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PubMed2006

[Problems of lung function testing in the laboratory].

Spirometry is indispensable for the screening test of general respiratory function, and measurements of lung volume and diffusing capacity play an important role in the assessment of disease severity, functional disability, disease activity and response to treatment. Pulmonary function testing requires cooperation between the subjects and the examiner, and the results obtained depend on technical as well as personal factors. In order to diminish the variability of results and improve measurement accuracy, the Japan Respiratory Society published the first guidelines on the standardization of spirometry and diffusing capacity for both technical and clinical staff in 2004. It is therefore essential to distribute the guidelines to both laboratory personnel and general physicians. Furthermore, training workshops are mandatory to improve their understanding of the basics of lung function testing. Recently, there has been increasing interest in noninvasive methods of lung function testing without requiring the patient's cooperation during spontaneous breathing. Three alternative techniques, i.e. the negative expiratory pressure (NEP) method to detect expiratory flow limitation, impulse oscillation system (IOS) to measure respiratory system resistance (Rrs) and reactance (Xrs), and interruption resistance (Rint) to measure respiratory resistance have been introduced. Further study is required to determine the advantage of these methods.

Airway Resistance↗

PubMed1993

Nail varnish allergy with far-reaching consequences.

Contact allergy to nail varnish is well-known, and toluene-sulphonamide formaldehyde resin (TSAfr) was identified as the main allergen in 1943. During the period October 1989-December 1991 we identified 18 cases of contact allergy to nail varnish. The aim of the study was to describe the clinical picture, patch-test results, course and socio-medical consequences. Seventeen of the 18 patients were patch-test positive to TSAfr and 17/18 were positive to their own nail varnishes. Fourteen of the 18 were also positive to one or more substances in the standard patch-test series. The lesions were scattered, involving the face, eyelids, neck and hands. Periungual lesions were recorded in 11/18. The dermatitis resolved within a few weeks when the use of nail varnish was stopped. The socio-medical consequences of contact allergy to nail varnish had been severe: sick leave (nine cases), hospitalization (four cases), cessation of visual-display-unit (VDU) work (two cases), and job-loss (two cases). Our conclusions are that contact allergy to nail varnish and TSAfr is common; the socio-medical consequences may be severe; periungual lesions occur more frequently than previously stated, and the presence of other contact allergies makes the diagnosis easy to miss. TSAfr should be included in the standard patch-test series and patients should also be tested with their own nail varnishes. The study illustrates the need for mandatory declaration of the ingredients of cosmetics, as is required in the U.S.A.

Adult↗

PubMed2006

Methotrexate therapy for rheumatoid arthritis: clinical practice guidelines based on published evidence and expert opinion.

OBJECTIVES: To develop clinical practice guidelines for the use of methotrexate in rheumatoid arthritis (RA), using the evidence-based approach and expert opinion. METHODS: A scientific committee used a Delphi procedure to select five questions, which formed the basis for developing recommendations. Evidence providing answers to the five questions was sought in the Cochrane databases, PubMed, and proceedings of meetings of the French Society for Rheumatology, European League Against Rheumatism, and American College of Rheumatology. Using this evidence, a group of rheumatologists developed and validated the recommendations. For each recommendation, the level of evidence and the extent of agreement among experts were specified. RESULTS: The recommendations were as follows: 1: The starting dosage for methotrexate in patients with RA should not be less than 10 mg/week and should be determined based on disease severity and patient-related factors; 2: When a patient with RA shows an inadequate response to methotrexate, the dosage should be increased at intervals of 6 weeks, up to 20 mg/week, according to tolerance and patient-related factors; 3: When starting methotrexate treatment in a patient with RA, preference should be given to the oral route. A switch to the intramuscular or subcutaneous route should be considered in patients with poor compliance, inadequate effectiveness, or gastrointestinal side effects; 4: At present, there is no evidence indicating that a change in methotrexate dosage is in order when a TNF antagonist is given concomitantly; 5: The investigations that are mandatory before starting methotrexate therapy in a patient with RA consist of a full blood cell count, serum transaminase levels, serum creatinine with computation of creatinine clearance, and a chest radiograph. In addition, serological tests for the hepatitis viruses B and C and a serum albumin assay are recommended. In patients with a history of respiratory disease or current respiratory symptoms, lung function tests with determination of the diffusing capacity for carbon monoxide are recommended; 6: Investigations that are mandatory for monitoring methotrexate therapy in patients with RA consist of full blood cell counts and serum transaminase and creatinine assays. These tests should be obtained at least once a month for the first 3 months then every 4-12 weeks; 7: Folate supplementation can be given routinely to patients treated with methotrexate for RA. In practice, a minimal dosage of 5 mg of folic acid once a week, at a distance from the methotrexate dose, is appropriate; 8: In the event of respiratory symptoms possibly related to methotrexate toxicity, the drug must be stopped and symptom severity evaluated. Should evidence of serious disease be found, the patient should be admitted immediately or advice from a pulmonologist should be obtained immediately. CONCLUSION: Recommendations about methotrexate therapy for RA were developed. These recommendations should help to improve practice uniformity and, ultimately, to improve the management of RA.

