Concurrent infectious mononucleosisand acute leukemia. Case reports. Review of theliterature and serologic studies with the herpes-type virus (EB virus).
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Child↗
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Schizophrenia and rheumatic disease. A study on the concurrence of inflammatory joint diseases and a review of 58 case-records.
The coincidental occurrence of schizophrenia and rheumatoid arthritis is considered to be low in relation to the prevalence of the two diseases. In the present study, data from the patient statistics prepared by the Swedish Social Welfare Board were examined for the occurrence of rheumatic disease in schizophrenic patients. With the aid of the statistics and of questionnaires, 58 case-records were collected and studied. Very few cases were found of co-existing schizophrenia and inflammatory joint disease, rheumatoid arthritis in particular. There were, however, some cases of genuine schizophrenia and definite seropositive rheumatoid arthritis in the same patient. Rheumatoid arthritis is possibly uncommon also in combination with other psychiatric diseases that require hospital care. The ankylosing-spondylitis cases were over-represented in relation to the rheumatoid-arthritis cases included in the statistics from psychiatric care. Most of the 13 ankylosing-spondylitis patients whose case-records were studied had schizoaffective psychosis or atypical psychosis. The results of the investigation should be confirmed by epidemiological studies; this may contribute to the understanding of the aetiology of rheumatoid arthritis and of schizophrenia.
Adult↗
Left-sided splenorenal fusion with marked extramedullary hematopoiesis and concurrent lithium toxicity. A case report and review of the literature.
Occasionally, heterotopic splenic tissue can occur in the renal fossa secondary to splenosis following splenic trauma or splenectomy. More rarely, it can represent a developmental anomaly secondary to the fusion of splenic and renal tissues. Splenorenal fusion can present as a renal mass, mimicking primary or secondary renal neoplasms on imaging studies, and patients can also present with symptoms of hypersplenism (anemia). We report a case of splenorenal fusion in a 51-year-old woman who initially presented with lithium toxicity, anemia, thrombocytosis, and a large renal mass that mimicked a primary renal neoplasm. The possible embryologic origin of splenorenal fusion, effects of lithium toxicity, and utility of various imaging modalities are discussed. The literature on renal heterotopic splenic tissue is also briefly reviewed.
Anemia↗
An interventional program to improve antibiotic use.
BACKGROUND: Large volume and often inappropriate use of specific antimicrobial agents increase selective pressure for emergence of resistant bacteria and place strain on the pharmacy budget. OBJECTIVE: To initiate a multidisciplinary program designed to align intravenous vancomycin and fluoroquinolone prescribing practices with guidelines for appropriate use of these agents. METHODS: A multidisciplinary, prospective interventional program was implemented to encourage early discontinuation of inappropriate vancomycin and fluoroquinolone therapy and decrease inappropriate duplicative gram-negative coverage using fluoroquinolones. A computerized review was performed for patients receiving intravenous vancomycin and fluoroquinolones for 1998 in a Veterans Affairs Medical Center. In June 1999, guidelines were disseminated and an interventional program was initiated, with a monthly conference for medical residents regarding antimicrobial resistance and local hospital practices. Concurrently, a prospective review of new orders was assessed by the clinical pharmacist and interventions performed when inappropriate use occurred. RESULTS: The interventional program was successful in reducing unnecessary duplicative gram-negative coverage with intravenous fluoroquinolones by 26% (p < 0.001) from 1998 to 2001. Overall, a 43% reduction in the number of courses of intravenous fluoroquinolones was seen during these 4 years. Courses lasting >5 days were reduced by 22% (p < 0.001). Vancomycin prescriptions deemed inappropriate that were administered >5 days were reduced by 16% (p < 0.001) during the same time period. The interventions performed by the clinical pharmacist were deemed successful, with a 76% acceptance rate by providers. CONCLUSIONS: Education of physicians through monthly conferences and personal interventions resulted in an increase in appropriate empiric antibiotic use, a decrease in the duration of inappropriate use, and a decrease in duplicate gram-negative coverage.
Anti-Bacterial Agents↗
Youth solar ultraviolet radiation exposure, concurrent activities and sun-protective practices: a review.
