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[Hepatic puncture biopsy in ambulatory care. Advantages and disadvantages].

There is a clear trend towards favoring outpatient care in an attempt to control health care costs. Despite widespread acceptance in some countries, many teams in France still prefer to hospitalize patients requiring percutaneous liver biopsy because the outpatient setting has not been encouraged in French text books on hepatology, many gastroenterologists do not have access to outpatient facilities, and the lack of French references which has raised questions as to the legal responsibilities involved. The series of 231 outpatient percutaneous liver biopsies reported by Bourgaux in this issue of La Presse Médicale will remove the doubt in many minds. There are many advantages for the generally young population with early stage liver disease, frequently hepatitis C, requiring percutaneous liver biopsy. Lower cost is probably the primary advantage, but improved patient comfort, especially if repeated procedures are needed, is also greatly appreciated. The outpatient procedure is safe when all the selection criteria are met including: normal coagulation, ultrasonographically homogeneous liver, patient compliance and availability of a structured outpatient clinic, and absence of a severe concomitent disease. These apparently restrictive criteria actually include the majority of the indications for liver biopsy. There is another debate on whether echo-guided biopsy would be even safer but as emphasized by Bourgaux et al. this would require a reorganization of most of the hepatogastroenterology departments. One other point cannot be overlooked. Some operators (and patients) may also feel that the impressive nature of the procedure merits a more impressive setting, i.e. full hospitalization. Consequently, while it is quite reasonable to propose outpatient liver biopsy as a classical procedure, there are situations when personal preference may still dictate hospitalization.

Ambulatory Care↗

Open book tests: assessment of academic learning in clerkships.

An examination of an open-book testing approach in a family medicine clerkship seeks to determine whether this method more closely mirrors the discipline of family medicine, where practitioners refer daily to written resource materials in order to make clinical decisions without compromising the learning and assessment process. Student scores on the multiple-choice test were analysed by year, by quarter and by site using ANOVA. Students in the experimental site were interviewed to determine preparation style, use of text during test, as well as attitudes toward open-book testing. Analysis of variance showed that the interaction of site and year was significant at p = 0.03. The mean score of 88.2 for Maine students in 2002 was significantly different from the other three mean scores. The desired qualitative outcomes of the intervention were confirmed: reducing the anxiety of students, wider reading of the textbook, knowing the structure of the textbook as a learning resource, and deeper understanding of concepts and principles rather than time spent on memorization. While the difference in scores did reach statistical significance, it is important to note that the difference in mean score was only four points on a 100-point scale. Given the percentage of the total grade represented by the test score, it is unlikely that this difference represents any real difference in grade for students in Maine compared with Vermont. The students appeared to approach the textbook and therefore, perhaps, the body of knowledge as a whole with the orientation of a generalist. The MMC Clerkship Director recommended the implementation of the open-book approach to the Family Practice clerkship at all sites and the University of Vermont Medical School accepted the proposal. This recommendation supports advising students on the preparation for an open-book test and on tactics for the best use of the textbook during the test.

Attitude of Health Personnel↗

Rational evaluation of urinary stone disease.

This article outlines the recent state of the art in the metabolic diagnosis of stone disease. The current literature in the field of urolithiasis-including the existing German and EAU-Guidelines as well as the Conference Book of the 1st International Consultation on Stone Disease-was critically reviewed. As far as possible the references were rated according to the EBM criteria. The occurrence of stone disease in the western world is increasing greatly. Modern lifestyle, dietary habits and excess weight-problems of affluent societies-are emerging as the important promoters of the "stone boom" in the new millennium. This even affects children, whose stone prevalence is otherwise significantly less than that of adults. Criteria for the high-risk group of stone formers were clearly defined. A diagnostic standard is formulated for the basic and the elaborate metabolic evaluation of a stone patient. The diagnostic pathways for the most important stone types and metabolic disorders, respectively, are described. The present concept allows a precise risk classification of each stone former and facilitates the decision whether stone-specific measures in addition to the basic metaphylaxis are recommendable or not.

Adult↗

Nappy handling and risk of giardiasis.

We did a case-control study to identify modifiable risk factors for giardiasis in people aged 15-64 years living in Auckland, New Zealand. 183 patients with stool-positive Giardia spp referred to community laboratories were compared with 336 age-matched controls identified randomly from the Auckland telephone book. Exposure information for the previous 3 weeks was obtained retrospectively by telephone. Nappy changing was associated with a four-fold increased risk of infection after controlling for other confounders. We conclude that children wearing nappies could be an important source of giardia infection in the community.

Adolescent↗

What nutrition knowledge and skills do primary care physicians need to have, and how should this be communicated?

