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PubMed1977

Psychotherapy: theory, experience, and personalized actuarial tables.

This paper addresses the issue of the role of theory in the actual application of psychotherapeutic operations. Within the present framework, psychotherapeutic effectiveness is seen as an empirical, actuarial process which occurs in an interpersonal setting separate from theoretical considerations. The role of theory is discussed and a rationale for the coexistence of equally 'effective' contradictory theories is presented. Suggestions for future research in the area of behaviour change are made and an argument for the eventual development of a 'therapeutic cookbook' is presented.

Attitude of Health Personnel↗
PubMed1999

The two by two diagram: a graphical truth table.

The two by two table is widely used in statistics, and in particular in the medical literature, to present the results of experimental and clinical studies in which two different operators (such as a reference standard and a new diagnostic test) sort a sample into two groups. The four cells of the table reflect the four possible categories of results. Despite the simplicity of the table, the interplay of its contents is surprisingly complex, and description of this interplay can be confusing if rendered with the conventional descriptive terms alone, such as sensitivity and predictive value. We present a graphical transformation of the table, comprised of a rectangular box in a special coordinate system. This diagram is offered as a flexible and subtle conceptual tool to help physicians, authors, and students to understand, plan, and present clinical research studies.

Data Display↗
PubMed1996

Musculoskeletal Symptoms among Computer-assisted Design (CAD) Operators and Evaluation of a Self-assessment Questionnaire.

A self-administered questionnaire with questions related to the physical workload at video display units (VDUs) was tested for intra- and intermethod reliability among 36 men and 64 women working with research and documentation. The results showed an acceptable test-retest agreement. The answers to three questions were validated by direct measurements: the locations of keyboard and mouse on the table, and the distance between elbow and keyboard heights when working. The self-reported locations of keyboard and mouse showed good agreement with the direct measurements. A revised version of the questionnaire was used at a telecommunication laboratory to study work postures and musculoskeletal symptoms. Among CAD operators with identical work tasks, the women (n = 67) reported a higher prevalence of musculoskeletal symptoms than did the men (n = 475). Calculated prevalence rate ratios (women/men) for musculoskeletal symptoms ranged from 1.4 (low back) to 3.4 (left elbow). The CAD operators with at least 5.6 hours of mouse use/week (median) reported more symptoms in the arms than did the CAD operators with fewer hours' work. Operators with the mouse located outside an "optimal" area on the table reported more symptoms from shoulder joints (upper arms), shoulders (scapular), elbows, and wrists than did operators with the optimal mouse location. Thus, long hours of work with the mouse, as well as working with the mouse non-optimally located on the table, seemed to be risk factors for upper-limb symptoms.

Journal Article↗
PubMed1999

On the generation of operator equivalents and the calculation of their matrix elements.

To find all components T((k))(+/-q) = N(k,q)J(q)(+/-) summation operator(k-q)(m=0) (+/-1)(k-m)a(k, q; m)J(m)(z) (0 </= q </= k) of an irreducible tensor operator of rank k, a recursion formula for the coefficients a(k, q; m) is derived. Various kinds of operator equivalents and forms of their expression are examined. Matrix elements of operator equivalents are expressed through the coefficients a(k, q; m). A table for the coefficients a(k, q; m) with k = 2, 4, and 6 is given.

Algorithms↗
PubMed1983

Diagnostic value of serum bile acids and routine liver function tests in hepatobiliary diseases. Sensitivity, specificity, and predictive value.

Total serum bile acids measured by enzymatic fluorometry and routine liver function tests were determined in a large population including 97 healthy subjects, 138 patients free of hepatobiliary diseases but affected by other diseases, and 344 patients with mild or severe hepatobiliary diseases. In order to define the diagnostic value and some operational characteristics of serum bile acids, sensitivity, specificity, and several predictive value tables for increasing cutoff levels of serum bile acids were calculated by means of a computer program. Serum bile acids and aspartate aminotransferase were found to be similar in sensitivity, specificity, and predictive value. Serum aspartate aminotransferase was found to be more suitable than serum bile acids in detecting mild hepatobiliary diseases, whereas serum bile acids were more sensitive than routine liver tests in the evaluation of severe hepatobiliary diseases. In view of its ability to detect severe hepatobiliary diseases, serum bile acids test may play a decisive role in clinical practice (eg, decision to perform a liver biopsy).