To assist standardization of procedures, facilitate comparisons, and help guide research efforts to optimally inform development of appropriately targeted interventions, there is a need to review methods used to quantify child and adolescent solar ultraviolet radiation (UV) exposure, related outdoor activities and sun-protective practices. This holistic approach is essential for comprehensive research that will provide all-inclusive, informative and meaningful messages for preventive measures of harmful UV exposure. Two databases were searched and 29 studies were retrieved, and these studies report measurement or assessment techniques documenting UV exposure patterns and related outdoor activities. Polysulfone film badges were the main measurement instrument used in 10 studies, with questionnaire, survey data, observation, a model, electronic dosimeters, biological dosimeters, colorimeter and UV colouring labels used in the remaining studies. Methods used to record activities included self-report, parental report, a logbook and observation. Measurement duration and unit of UV exposure varied in most studies, but a method common to 15 studies was measured UV exposure as a percentage of ambient UV. The studies reviewed do not provide sufficient information for the development and evaluation of targeted youth sun protection programs. Studies are required which document precise UV exposure, concurrent activities and sun protection usage for children and adolescents.
Adolescent↗
Improving health care quality for racial/ethnic minorities: a systematic review of the best evidence regarding provider and organization interventions.
BACKGROUND: Despite awareness of inequities in health care quality, little is known about strategies that could improve the quality of healthcare for ethnic minority populations. We conducted a systematic literature review and analysis to synthesize the findings of controlled studies evaluating interventions targeted at health care providers to improve health care quality or reduce disparities in care for racial/ethnic minorities. METHODS: We performed electronic and hand searches from 1980 through June 2003 to identify randomized controlled trials or concurrent controlled trials. Reviewers abstracted data from studies to determine study characteristics, results, and quality. We graded the strength of the evidence as excellent, good, fair or poor using predetermined criteria. The main outcome measures were evidence of effectiveness and cost of strategies to improve health care quality or reduce disparities in care for racial/ethnic minorities. RESULTS: Twenty-seven studies met criteria for review. Almost all (n = 26) took place in the primary care setting, and most (n = 19) focused on improving provision of preventive services. Only two studies were designed specifically to meet the needs of racial/ethnic minority patients. All 10 studies that used a provider reminder system for provision of standardized services (mostly preventive) reported favorable outcomes. The following quality improvement strategies demonstrated favorable results but were used in a small number of studies: bypassing the physician to offer preventive services directly to patients (2 of 2 studies favorable), provider education alone (2 of 2 studies favorable), use of a structured questionnaire to assess adolescent health behaviors (1 of 1 study favorable), and use of remote simultaneous translation (1 of 1 study favorable). Interventions employing more than one main strategy were used in 9 studies with inconsistent results. There were limited data on the costs of these strategies, as only one study reported cost data. CONCLUSION: There are several promising strategies that may improve health care quality for racial/ethnic minorities, but a lack of studies specifically targeting disease areas and processes of care for which disparities have been previously documented. Further research and funding is needed to evaluate strategies designed to reduce disparities in health care quality for racial/ethnic minorities.
Ethnicity↗
Changes in average length of stay and average charges generated following institution of PSRO review.
A five-year review of accounting data at a university hospital shows that immediately following institution of concurrent PSRO admission and length of stay review of Medicare-Medicaid patients, there was a significant decrease in length of stay and a fall in average charges generated per patient against the inflationary trend. Similar changes did not occur for the non-Medicare-Medicaid patients who were not reviewed. The observed changes occurred even though the review procedure rarely resulted in the denial of services to patients, suggesting an indirect effect of review.
Accounting↗
Hormono-chemotherapy in the treatment of advanced breast cancer.
The current situation in the treatment of metastatic breast cancer is reviewed. Overall the concurrent use of endocrine treatment and chemotherapy does not improve the therapeutic results as compared to a treatment encompassing only one modality. However, results diverge widely in different subgroups. Data emerging from various randomized trials are beginning to define subgroups of patients, who should be treated differently. Such data are discussed and their importance for future trials in the field of advanced breast cancer reviewed.
Adult↗
Peer review of psychodynamic psychotherapy. Experimental studies of the American Psychological Association/CHAMPUS program.
Two factorial experiments examined the effects of reviewer theoretical orientation, documented treatment progress, and patient concurrence data on the peer review of clinical treatment reports that described long-term psychodynamic psychotherapy with a depressed, female outpatient. The experiments employed an unobtrusive methodology; peer reviewers believed that their evaluations would affect the disposition of actual mental health insurance claims. Subjects (n = 105) were American Psychological Association/Civilian Health and Medical Program of the Uniformed Services (CHAMPUS) peer reviewers of a psychodynamic, behavioral, or eclectic theoretical orientation. The psychodynamic reviewers, compared with the behavioral and eclectic reviewers, were more positive in their ratings of treatment and more generous in their future care reimbursement recommendations. Additionally, the data demonstrated that APA/CHAMPUS peer review was sensitive to reported treatment progress, and that reviewers of diverse orientations were equally responsive to documented progress in psychodynamic psychotherapy. The patient concurrence manipulation had little effect on the dependent measures. Implications for mental health quality assurance programs are discussed.