Arthritis, Rheumatoid↗

PubMed1989

Evaluation of an intervention aimed at reducing inappropriate use of preoperative blood coagulation tests.

A multiphase intervention trial based on education, implementation of criteria, and restriction, aimed at modifying the established clinical policy of mandatory preoperative screening for coagulation abnormalities, was carried out on five surgical wards of a general hospital. The education period did not influence the ordering of partial thromboplastin time tests, despite a significant posteducational change in surgeons' attitudes. In contrast, administrative restriction of coagulation test orders led to a 50% decline on four of the five study wards. We conclude that an educational intervention followed by administrative restriction may be considered an acceptable means of overcoming clinician reluctance to change well-established but redundant clinical policy.

Attitude of Health Personnel↗

PubMed1996

Diagnosis of Helicobacter pylori infection.

A number of invasive and non-invasive techniques are available for the diagnosis of infection with Helicobacter pylori. These can be used to establish whether infection is present and to confirm that eradication has been achieved after treatment. Invasive techniques require biopsy of the gastric mucosa; such techniques include histology, bacterial culture, the rapid urease test and the polymerase chain reaction (PCR) technique. The principal non-invasive techniques are the 13C-urea breath test and serological assays in serum or saliva samples. Histological examination of gastric biopsy samples should be mandatory at the initial presentation of the patient because it also gives insight on the status of the gastric mucosa. The rapid urease test can be used to give a rapid diagnosis of infection. Eradication should also be confirmed by histological examination, though other sensitive tests such as bacterial culture, PCR or the 13C-urea breath test may also be used.

Helicobacter Infections↗

PubMed1984

A cost-benefit analysis of California's mandatory premarital screening program for syphilis.

As do most states, California requires premarital serologic tests for syphilis. The Venereal Disease Research Laboratory (VDRL) test and a fluorescent treponemal antibody-absorbed (FTA-ABS) are often used in series for this purpose. In 1979 in California, there were approximately 300,000 persons tested premaritally, but only 35 were found to have asymptomatic infectious syphilis (incidence=0.012%). Including all the direct costs of this screening program, the yearly costs of premarital screening is $8.5 million or almost $240,000 per case found. If one takes into account the sensitivities and specificities of the tests, one still has 6 false-negative and 90 false-positive tests using the 1979 figures. The benefits of the program are the number of cases of congenital syphilis that are prevented. Using a worse-case method, no more than 1.5% of the cases of syphilis detected would result in a case of congenital syphilis. The estimated benefits would result in a savings of approximately $161,000. The economic costs of the premarital screening program far outweigh the benefits.

California↗

PubMed1991

Neuropsychological assessment for detecting adverse effects of volatile organic compounds on the central nervous system.

Because there are no direct biological markers for the substances implicated in indoor air exposure, it is impossible to directly measure if an individual or group of individuals has been exposed to a potentially neurotoxic substance in the workplace. Behavioral changes may be the earliest and only manifestation of central nervous system (CNS) effects and are often too subtle to be revealed by routine physical or neurological examination. Neuropsychological techniques are sensitive to subtle behavioral/cognitive changes that can result from exposure to neurotoxins. These techniques consist of oral and written tests that are administered by a trained examiner on a one-to-one basis. In general, a wide variety of cognitive domains are evaluated. The typical battery generally includes assessing orientation, attention, intelligence, language, visual memory, verbal memory, perception, visuoconstruction, simple motor speed, psychomotor speed, and mood. As with most assessment techniques, the neuropsychological methods have limitations. One major drawback is the availability of appropriate norms that are used to compare the results of a specific individual. Because these tasks are greatly affected by age, intelligence, and in some instances sex, the availability of appropriate norms is mandatory to determine if the CNS has been effected. Although neuropsychological tests are sensitive to the presence of CNS involvement, they are not specific. Patterns of performance seen with specific instances of neurotoxic exposure may also be seen with a number of other diseases of the CNS such as dementia, cerebrovascular disease, hydrocephalus, or normal aging. In addition, neuropsychiatric symptoms such as anxiety and/or depression are often manifested as cognitive difficulties that will mimic the cognitive dysfunction seen with toxicity of the CNS.(ABSTRACT TRUNCATED AT 250 WORDS)

Brain↗

PubMed2004

Papanicolaou screening in developing countries: an idea whose time has come.