Adolescent↗
PubMed2004

[The "Würzburg T". A concept for optimization of early multiple trauma care in the emergency department].

INTRODUCTION: Anaesthesia management, radiological diagnostic and the concept of damage control surgery should be combined in the resuscitation room. Defined clinical targets and their realisation are a CT-scan and complete damage control surgery in the shock room. Furthermore minimised patient transfer and positioning with continuous access to the head, upper parts of the body and anaesthesia machine should be realised during diagnostic procedures. METHODS: Based on a carbon-slide fixed on a turntable and innovative alignment of diagnostic devices, a three phase treatment algorithm has been established. RESULTS: Phase A includes primary survey, anaesthetic management and ultrasound examination. Following a turn of the table conventional x-ray diagnostic is assessed in phase B. Tracks for the slide enable immediate transfer to a spiral CT-scan without additional patient positioning (phase C). Following complete CT-scan rearrangement of the table to phase A facilitates immediate damage control surgery. To accelerate device operation and treatment the integrated anaesthesia workstation is ceiling-mounted and manoeuvres close to the patient. CONCLUSIONS: This concept realizes complete diagnostic procedures and damage control surgery without time consuming patient transfer or rearrangement.

Algorithms↗
PubMed1981

Aortofemoral bypass for severe limb ischemia. Long-term survival and limb salvage.

Long-term survival, graft patency and limb salvage in 74 patients with 96 severely ischemic limbs after aortofemoral bypass grafting is presented. Results in 73 limbs reconstructed for rest pain and 23 limbs reconstructed for ulceration or gangrene were compared by life table analysis, with follow-up of up to 98 months. The operative mortality was 4 percent. Overall 5 and 8 year survival was 74.8 and 52.3 percent, respectively. Overall graft patency at 5 years was 80.8 percent (rest pain 74.4 percent versus ulceration or gangrene 100 percent). Overall limb salvage was 76.7 percent at 5 years (rest pain 83 percent versus ulceration or gangrene 55 percent) (p < 0.001) and 68 percent at 8 years. Distal reconstructions were necessary in 19 limbs (21 percent); limbs with ulceration or gangrene required further attempts at salvage more often (34 percent versus 16 percent for rest pain) (p < 0.01). Aortofemoral bypass for impending limb loss yields satisfactory long-term results, and the extent of tissue loss preoperatively is an important prognostic factor. Prognosis for survival and limb salvage is worse and the need for additional distal reconstruction greater in patients with ischemic ulcer or gangrene.

Adult↗
PubMed1989

Axillary dissection: use of a mechanical retractor.

Operative axillary exposure can be conveniently maintained by means of a table-based retractor which serves to displace the pectoral muscles medially. The shoulder is abducted and the arm hung from the horizontal cross bar of the device. By means of this method, complete axillary clearance can be accomplished with less assistance and improved visibility for the participants.

Axilla↗
PubMed1997

Placental vascular lesions and likelihood of diagnosis of preeclampsia.

OBJECTIVE: To test the hypothesis that a range of severity of placental vascular lesions underlies preeclampsia and that the likelihood of its clinical diagnosis increases with the extent and severity of uteroplacental vascular lesions. METHODS: Four hundred sixty-five consecutive placentas of singleton, nonanomalous, live-born infants born before 32 weeks' gestation were examined prospectively, and uteroplacental vascular and related villous lesions were assigned a semiquantitative lesion score based on severity and extent of lesions. The summed scores of individual lesions yielded a total uteroplacental vascular lesion score, ranging from 0 to 21, that was correlated with the odds of a clinical diagnosis of preeclampsia, as well as with potential confounders, including maternal age, race, gestational age at delivery, and birth weight centile. Statistical analysis was performed using contingency tables, one-way analysis of variance, multiple logistic regression, and receiver operating characteristic curve. P < .05 was considered significant. RESULTS: A clinical diagnosis of preeclampsia was present in 78 of 465 (17%) cases. Logistic regression demonstrated that the total uteroplacental vascular lesion score related significantly to the diagnosis of preeclampsia (odds ratio 1.43, 95% confidence interval 1.31, 1.57) and this association was independent of gestational age at delivery and birth weight centile. Preeclampsia was diagnosed in 12 of 284 (4%) cases with no or minimal histologic evidence of placental vascular injury (total score less than 4). Conversely, the diagnosis was not made in 4% of cases despite the presence of extensive placental vascular injury (total score at least 14). CONCLUSION: The likelihood of clinical diagnosis of preeclampsia before 32 weeks increases with progressive impairment of the uteroplacental circulation. Histopathologic examination of the placenta can be used to confirm the diagnosis of preeclampsia.