The last Heelsum workshop agreed that general practitioners should concentrate on dietary advice for treatment or secondary prevention, though nutritional advice for health is part of the doctor's work with pregnancy, infants and the very old. Nutrition prescriptions contrast with drug prescriptions. For drugs information is authoritative, evidence-based and easily available. Drug prescriptions are potentially liable to litigation. Dietary prescriptions are less serious and more the patient's responsibility. Nutrition information comes in a plethora of different forms, some of it unscientific, some out of date, some commercially biased. While waiting for some system (?authoritative, ?electronic) that can help general practitioners (GPs) organise nutrition information, there are three modern books that have been written by nutrition specialists for GPs in the English language (there may be others in North America) and another was written for practice nurses. As well as general books like this most large countries have expert reports on some nutritional topics by government committees available for reference. In relating foods and food components to disease, most of the reliable evidence is about their effect on risk factors-plasma cholesterol, blood glucose, blood pressure or body weight. A smaller amount of evidence relates food intake data from large cohort studies to incidence of disease. Very few randomised controlled trials (the ultimate evidence-based medicine) have been achieved for nutrition. Dietary recommendations may have to change with time because of new research-and drugs. Advice for secondary prevention of coronary heart disease is shown as an example of this.

Coronary Disease↗

Lyme disease: a neuropsychiatric illness.

OBJECTIVE: Lyme disease is a multisystemic illness that can affect the central nervous system (CNS), causing neurologic and psychiatric symptoms. The goal of this article is to familiarize psychiatrists with this spirochetal illness. METHOD: Relevant books, articles, and abstracts from academic conferences were perused, and additional articles were located through computerized searches and reference sections from published articles. RESULTS: Up to 40% of patients with Lyme disease develop neurologic involvement of either the peripheral or central nervous system. Dissemination to the CNS can occur within the first few weeks after skin infection. Like syphilis, Lyme disease may have a latency period of months to years before symptoms of late infection emerge. Early signs include meningitis, encephalitis, cranial neuritis, and radiculoneuropathies. Later, encephalomyelitis and encephalopathy may occur. A broad range of psychiatric reactions have been associated with Lyme disease including paranoia, dementia, schizophrenia, bipolar disorder, panic attacks, major depression, anorexia nervosa, and obsessive-compulsive disorder. Depressive states among patients with late Lyme disease are fairly common, ranging across studies from 26% to 66%. The microbiology of Borrelia burgdorferi sheds light on why Lyme disease can be relapsing and remitting and why it can be refractory to normal immune surveillance and standard antibiotic regimens. CONCLUSIONS: Psychiatrists who work in endemic areas need to include Lyme disease in the differential diagnosis of any atypical psychiatric disorder. Further research is needed to identify better laboratory tests and to determine the appropriate manner (intravenous or oral) and length (weeks or months) of treatment among patients with neuropsychiatric involvement.

Comorbidity↗

B. F. Skinner's Science and Human Behavior: its antecedents and its consequences.

Skinner's Science and Human Behavior marked a transition from a treatment of behavior that took physics as its reference science to one that emphasized behavior as a fundamental part of the subject matter of biology. The book includes what may be Skinner's earliest statement about the similarity of operant selection to Darwinian natural selection in phylogeny. Other major topics discussed in the book included multiple causation, private events, the self, and social contingencies. Among the important antecedents were Skinner's own Behavior of Organisms and Keller & Schoenfeld's Pincinples of Psychology. Current developments in education, behavioral economics, and some behavior therapies can be attributed at least in part to Skinner's seminal work. The effective behavioral analysis of governmental and religious systems will probably depend on elaborations of our understanding of verbal behavior.

Animals↗

Obstetric mortality in a Nigerian general hospital.

BACKGROUND: The aim of the study was to evaluate the progress towards achieving a 50% reduction in maternal mortality by the year 2000 at a referral hospital. METHODS: A retrospective review of births and maternal deaths over an 18-year period from 1981 to 1998. RESULTS: There was a 30% reduction among booked women in the period 1990-1998 compared to 1981-1989 while only 8% reduction was achieved among referred women. Infection and hypertensive disorders remained the leading causes of death but the contribution of haemorrhage declined due to improved blood transfusion services. CONCLUSION: Further improvement in maternal survival can be achieved by training health personnel involved in maternity care to recognise or anticipate complications early and refer.

Adult↗

Volume rendering of visible human data for an anatomical virtual environment.