Cervical cancer is the leading cause of cancer-related death among women in developing countries. Although progress is optional in all settings, Papanicolaou screening is feasible anywhere that cervical screening is appropriate and should be implemented without further delay in high-risk communities with access to curative treatment services. Successful prophylactic cervical cancer vaccines, prospects for which remain uncertain, will not eliminate requirements for cervical screening. The feasibility of human papillomavirus test analysis has not been demonstrated in low-resource developing country settings. Because past failures of cervical screening in developing countries are attributable to failures in programmatic quality rather than to technological limitations of the screening test, a shift in paradigmatic focus from technology toward quality is mandatory. Because visual screening techniques coupled with immediate ablative treatment are rendered obsolete by an embedded quality-control paradox, a moratorium should be placed on all such programs. Considerable opportunity costs, borne by the underserved, are associated with prioritizing research of novel interventions in developing countries when satisfactory interventions already exist.

Developing Countries↗

PubMed2004

Heavy metal content of ayurvedic herbal medicine products.

CONTEXT: Lead, mercury, and arsenic intoxication have been associated with the use of Ayurvedic herbal medicine product (HMPs). OBJECTIVES: To determine the prevalence and concentration of heavy metals in Ayurvedic HMPs manufactured in South Asia and sold in Boston-area stores and to compare estimated daily metal ingestion with regulatory standards. DESIGN AND SETTING: Systematic search strategy to identify all stores 20 miles or less from Boston City Hall that sold Ayurvedic HMPs from South Asia by searching online Yellow Pages using the categories markets, supermarkets, and convenience stores, and business names containing the word India, Indian cities, and Indian words. An online national directory of Indian grocery stores, a South Asian community business directory, and a newspaper were also searched. We visited each store and purchased all unique Ayurvedic HMPs between April 25 and October 24, 2003. MAIN OUTCOME MEASURES: Concentrations (microg/g) of lead, mercury, and arsenic in each HMP as measured by x-ray fluorescence spectroscopy. Estimates of daily metal ingestion for adults and children estimated using manufacturers' dosage recommendations with comparisons to US Pharmacopeia and US Environmental Protection Agency regulatory standards. RESULTS: A total of 14 (20%) of 70 HMPs (95% confidence interval, 11%-31%) contained heavy metals: lead (n = 13; median concentration, 40 microg/g; range, 5-37,000), mercury (n = 6; median concentration, 20,225 microg/g; range, 28-104,000), and/or arsenic (n = 6; median concentration, 430 microg/g; range, 37-8130). If taken as recommended by the manufacturers, each of these 14 could result in heavy metal intakes above published regulatory standards. CONCLUSIONS: One of 5 Ayurvedic HMPs produced in South Asia and available in Boston South Asian grocery stores contains potentially harmful levels of lead, mercury, and/or arsenic. Users of Ayurvedic medicine may be at risk for heavy metal toxicity, and testing of Ayurvedic HMPs for toxic heavy metals should be mandatory.

Arsenic↗

PubMed1992

Ethical and legal implications of the new genetics: issues for discussion.

The so-called 'new genetics,' a phrase sometimes associated with The Human Genome Initiative, poses no really new ethical problems, but exacerbates old ones. The issues of most concern to geneticists and their patients are summarized under the eleven headings below. These issues emerged from a 19-nation study of ethics and genetics in 1985-86 and from preliminary work on a forthcoming 36-nation study by the same authors.

Abortion, Legal↗

PubMed1999

The laboratory and the general practitioner.

Clinical laboratories provide vital services for primary care and such work will inevitably increase with the moves to increase the extent to which patients are treated in the primary care setting, an increase in day-case surgery and shorter in-patient stay. The relationship between clinical laboratories and general practitioners should be a partnership with both the parties communicating efficiently in the interest of the patient. In particular, a close relationship between general practitioners and specialists in laboratory medicine is mandatory for handling the increasing number and complexity of laboratory tests, assuring the appropriateness of their request and utilization. In addition, the enormous increase in near-patient testing procedures claims for joint efforts to assure the quality of laboratory results. The General Practitioner always has the responsibility to understand the relevance of a test result and, where appropriate, to investigate further or to refer, irrespective of where the test has been done, but laboratory consultation can assure a better utilization of laboratory services for improving patient outcomes.