Adult↗
PubMed1994

The influence of cold ischemia time on biliary complications following liver transplantation.

Biliary complications are a continuing source of morbidity and mortality following orthotopic liver transplantation. The results of 100 whole-liver allografts performed in 92 adult patients were reviewed to determine whether cold ischemia time and preservation injury influenced both the incidence and type of biliary complications. Mean cold ischemia time was 10.2 +/- 0.5 h (range 3.6-19). Eighteen patients (19.6%) developed 25 biliary complications: there were eight anastomotic leaks, eight anastomotic strictures, six non-anastomotic strictures, two cystic duct mucoceles, and one biliary fistula following T-tube removal. Despite the high rate of reoperative surgery (68%), no death was attributable to biliary complications. Neither cold ischemia time nor early graft function influenced the rate of biliary complications or strictures of either type. Furthermore, an analysis of different factors revealed no predisposing effect of the pre-operative status of the recipient, type of biliary reconstruction, blood requirement, vascular complications, rejection or cytomegalovirus infection on the incidence of biliary complications or strictures. Only chronic rejection could be singled out as a risk factor for non-anastomotic strictures (p = 0.05). These results suggest that prolonged cold ischemia time does not seem to affect the rate or type of biliary complications following orthotopic liver transplantation. In view of these data, there is no clear reason to reconsider prolonged cold ischemia up to 15 h in University of Wisconsin solution, as it has transformed liver transplantation from an emergency operation to a semi-elective procedure and allows longer back-table preparation for graft reduction of splitting.

Adolescent↗
PubMed1989

Staging in cholesteatoma surgery.

Single stage surgery was used for 174 operations for cholesteatoma. The results were analysed using months at risk (actuarial) statistics. The methods of data collection and of creating a life-table for cholesteatoma follow-up are described. Ninety-one canal-down procedures are compared with 82 canal-up procedures as to the recidivism rate as well as hearing results. The actuarial tables showed a 50 per cent cumulative success rate for canal-up procedures versus a 90 per cent rate for canal-down operations. The successful canal-up procedures, however, demonstrated slightly better hearing results. These success rates seemed to be comparable to those using planned staged surgery. It was concluded that if single stage canal-up procedures were used with larger mastoids and canal-down procedures with smaller mastoids, 80 per cent of patients could be controlled without either residual or recurrent disease appearing. For the others, it was felt safe to wait for the disease to reappear rather than to do planned two-stage procedures for all patients. It was further urged that actuarial statistics be employed when reporting the results of surgery for cholesteatoma.

Actuarial Analysis↗
PubMed1989

Predictive value of renal pathology in diffuse proliferative lupus glomerulonephritis. Lupus Nephritis Collaborative Study Group.

We tested the value of the activity (AI) and chronicity (CI) indices devised by Austin et al as predictors of outcome in lupus patients with diffuse proliferative glomerulonephritis (DPGN). Four renal pathologists independently scored the AI and CI on 84 renal biopsy specimens from patients with lupus DPGN followed for 109 +/- 74 weeks (mean +/- SD), and the mean score was compared to the development of renal failure and to adverse outcome (combined data for renal failure, death and predefined clinical stop points). Receiver operator characteristic curves were derived from a series of 2 x 2 tables in which one variable was renal failure or adverse outcome and the other variable was AI or CI dichotomized by a cut-off point. Over the entire range (0 to 10) of the CI there was no value that separated patients who developed renal failure from those who did not. The ROC curve analysis indicated that the sensitivity and specificity of the CI were too low to allow it to function as a good test. Once patients entering renal failure were identified, the mean CI approached but did not reach a significant difference when compared to the mean CI of those who did not go into renal failure (4.38 +/- 0.42, mean +/- SE vs. 3.19 +/- 0.23, P = 0.0620). The CI did not predict the adverse clinical outcomes. There was no cut-off value of the CI which separated patients who had an adverse outcome from those who did not, and this result was confirmed by ROC analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Wrist arthroscopy in distal radial fractures using a modified horizontal technique.