Health Benefit Plans, Employee↗
Diagnosis and management of Alzheimer's disease and other disorders associated with dementia. The role of neurologists in Europe. European Federation of Neurological Societies.
In 1998 a task force to develop guidelines for diagnostic evaluation and treatment of dementia was initiated by the European Federation of Neurological Societies (EFNS) scientist panel on dementia. The aims of the task force were to provide evidence-based recommendations and to highlight the role of the neurologist in the management of patients with Alzheimer's disease and other disorders associated with dementia. We based our recommendations on a review of available evidence-based guidelines supplemented with further literature reviews. The recommendations were derived from consensus meetings and relate to individual patient management, as there are inadequate data on the cost-effectiveness of different diagnostic evaluations and treatments for dementia. Their specific applications will depend upon available resources. The particular contributions of the neurologist include: early identification and differential diagnosis of rare and common brain disorders causing cognitive and behavioural symptoms, referral for and interpretation of ancillary investigations, and identification and treatment of vascular and other concurrent diseases. A review of the management of dementia in Europe revealed considerable variation. In some countries neurologists have taken the lead in the management of patients with dementia, while in other countries the neurologist is rarely involved. We recommend that neurologists should have a clear role in the management of dementia in the whole of Europe. They should be involved in the diagnostic evaluation of dementia and facilitate the development of multidisciplinary teams for evaluation and management of patients with cognitive disturbances. The increasing role of neurology in the management of patients with dementia has important implications for training and education.
Alzheimer Disease↗
Polymicrobial gram-negative bacteremia associated with saline solution flush used with a needleless intravenous system.
BACKGROUND: During a 2-week period, seven cases of nosocomial polymicrobial gram-negative rod bacteremia occurred on a 39-bed medical and cardiac step-down unit. Combinations of Enterobacter cloacae (seven isolates), Klebsiella pneumoniae (five isolates), and Citrobacter freundii (two isolates) were isolated from blood cultures. METHODS: Concurrent and retrospective chart reviews were used to look for further cases and common exposures. Epidemiologic methods were used to refine determination of common exposure. Restriction enzyme DNA analysis was performed on the isolates. RESULTS: Concurrent and retrospective chart reviews revealed four additional possible cases during the same period. All case patients were exposed, through peripheral saline solution locks or central venous catheters, to saline solution "flush" from a central 0.9% saline solution bag and a needleless dispensing pin. Epidemiologic methods implicated probable extrinsic contamination of a single bag and pin used during a 24-48-hour period (Fisher's Exact Test, p < 0.002). There were no other common exposures. Restriction enzyme DNA analysis of the isolates further supported a common source for the outbreak. CONCLUSIONS: The introduction of needleless intravascular systems has been embraced for employee protection. Our report is the first to raise the question of patient safety with such systems. This outbreak highlights the inherent risks in rapid introduction of new technologies and points out the delicate balance among patient health, employee safety, and cost containment.
Bacteremia↗
Systemic heparin in the early management of ruptured intracranial aneurysms: review of 104 consecutive cases and comparison with concurrent controls.
The records of 104 patients treated prophylactically with heparin during gradual carotid ligation after rupture of an intracranial aneurysm, 11 patients, who received heparin after the development of an ischemic neurological deficit during clamp closure, and 46 patients who did not receive heparin during clamp closure were reviewed. The incidence of ischemic neurological deficit, both permanent and transient, was 19.2% in the prophylactic heparin group compared with 38.6% in the control group. The incidence of recurrent intracranial hemorrhage was 9.6% in the heparin group vs. 26.1% in the control group. All differences were statistically significant at or below P less than 0.01 by the Mantel-Haenszel statistical test. Possible mechanisms for the reduction in morbidity and mortality in patients receiving heparin are discussed.
Brain Ischemia↗
Polyomavirus nephropathy in renal transplantation: a clinico-pathological study.
Polyomavirus (PV) nephropathy is a rare cause of graft dysfunction, but it may accompany acute rejection (AR), resulting in complications with respect to its diagnosis and treatment. To examine the validity of tubulitis and inflammatory phenotype in the diagnosis of concurrent AR, we reviewed the renal histology of ten biopsy samples from nine patients with PV nephropathy, and the immunohistochemistry from eight samples. Tubulitis was present in seven patients and was associated with AR in six. The degrees of tubulitis and interstitial inflammation were higher in biopsy samples with AR than in those without, but the degree of tubulitis was not related to the degree of interstitial inflammation. Virally infected cells were rare in the samples with no, or mild, tubulitis, but did not increase with the degree of interstitial inflammation. Immuno-phenotyping of inflammatory cells did not show any T-cell dominance in AR: T cells were dominant over B cells in three of six samples with AR and both samples without AR. Although the degrees of tubulitis and interstitial inflammation were higher in the AR subjects, the presence of tubulitis or inflammatory phenotype was not helpful in the diagnosis of concurrent AR. Further studies will be required to find a better marker for coexisting AR in patients with PV nephropathy and to establish strategies for treatment.