Family Practice↗

PubMed2002

Does hypertension alone lead to cognitive decline in spontaneously hypertensive rats?

Spontaneously hypertensive rats (SHR) represent an animal model of cognitive decline associated with hypertension. Few studies have systematically investigated this decline in aging. We assessed spatial learning performances of SHR, the genetically similar Wistar-Kyoto rats (WKY), and Sprague-Dawley rats (SD), in a water maze (WM) task. The following age ranges were studied: 6, 12, and 20 months. The results demonstrated that all three strains show the same level of impairment at the age of 20 months. The rate of cognitive decline, however, is different: both SHR and WKY show moderate degrees of impairment at all age ranges, while SD display good cognitive abilities at 6 months, declining at 12, and reaching the performance level of the other two groups at 20 months. Besides, the nine groups showed substantial differences in swim velocity and WKY exhibited a peculiar motor behavior. These results suggest the following: (a) the decline in cognitive level exhibits different trends in the three strains; (b) learning impairment of aged SHR might not be entirely explained by hypertension; (c) WKY should be used cautiously as normotensive control for SHR, due to their unusual behavior and low learning abilities; (d) analysis of escape distances is mandatory for the comparison of different strains in the WM test.

Aging↗

PubMed2004

[Heparin-induced thrombocytopenia. Pathogenesis, diagnosis and treatment].

INTRODUCTION: Heparin-induced thrombocytopenia is due to the development of IgG antibodies specific to platelet factor 4. More frequently observed after administration of unfractionated heparin, this complication is characterized by a delayed decrease in platelet count (after the 5th day of treatment) associated with venous and/or arterial thromboses. CURRENT KNOWLEDGE AND KEY POINTS: It is often difficult to discard another potential cause for thrombocytopenia and to demonstrate by Elisa or platelet activation tests the presence of heparin-dependent antibodies is therefore mandatory in every patient. Withdrawal of heparin treatment is always necessary as well as the administration of an alternative antithrombotic agent. Danaparoid sodium (mixture of glycosaminoglycanes mainly with anti-Xa activity) or lepirudin (a recombinant hirudin with only antithrombin activity) are both recommended but these two drugs are associated with a significant risk of bleeding in case of renal failure. Oral anticoagulants such as coumadin can only be given when platelet count is normalized and if the clinical evolution is favorable. Potent antiplatelet agents (ilomedine or tirofiban) can be used in specific situations necessitating heparin such as extracorporeal circulation. FUTURE PROSPECTS AND PROJECTS: Early administration of coumadin for the treatment of venous thromboembolic disease efficiently prevent the occurrence of heparin-induced thrombocytopenia, which could disappear in the future with a wider use of the new antithrombotic agents, fondaparinux and ximelagatran.

Heparin↗

PubMed1992

An approach to the management of male infertility.

Male factors are present in nearly half the couples consulting for infertility. The correct approach to the management of male infertility follows a logical and scientifically sound sequence of procedures. These include history taking, systematic physical examination for general and local causes of abnormal semen quality, complemented by contact-thermoscopy, echography and hormone assays if available. Conventional semen analysis can be replaced by more accurate advanced methods measuring sperm motility characteristics. Several tests of sperm functional capacity are also available. It is mandatory to detect and treat known and accepted causes of impaired sperm quality using adequate and reliable methods. Complementary methods to stimulate spermatogenesis, or to assist reproduction should be offered in well-defined cases. The overall success rate of male infertility treatment remains lower than that of female treatment, though recent technology has improved results remarkably.

Humans↗

PubMed2004

Natural history of chronic HBV carriers in northern Italy: morbidity and mortality after 30 years.

