Interobserver reliability of digital and endovaginal ultrasonographic cervical length measurements

OBJECTIVE

Our purpose was to prospectively evaluate the interobserver reliability of digital and endovaginal ultrasonographic cervical length measurements.

STUDY DESIGN

Forty-three women were recruited from our antepartum clinic to participate in this study. Two independent and blinded digital cervical examinations were performed by the first author and a second examiner. Instructions were given to estimate the cervical length in millimeters. After micturition endovaginal ultrasonographic cervical length measurements were performed by two independent, blinded registered diagnostic medical sonographers. Cervical lengths were compared with the Student t test and Pearson's correlation coefficient. A kappa statistic was calculated for interobserver reliability at three levels of agreement +/- 1 mm, +/- 4 mm, and +/- 10 mm. Data are expressed as means +/- SD.

RESULTS

Digital cervical lengths were not different between the two examiners (18.7 +/- 4.8 mm, 20.5 +/- 6.2 mm) nor between the two ultrasonographic measurements (38.6 +/- 6.1 mm, 39.2 +/- 5.4 mm). The digital cervical lengths agreed (+/- 1 mm) 35% of the time (R2 0.10, p = 0.02). The endovaginal ultrasonographic measurements agreed (+/- 1 mm) 74% of the time with a stronger correlation (R2 0.53, p = 0.0001). The kappa statistic for interobserver variability was marginal for both digital and endovaginal cervical length measurements when agreement was defined as +/- 1 mm. Endovaginal ultrasonography was significantly more reliable than digital examination when agreement between examiners was defined as either +/- 4 mm or +/- 10 mm.

CONCLUSION

Although both digital and endovaginal ultrasonographic cervical length measurements show correlation between examiners, endovaginal ultrasonography is significantly more reliable when agreement is defined as > or = +/- 4 mm. Serial cervical length measurements to predict preterm labor will be enhanced by the interobserver reliability of endovaginal ultrasonography.

A biopsychosocial understanding of the irritable bowel syndrome: a review

OBJECTIVES

To review and examine the clinical and research literature on irritable bowel syndrome (IBS) with a view to establishing the role that psychiatric factors play in the pathogenesis and treatment of this syndrome.

RESULTS

Comorbid psychiatric illness is common with IBS, yet only a small proportion of these patients seek medical attention. Many patients are either satisfied by reassurance or experience symptom relief from medical treatment directed at target symptoms. A small group of patients do not experience much relief, and it is largely this group who come to the psychiatrist's attention. Psychotropic medication is helpful when clinically indicated, and tricyclic antidepressants in small doses (for example, 50 mg) may be helpful for those patients with a pain-predominant pattern of IBS. Psychotherapy (including cognitive, behavioural, relaxation, thermal-biofeedback, insight-oriented therapy, and hypnosis) has been shown to provide relief, although it has often been difficult to differentiate this improvement from a placebo response.

CONCLUSIONS

The group of patients with "refractory IBS" used a large amount of health care resources in an attempt to find relief to their distress. Further study is needed to gain a better understanding of which component of psychotherapy is most cost-effective and which patients are most likely to benefit. The large group of those who admit to symptoms compatible with IBS but who do not seek medical attention has to a large extent been excluded from most studies. Exploring this group may provide further insight into this perplexing syndrome.

Hip fracture incidence among elderly Asian-American populations

This study estimated national age- and sex-specific nontraumatic hip fracture incidence rates for elderly Chinese Americans, Japanese Americans, and Korean Americans. Based on a 50 percent sample of 1992 Medicare enrollees with the race/ethnicity code "Asian" and "other," cohorts of persons with distinctive Chinese (n = 24,366), Japanese (n = 28,762), and Korean (n = 5,470) names were followed passively for 2 years for a hospitalization with a diagnostic code indicating hip fracture. Cohorts of whites and blacks were followed for comparison. Year of immigration was deduced from the year of issuance of the Social Security number. Age-adjusted hip fracture incidence was lower for all three Asian-American groups than for whites. For females, the standardized fracture ratio relative to whites was 30.1 for Chinese, 73.2 for Japanese, and 52.8 for Koreans; for males, the standardized fracture ratio was 41.9 for Chinese, 58.1 for Japanese, and 90.7 for Koreans. Persons whose Social Security numbers were issued after the immigration Act of 1965 had an adjusted relative risk of 1.37 (95% confidence interval 1.05-1.78) compared with those in the US before that year, after adjustment for age, sex, and ethnic group.