Acute Disease↗
Concurrent chemoradiotherapy using high-dose-rate intracavitary brachytherapy for uterine cervical cancer.
OBJECTIVE: We retrospectively reviewed our experience with concurrent chemoradiotherapy (CCRT) using high-dose-rate intracavitary brachytherapy (HDR-ICBT) to assess its feasibility and efficacy in the treatment of patients with uterine cervical cancer. METHODS: Forty patients with uterine cervical squamous cell carcinoma treated with CCRT using HDR-ICBT were analyzed. The median cervical tumor size assessed by MRI was 63 mm (range: 40-86 mm). Eighteen patients (45%) had enlarged pelvic nodes on MRI (> or =10 mm). Cisplatin (20 mg/m2/day) was concurrently administered with radiotherapy for 5 days at 21-day intervals for a median of three courses (range: 1-5 courses). Thirty-eight (95%) patients received whole pelvic external beam radiotherapy (EBRT) with 40 Gy/20 fractions followed by HDR-ICBT with 18 Gy/3 fractions to point A. Subsequently, additional pelvic EBRT with 10 Gy/5 fractions was delivered with a midline block. The cumulative biological effective dose (BED) at point A of this schedule was 77 Gy10. The median follow-up period for all 40 patients was 37 months (range: 8-71 months). RESULTS: Grade 3/4 leukopenia was the most common acute side effect (83%). The actuarial 3-year pelvic control rate, disease-free survival rate, and overall survival rate were 91%, 67%, and 79%, respectively. Eight (20%) patients suffered late gastrointestinal complications (all grades). No patient suffered radiation cystitis (all grades). Only one patient experienced grade 3 complication (enterocolitis). The actuarial 3-year late complication rate (all grades) was 9% for proctitis and 15% for enterocolitis. CONCLUSION: This preliminary study suggests that CCRT using HDR-ICBT is feasible and efficacious for patients with locoregionally advanced uterine cervical cancer.
Adult↗
An investigation into the practice of concurrent chronic ambulatory peritoneal dialysis catheter insertion and arteriovenous fistula formation in patients needing dialysis.
To review the practice of concurrent chronic ambulatory peritoneal dialysis catheter insertion and arteriovenous fistula formation in patients needing dialysis, we retrospectively assessed the results of arteriovenous fistula procedures, the risk factors for fistula failure, and the selection strategy used to choose which patients with end-stage renal disease would be given dialysis. We analysed the medical records of 136 patients who had first-time arteriovenous fistulae created between 1 July 1986 and 1 May 1994 at a public hospital in Sydney, Australia. As many as 36% of fistulae were never used (24.5% due to primary failure) and 30.1% of the fistulae used had to be abandoned for various reasons. In addition, 22.8% of patients experienced complications, the most common being thrombosis and stenosis. None of the factors associated with fistula formation were significant in terms of fistula patency rates, but smokers and female patients had inferior fistula patency rates. Whereas the overall results were satisfactory, the practice of concurrent chronic ambulatory peritoneal dialysis catheter insertion and arteriovenous fistula formation to give vascular access for dialysis is questionable.
Adolescent↗
Pneumonectomy after high-dose radiation and concurrent chemotherapy for nonsmall cell lung cancer.
