonate blood concentration of 9.2 mg . 1(-1) (SD 2.9). Transient nasal irritation was experienced by all subjects during the initial stages of infusion. A rise in pulse rate (33%, SD 8) was a prominent feature but blood pressure and respiratory rates were very stable.

An evaluation of thermodilution cardiac output measurement using the Swan-Ganz catheter.

Errors in thermodilution cardiac output measurement were quantitated to determine the order of accuracy of routine measurements performed by unskilled personnel. In vitro and in vivo studies were undertaken to examine factors affecting the volume and temperature of the injectate, catheter thermistor and computer performance, effect of respiration, use of cold (0-4 degrees C) versus ambient temperature (20-25 degrees C) injectate, and the interpretation of measurements. Ambient temperature injectate incurred unacceptably large errors; cold injectate (injections were timed with respiration) produced variations in performance by equipment and personnel which accounted for only 2% of the variation between successive measurements. Real changes in cardiac output and inherent variability of the downslope of the thermal curve, necessitating an empirically based calculation, account for up to 10% variation between successive measurements. When cold injectate was used, and the average of three corrected measurements taken, thermodilution cardiac output measurements were within 10% of a simultaneous dye dilution measurement.