In this work, we utilize the axial anatomical human male sections from the National Library of Medicine's Visible Human Project to generate three-dimensional (3-D) volume representations of the human male subject. The two-dimensional (2-D) projection images were produced by combining ray tracing techniques with automated image segmentation routines. The resultant images provide accurate and realistic volumetric representations of the Visible Human data set which is ultimately needed in medical virtual environment simulation. Ray tracing techniques provide methods by which 2-D volume views of a 3-D voxel array can be produced. The cross-sectional images can be scanned at different angles to produce rotated views of the voxel array. By combining volume views at incremental angles over 360 degrees a full volumetric representation of the voxel array, in this case the human male data set, can be computer generated and displayed without the speed and memory limitations of trying to display the entire data array. Additional texture and feature information can be obtained from the data by applying optical property equations to the ray scans. The imaging effects that can be added to volume renderings using these equations include shading, shadowing, and transparency. The automated segmentation routines provide a means to distinguish between various anatomical structures of the body. These routines can be used to differentiate between skin, fat, muscle, cartilage, blood vessels, and bone. By combining automated segmentation routines with the ray-tracing techniques, 2-D volume views of various anatomical structures and features can be isolated from the full data set. Examples of these segmentation abilities are demonstrated for the human male data set which include volume views of the skeletal systems, the musculoskeletal system, and part of the vascular system. The methods described above allow us to generate lifelike images, NURBS surface models, and realistic texture maps of specific anatomical structures. We have the capability to generate images that are both accurate and lifelike, much like photographic anatomical atlases. We can also generate images, models, and textures that have the clarity of medical artwork/illustrations, by highlighting the coloring of the ray traced structures with conventional colors instead of the natural color of the specimen. We are currently in the process of generating a comprehensive reference atlas of volume rendered images of the human body, soon to be published by Mosby-Year Book. The segmentation techniques needed to create this atlas also offer the accuracy and realism needed to create surface models and texture maps for a virtual environment for surgery simulation.

Anatomy, Cross-Sectional↗

[Sickle cell disease and infection].

OBJECTIVE: To discuss the high prevalence of sickle cell disease in our environment and the increased morbidity and mortality as a result of infection associated with this condition. SOURCES OF DATA: Review of MEDLINE from 1986 to 2003. We found around 600 references about the subject. Thirty-five journal articles were reviewed, in addition to chapters in two text books. SUMMARY OF THE FINDINGS: We discuss general information concerning sickle cell disease as well as a few topics about the most frequently observed infections in these patients. Drug prophylaxis and immunizations are also covered. CONCLUSIONS: This review hopes to provide the pediatric community with information concerning the association between sickle cell disease and infections, so as to minimize the occurrence of complications.

Anemia, Sickle Cell↗

[Reference groups as a form of training in general practice].

In 1985 the first "reference groups" were established within the Norwegian College of General Practitioners. Today there are 20 such groups, with a total of 117 members. The reports of these groups have been studied in order to obtain a picture of how they are organized, how and how often they meet, their aims, and what they produce. The reference groups represent a unique way of studying which seems to produce substantial results in the form of books, booklets, articles, courses and know-how within different fields of Norwegian general medicine.

Education, Medical, Continuing↗

Normalization of pregnancy outcome in pregestational diabetes through functional insulin treatment and modular out-patient education adapted for pregnancy.

AIM: To investigate whether modular out-patient group education for flexible, Functional Insulin Treatment (FIT) adapted for pregnancy can eliminate diabetes-associated neonatal complications in pregestational diabetes. RESEARCH DESIGN AND METHODS: Outcome analysis of the modular out-patient group education and FIT based on separate insulin dosages for fasting, eating or correcting hyperglycaemia in 76 consecutive pregnancies (in 20 cases first after conception) of 59 patients with pregestational diabetes (Type 1 diabetes, n = 54). CONTROLS: (a) diabetic pregnancies: historical controls; (b) non-diabetic pregnancies: retrospective case-controlled study; (c) population-based data of all Austrian newborns registered within the respective time period. RESULTS: HbA1c of 113 +/- 18% of mean value (= 100%) of non-diabetic, non-pregnant population (103 +/- 14% during the last pregnancy trimester), and self-monitored blood glucose of 5.6 +/- 0.7 mmol/l (5.3 +/- 0.7 mmol/l during the last trimester) was achieved throughout all FIT pregnancies. Severe hypoglycaemia occurred in 14 pregnancies. The gestational age at delivery was 39.2 +/- 1.5 weeks (four cases (5.4%) < 37 weeks) with a birth weight of 3305 +/- 496 g. Four newborns (5.3%) were above the 90th, and nine (11.8%) below the 10th percentile for weight of reference population-based data. Hypoglycaemia was recorded in six newborns (8%). Malformations were found in two infants whose mothers booked for diabetes FIT education only after conception. The caesarean delivery rate was 25%. In comparison with historical diabetic pregnancy controls we demonstrated a reduction in major complications, and compared with non-diabetic women, a lowering of diabetes-related neonatal complication rates to general population levels. CONCLUSIONS: Structured, comprehensive, modular out-patient group education promoting self-choice of insulin dose for flexible, normal eating prior to conception normalizes pregnancy outcome in diabetes.

Adult↗

Neural edelmanism.