BACKGROUND: Pneumonectomy after high-dose radiotherapy and concurrent chemotherapy has been associated with high operative mortality. Therefore, most induction protocols limit radiation to 5,000 cGy or less. Additionally, the safety of right pneumonectomy after induction therapy has been questioned. The feasibility of pneumonectomy after high-dose radiotherapy and concurrent chemotherapy is reviewed. METHODS: From 1990 to 2005, 30 patients with locally advanced nonsmall-cell lung cancer underwent pneumonectomy after 5,940 cGy of radiation and two cycles of etoposide and cisplatin. To minimize postpneumonectomy pulmonary edema, patients were treated with a protocol that included fluid restriction and 48 hours of mechanical ventilation. Morbidity, mortality, and survival were examined. RESULTS: There were 18 right and 12 left pneumonectomies. Death occurred in 4 patients (13.3%) but in only 1 (5.6%) after right pneumonectomy. Causes of death included aspiration, bronchopleural fistula, pneumonia, and massive pulmonary embolus. Major morbidity occurred in 5 (pneumonia in 2 and aspiration in 3). Median hospital stay was 9 days (range, 2 to 45), and intensive care unit stay was 2 days (range, 2 to 35). Median overall survival was 22 months with a 5-year survival of 33%. Patients surviving operation had a median survival of 33 months and a 5-year survival of 38%. CONCLUSIONS: The mortality rate after pneumonectomy after high-dose radiation and concurrent chemotherapy is relatively high but results in significant survival. The mortality rate is not increased after right-sided operations. Pneumonectomy should continue to be offered to patients with advanced locoregional disease after induction high-dose radiotherapy and concurrent chemotherapy when a complete resection cannot be carried out with a lesser procedure.
Adult↗
A proposed model for examining the interference phenomenon between concurrent aerobic and strength training.
A review of the current research on the interference phenomenon between concurrent aerobic and strength training indicates modest support for the model proposed in this article. However, it is clear that without a systematic approach to the investigation of the phenomenon there is lack of control and manipulation of the independent variables, which makes it difficult to test the validity of the model. To enhance the understanding of the interference phenomenon, it is important that researchers are precise and deliberate in their choice of training protocols. Clear definition of the specific training objectives for strength (muscle hypertrophy or neural adaptation) and aerobic power (maximal aerobic power or anaerobic threshold) are required. In addition, researchers should equate training volumes as much as possible for all groups. Care needs to be exercised to avoid overtraining individuals. There should be adequate recovery and regeneration between the concurrent training sessions as well as during the training cycle. The model should be initially tested by maintaining the same protocols throughout the duration of the study. However, it is becoming common practice to use a periodised approach in a training mesocycle in which there is a shift from high volume and moderate intensity training to tower volume and higher intensity. The model should be evaluated in the context of a periodised mesocycle provided the investigators are sensitive to the potential impact of the loading parameters on the interference phenomenon. It may be that the periodised approach is one way of maintaining the training stimulus and minimising the amount of interference. The effects of gender, training status, duration and frequency of training, and the mode of training need to be regarded as potential factors effecting the training response when investigating the interference phenomenon. Other experimental design factors such as unilateral limb training or training the upper body for one attribute and the lower body for another attribute, may help establish the validity of the model.
Adaptation, Physiological↗
Endoleak after aortic stent graft repair: diagnosis by color duplex ultrasound scan versus computed tomography scan.
PURPOSE: The purpose of this study was to compare the accuracy of a color duplex ultrasound scan (CDU) to a computerized axial tomography scan (CT) in the diagnosis of endoleaks after stent graft repair of abdominal aortic aneurysms. METHODS: The Endovascular Aneurysm Clinical Trial Core Laboratory records were reviewed from 117 concurrent CDU and CT studies that were performed in 79 patients who were implanted with the Endovascular Technologies stent graft device between December 1995 and January 1997. All of the studies were interpreted by the Core Laboratory as having the presence or the absence of an endoleak or as being indeterminate because of technical factors. Of the 117 videotaped CDU studies available for reexamination, 100 were reassessed for technical adequacy on the basis of the following criteria: a satisfactory imaging of the aneurysm sac and of the stent graft with gray scale, and both color and spectral Doppler scan evaluation for endoleak outside the endograft and within the aneurysm sac. RESULTS: Of the 117 studies, 103 CDUs (88%) and 114 CTs (97%) were recorded as having the presence or the absence of an endoleak and 14 CDUs (12%) and 3 CTs (3%) were indeterminate. For the studies that were recorded to have the presence or the absence of an endoleak, the sensitivity, the specificity, the positive and the negative predictive values, and the accuracy of CDUs as compared with CTs were 97%, 74%, 66%, 98%, and 82%, respectively. Of the 100 CDU videotaped studies available for review, the following results were seen: (1) 93 CDUs had satisfactory B-mode images, (2) 76 had satisfactory color Doppler scan images to evaluate for endoleaks, (3) 55 had color Doppler scan assessment of the entire abdominal aortic aneurysm sac for endoleak, and (4) 27 had spectral Doppler scan waveform confirmation of suspected endoleaks. Only 19 CDU studies (19%) with all 4 criteria for complete assessment of endoleak were performed. CONCLUSION: Although most of the CDU studies were technically suboptimal, the CDUs reliably identified endoleaks with an excellent sensitivity and a negative predictive value as compared with CT scans.
Aorta, Abdominal↗