Wrist arthroscopy has today become an important adjunct in the management of displaced intra-articular distal radial fractures, with reduction of joint incongruencies as well as detection and treatment of associated soft-tissue injuries. However, standard upright arthroscopy makes it difficult to combine arthroscopic-assisted reduction with additional treatment of the often comminuted, extra-articular fracture component. This article describes a modified arthroscopic technique in which the arm is blocked in pronation with the traction horizontally over a handle on a normal hand table, without any other changes in the arthroscopy itself. The author has operated on 17 patients using this horizontal technique in combination with arthroscopic-assisted reductions, closed and open osteosynthesis, and soft-tissue procedures. The horizontal technique allows complete treatment of comminuted, unstable distal radial fractures, intra-articular and extra-articular reduction, and bone grafting, as well as assessment and treatment of associated soft-tissue injuries.

Adult↗
PubMed2000

Incidence and risk factors of late rupture, conversion, and death after endovascular repair of infrarenal aortic aneurysms: the EUROSTAR experience. European Collaborators on Stent/graft techniques for aortic aneurysm repair.

OBJECTIVE: The EUROSTAR (European Collaborators on Stent/graft techniques for aortic aneurysm repair) Registry was established in 1996 to collect data on the outcome of treatment of patients with infrarenal aortic aneurysms with endovascular repair. To date, 88 European centers of vascular surgery have contributed. The purpose of the study was to evaluate the results of this treatment in the medium term (up to 4 years) according to the analysis of "hard" or primary end points of rupture, late conversion, and death. PATIENTS AND METHODS: Patients with aortic aneurysms suitable for endovascular aneurysm repair were notified to the EUROSTAR Data Registry Centre before treatment to eliminate bias due to selective reporting. The following information was collected on all patients: (1) demographic details and the anatomic characteristics of their aneurysms, (2) details of the endovascular device used, (3) complications encountered during the procedure and the immediate outcome, (4) results of contrast enhanced computed tomographic imaging at 3, 6, 12, and 18 months after operation and at yearly intervals thereafter, and (5) all adverse events. Life table analysis was performed to determine the cumulative rates of (1) death from all causes, (2) rupture, and (3) late conversion to open repair. Risk factors for rupture and late conversion were identified through regression analysis. RESULTS: By March 2000, 2464 patients had been registered, and their mean duration of follow-up was 12.19 months (SD, 12.3 months). There were 14 patients with confirmed rupture of their aneurysms. The cumulative rate (risk) of rupture was approximately 1% per year. Emergency surgery was undertaken in 12 (86%) patients, of whom five (41.6%) survived. Two patients who were not treated surgically also died, which resulted in an overall death rate of 64.5% (9/14) of the patients. Significant risk factors for rupture were proximal type I endoleak (P =.001), midgraft (type III) endoleak (P =.001), graft migration (P =.001), and postoperative kinking of the endograft (P =.001). Forty-one patients underwent late conversion to open repair with a perioperative mortality rate of 24.4% (10/41). The cumulative rate (risk) of late conversion was approximately 2.1% per year. Risk factors (indications) for late conversion were proximal type I endoleak (P =. 001), midgraft (type III) endoleak (P =.001), type II endoleak (P =. 003), graft migration (P =.001), graft kinking (P =.001), and distal type I endoleak (P =.001). CONCLUSIONS: Endovascular repair of infrarenal aortic aneurysms with the first- and second-generation devices that predominated in this study was associated with a risk of late failure, according to an analysis of observed hard end points of 3% per year. Action taken to address the risk factors identified by the study may improve results in the future.

Aortic Aneurysm, Abdominal↗
PubMed1984

Hepatic resection for metastatic cancer.

One-year survival is infrequent in patients with metastatic cancer to the liver. This report includes 21 patients who underwent hepatic resection between 1974 and 1981. Operative procedures included one trisegmentectomy, 12 right hepatic lobectomies, two left hepatic lobectomies, two left lateral segmentectomies, and four wedge resections. Operative morbidity and mortality rates were 43% and 5%, respectively. Life-table analysis revealed an overall 7-year survival rate of 34%. The subset of patients (16) with colorectal adenocarcinoma had a 7-year survival rate of 29% after hepatic resection. In three patients with colorectal adenocarcinoma, frequent CEA determinations were made after surgery in order to calculate the serum half-life of CEA. The data fitted a biexponential function yielding two half-lives for CEA disappearance, 0.8 +/- 0.5 days and 25.9 +/- 10.3 days. We conclude that hepatic resection for isolated hepatic metastases can be performed with acceptable morbidity, low mortality, and prolongation of patient survival.