The recent book Neural Darwinism (ND) by Gerald Edelman, claims to put forward 'a radically new view of the function of the brain and nervous system'. Its main focus is on the understanding of the biological basis of perception. This new view is based on what Edelman calls 'The Theory of Neuronal Group Selection', the subtitle of his book. In spite of Edelman's lengthy and spirited account of this new theory, most readers appear to have had some difficulty in grasping his ideas and many have complained that the book is not easy to read. It has been particularly difficult to relate Edelman's ideas to those already current and well-known, especially as Edelman himself says rather little on this topic. In this critique I aim to set out Edelman's central ideas, as they appear to me, in a clearer and more digestible form. I examine both his general exposition of these ideas and the simulations he has presented to support them, giving page references so that the concerned reader can check my statements against the text. I have considered also Edelman's original papers, upon which the book is based, but I have not considered more recent papers which deal with matters (such as Darwin III) that are not covered in the book.

Animals↗

Review and assessment of selection criteria used when booking pregnant women at different places of birth.

OBJECTIVE: To describe and assess the selection criteria currently being used when booking women for different places of birth. DESIGN: A cross-sectional survey. SETTING: The South and West region of England. SAMPLE: The 27 NHS Trusts who provide maternity care in the South and West region of England. MAIN MEASURES: Selection criteria used when booking pregnant women for different places of birth; length of time criteria in use; whether criteria applied individually or as part of a risk score; and method by which criteria developed. RESULTS: The response rate was 81%; 128 different, individual criteria, used as the basis to select women for different places of birth, were identified. No single criterion appeared on all the sets of criteria. None of the trusts who responded used the criteria in order to calculate a risk score. In all but one case the criteria were being used to select women who might be suitable for birth outside a consultant-led maternity unit. Only two trusts used sets of criteria which identified, to any extent, 1. outcomes for which women could be at risk and 2. strategies that should be implemented to reduce that risk. Over half the trusts were able to identify a rationale for the particular set of criteria which they used but in only two cases was any reference made to an evidence base. CONCLUSIONS: A large variety of criteria are being used as a basis on which to book women for different places of birth but they appear to be poorly focused on particular adverse outcomes. To be effective, selection criteria must identify quantifiable differences in the risk of particular preventable adverse outcomes for births booked at different locations. Furthermore, there must be evidence that the risk could be reduced by a selecting a particular location. A systematic review is required to determine which selection criteria, if any, should be employed at booking.

Adult↗

Fears and coping strategies associated with pregnancy and childbirth in Finland.

The purpose of this study was to describe the causes of fear associated with pregnancy and childbirth and to describe coping strategies of pregnant women who have fears. Data were collected by using semistructured interviews on the maternity units of two university hospitals in Finland. A convenience sample of 20 women served as participants, and data were analyzed by using content analysis techniques. In most cases, the source of fear was either previous experience and knowledge or uncertainty. In some cases, the source of fear was beliefs about childbirth with no clear origin of the belief. Knowledge was described as a means of dealing with fear, as were talking, writing, and reasoning. When seeking help, many participants relied on their social network and on health care professionals, but some sought information independently from books, magazines, etc. Methods for dispelling or alleviating fear included talking about feelings, increasing knowledge, accessing health care services, referring to positive experiences, receiving reassurance from medical screening, and/or feeling the baby move. Knowledge can be a cause of fear, but its ability to decrease fear is of greater consequence. What seemed to matter most was the way in which information is given.

Adaptation, Psychological↗

The families of cognition enhancers.

An attempt has been made to classify the numerous drugs used to treat cognition deficits according to their chemical structures and to their main physiological effects. Particular emphasis has been given to the following families: Piracetam-type, Co-dergocrine-type and vincamine-type compounds; cholinergic agents, psychostimulants, vasodilators, antianoxic agents, peptides, growth factors and gangliosides. Compounds described in the scientific literature and in patents are presented. Reference has been made to preclinical and clinical studies (973 quotations from original articles, 100 quotations of reviews and books).

Animals↗

"Running the vicious cycle backward" and other systems solutions to nursing problems.

Peter Senge's book, The Fifth Discipline: The Art and Practice of the Learning Organization, is a business bestseller. The fifth discipline refers to systems thinking, a conceptual framework for making the full pattern of complex, interrelated actions clearer and helping people see how to change them. This article summarizes selected key concepts from Senge's work and explains how nurse executives can use systems thinking to gain a deeper understanding of the forces operating in recurrent situations and identify opportunities for leverage to benefit patients, staff, and healthcare organizations.

Humans↗

Area wide electronic booking: a revolution in the management of health and well being.

Area wide electronic booking provides patients with the choice of date, time and place as well as the certainty of appointment when referred into secondary care by their GP. The system provides substantial benefits to both primary and secondary care as well as to the patient. This model is to be imminently implemented throughout the NHS in England, drawing from the experiences gained in South East London.

Appointments and Schedules↗