BACKGROUND & AIMS: Increased morbidity and mortality from liver disease have been reported in chronic hepatitis B surface antigen (HBsAg) carriers, but data on survival are equivocal. To assess the impact of hepatitis B virus (HBV) infection on survival and liver-related complications, we re-evaluated, after a mean follow-up of 30 years, a cohort of 296 blood donors excluded from donation 30 years ago when HBsAg screening became mandatory. METHODS: Clinical and ultrasound examination and biochemical and virologic tests were performed. The cause of death was recorded and survival was compared with a control population of 157 HBV-negative blood donors selected at baseline. RESULTS: Thirty-two (10.8%) cases and 14 controls (8.9%) ( P = 0.625) had died; 3 of 32 (9.3%) and 1 of 14 (7.1%) deaths were liver-related. Hepatocellular carcinoma (HCC) caused death in 2 of 296 and 1 of 157 subjects (0.6% in each group). Alcohol-induced cirrhosis occured in the remaining subject. By Cox regression analysis, survival was independently predicted by older age, abnormal gamma-glutamyl transpeptidase (GGT) levels, and presence of medical comorbidities at baseline. Unequivocal liver disease was found in 4 carriers only. No disease decompensation occurred during follow-up. Fifty-nine (32.2%) carriers cleared HBsAg (yearly incidence, 1.0%). Full-length serum HBV DNA was present in 32.2% of persistently HBsAg-positive individuals (average titer always <10 5 copies/mL). CONCLUSIONS: Over a 30-year period, chronic HBV carrier blood donors from Northern Italy did not develop clinically significant liver disease, hepatocellular cancer, or other liver-related morbidity or mortality at a higher rate than uninfected controls. The presence of medical comorbidities, older age at diagnosis, and abnormal GGT levels were independent predictors of death among chronic HBV carriers.

Adult↗

PubMed2001

Work-related injuries from mandatory fitness training among Swedish firemen.

A considerable amount of employees incur injuries in professions with mandatory on-duty fitness training. The training is necessary for maintaining a good health status, physical condition and strength in professions requiring such qualities. Injuries in Swedish firemen from on-duty fitness training between 1992 and 1998 were selected retrospectively from the Information System of Occupational Injuries (ISA) at the National Board of Occupational Safety and Health and, if having caused a sick-leave exceeding 2 weeks, to the Labour Market Insurance (AMF Insurance). The latter comprised injuries from 1995 only. During the seven-year period 1,468 injuries from fitness training occurred in male firemen. With an estimated 147 h per man and year the injury incidence was 2.6 per 10,000 h of exposure. The mean number of days of absence from work was 24.1 days (SD 39.8). In 1995, the mean cost per injury for medical treatment was close to 7,000 Euro and for production loss almost 4,500 Euro. By far the major part of the injuries, 75 %, occurred during team and contact sports (primarily floorball and soccer) and this sport category also accounted for 83% of the medical costs and 78% of the costs for production loss. It is suggested that a restriction of team and contact sports as mandatory on-duty fitness training for firemen should be tested and evaluated concerning the injury incidence.

Accidents, Occupational↗

PubMed1982

Exercise training in patients with COPD.

Exercise is a useful therapeutic intervention for many COPD patients. The progressive stress test is the single most important means of clinical evaluation, although a thorough physical examination and preexercise ECG are also mandatory. The exercise program is prescribed according to duration of exercise and the maximal load reached by the patient during testing. As tolerance builds, exercise time, speed, and grade level are increased. Patients who exercise routinely should be watched carefully for problems, such as hypoxia, hypertension, abnormal right-sided cardiac function, and air tapping. Supplemental oxygen is required for those who are hypoxic.

Aged↗

PubMed2005

Effects of sympathetic nerves and angiotensin II on renal sodium and water handling in rats with common bile duct ligature.

We tested the hypothesis that angiotensin II is likely to be mandatory for the neurogenic sodium and volume retention in cirrhotic rats with common bile duct ligature (BDL) following an acute volume load. To assess the neural control of volume homeostasis, 21 days after common BDL rats underwent volume expansion (0.9% NaCL; 10% body wt over 30 min) to decrease renal sympathetic nerve activity. Untreated animals, rats with renal denervation or pretreated with a nonhypotensive dose of an angiotensin II type 1 receptor antagonist were studied. The renal renin-angiotensin system was assessed by immunohistochemistry and RT-PCR. Rats with BDL excreted only 71 +/- 4% of the administered volume load. In cirrhotic rats pretreated with an angiotensin II AT1 inhibitor or after renal denervation, these values ranged significantly higher from 98 to 103% (P < 0.05 for all comparisons). Renal sympathetic nerve activity decreases by volume expansion were impaired in BDL rats (P < 0.05) but unaffected by angiotensin II receptor inhibition. In kidneys of BDL animals, renin mRNA was increased, and immunohistochemistry revealed increased staining for peritubular angiotensin II. Renal denervation in BDL animals reduced renin expression within 5 days to control levels. In conclusion, the impaired excretion of an acute volume load in rats with liver cirrhosis is due to effects of an increased renal sympathetic nerve activity that are likely to be dependent on intrarenal angiotensin II and renin. We speculate that similar changes may contribute to long-term volume retention in liver cirrhosis.

Angiotensin II↗