Adenocarcinoma↗
PubMed1997

The molecular mechanisms of term and preterm labor: recent progress and clinical implications.

Current tocolytic protocols rely largely on the use of beta-mimetics to induce myometrial quiescence and delay delivery. Unfortunately, the rapid transplacental passage and poor receptor specificity of the commonly used beta-mimetics results in widespread activation of intrauterine and extrauterine beta 1 and beta 2 receptors. The use of beta-mimetics is associated with a range of well-recognized and potentially dangerous side effects for mother and fetus. The value of continued use of beta-agonists after obtaining uterine quiescence also has been the subject of recent debate. In this article we have attempted to explore the biochemical and molecular rationale for the use of alternative therapeutic modalities in the treatment and prevention of PTL. In the light of the current view that the term "preterm labor" covers a considerable diversity of causes, we propose that a range of treatment regimes should be chosen on the basis of the diagnosis and classification of the patient according to the their particular condition. Although the measurement of several biochemical parameters have been suggested to be of use in predicting PTL, we believe that a panel of diagnostic indicators (e.g., free or total CRH, IL-6, extracellular matrix proteases, fetal fibronectin) is more likely to provide useful diagnostic information on which appropriate treatment modalities can be selected (Table 1). Because of the complex and interactive nature of the mechanisms operating within the intrauterine environment to regulate myometrial activation and uterotonin production, we speculate that a combination of tocolytics, anti-inflammatory agents, uterotonic antagonists, and receptor blockers is likely to be more effective than a monotherapeutic approach, which focuses on only one facet of the process of uterine activation for pharmacologic intervention. For example, the use of antibiotics, PGHS inhibitors, and/or beta-mimetics might be an appropriate first line of treatment for infection-associated PTL in extreme prematurity. If it is successful, this treatment might be followed by longer term use of a progestagen and/or NO donor to maintain myometrial quiescence until closer to term. Alternatively, use of progesterone or oxytocin antagonists may be effective in augmenting the actions of beta-mimetics while reducing their side effects, whereas other combinations may be useful as long-term prophylactics in women with a high risk of developing PTL. Improvements continue in our diagnostic ability to correctly identify the different causes of preterm labor. We anticipate that careful selection of differing combinations of therapeutic options will result in significant reductions in the morbidity, mortality, and healthcare costs associated with preterm birth.

Female↗
PubMed1988

Cosmetic surgery and criminal rehabilitation.

The contribution of physical appearance to criminal behavior has long been a matter of general interest. We investigated the influence of cosmetic surgery on recidivism rates in the Texas state prison system. The baseline prison population recidivism rates have been 14%, 32%, and 36% at one, two, and three years, respectively. The study group consisted of 253 inmates who had cosmetic procedures between 1982 and 1984 and who were released from prison between the time of operation and the end of 1986. The recidivism rates, calculated by life table analysis, were 8% at one year, 17% at two years, and 25% at three years. All were significantly less than baseline (P less than .01, P less than .001, P less than .01). The rates for those who had been incarcerated for violent crimes were 3.3%, 7.7%, and 15.0% (all P less than .001). We conclude that a positive relationship exists between cosmetic surgery and criminal rehabilitation, as measured by a decrease in recidivism.

Actuarial Analysis↗
PubMed1975

A study of 137 cases of renal trauma.

Renal injuries are rarely a threat to life and all patients should have an intravenous urogram performed at the time of admission. Patients with a normal urogram may be mobilised for early discharge. Patients with minor abnormalities of the urogram, but in whom all the collecting system is visible, rarely caused any difficulties in management. Should the haematuria persist beyond a week, then arteriography should be performed. The arteriogram sometimes shows the presence of major cortical lacerations with minor abnormalities of the intravenous urogram. If the initial urogram fails to opacify the injured kidney, immediate arteriography is required to exclude a vascular injury. We also believe that early arteriography is advisable in those patients where part of the kidney appears to be non-functioning as it is in this group of patients that operation may become necessary. The indications for renal arteriography are summarised in Table II.

Adult↗