Late memory-related genes in the hippocampus revealed by RNA fingerprinting

Although long-term memory is thought to require a cellular program of gene expression and increased protein synthesis, the identity of proteins critical for associative memory is largely unknown. We used RNA fingerprinting to identify candidate memory-related genes (MRGs), which were up-regulated in the hippocampus of water maze-trained rats, a brain area that is critically involved in spatial learning. Two of the original 10 candidate genes implicated by RNA fingerprinting, the rat homolog of the ryanodine receptor type-2 and glutamate dehydrogenase (EC 1.4.1.3), were further investigated by Northern blot analysis, reverse transcription-PCR, and in situ hybridization and confirmed as MRGs with distinct temporal and regional expression. Successive RNA screening as illustrated here may help to reveal a spectrum of MRGs as they appear in distinct domains of memory storage.

Cell signaling pathways elicited by asbestos

In recent years, it has become apparent that minerals can trigger alterations in gene expression by initiating signaling events upstream of gene transactivation. These cascades may be initiated at the cell surface after interaction of minerals with the plasma membrane either through receptorlike mechanisms or integrins. Alternatively, signaling pathways may be stimulated by active oxygen species generated both during phagocytosis of minerals and by redox reactions on the mineral surface. At least two signaling cascades linked to activation of transcription factors, i.e., DNA-binding proteins involved in modulating gene expression and DNA replication, are stimulated after exposure of lung cells to asbestos fibers in vitro. These include nuclear factor kappa B (NF kappa B) and the mitogen-activated protein kinase (MAPK) cascade important in regulation of the transcription factor, activator protein-1 (AP-1). Both NF kappa B and AP-1 bind to specific DNA sequences within the regulatory or promoter regions of genes that are critical to cell proliferation and inflammation. Unraveling the cell signaling cascades initiated by mineral dusts and pharmacologic inhibition of these events may be important for the control and treatment of mineral-associated occupational diseases.

Familial determinants of moderate and intense physical activity: a twin study

This twin study estimates familial clustering of moderate and intense leisure-time physical activity and investigates quantitatively its genetic and environmental components. Study subjects are 3,344 male twin pairs aged 33-51 yr. Moderate activity levels were assessed with six questions about discretionary walking or stair climbing for exercise. Five questions assessed regular participation in specific, intense athletic activities (running, bicycling, swimming, racquet, and other sports). Familial aggregation is estimated by odds ratio of one twin engaging in an activity when his co-twin does. Monozygotic and dizygotic twin correlations were compared to estimate genetic and nongenetic sources of phenotypic variation. For each activity, the familial aggregation odds ratio was statistically significant with values between 2.9 to 4.6 for intense activities and between 1.4 to 1.9 for all moderate activities but one. Monozygotic twin correlations were higher than dizygotic, suggesting genes play a role in the observed phenotypic variation. For four questions, and a compromise scale of moderate activity, the difference between correlations was statistically significant (P < 0.05). In this cohort, much of the phenotypic variability for both moderate and intense activities is a result of familial effects. Genes may influence regular participation in specific intense exercises more than moderate activity, such as walking for exercise.

Site-directed mutagenesis of amino acid residues of protein phosphatase 1 involved in catalysis and inhibitor binding

Site-directed mutagenesis of selected residues of mammalian protein phosphatase 1 (PP-1) has been carried out to further define the mechanism of catalysis, activation by divalent cations, and inhibition by toxins and inhibitory proteins. Mutation of active site residues predicted to bind metals (N124D and H248N) resulted in a large loss of enzyme activity and decreased affinity for metal ions; mutation of residues predicted to bind phosphosubstrate (R96A or R221S) led to a large loss of enzyme activity; and mutation of active site residues (D95A and D208A) resulted in a large loss of enzyme activity. Mutants N124D, H248N, R96A, and R221S exhibited large decreases in sensitivity to the toxins calyculin A, okadaic acid, and microcystin and to thiophospho-DARPP-32. Mutation of Y272 (Y272F) had little effect on activity but resulted in a large decrease in sensitivity to okadaic acid and calyculin A. Mutant D208A exhibited a decrease in sensitivity to okadaic acid and calyculin A, but, paradoxically, the sensitivity to inhibition by thiophospho-DARPP-32 was increased. Mutation of acidic groove residues (E256R, E275R, E252A:D253A, and E252A:D253A:E256R) exhibited little change in enzyme activity and no change in sensitivity to toxins, but increased sensitivity to thiophospho-DARPP-32. These results suggest that toxins and phospho-DARPP-32 interact at the active site of PP-1 in a similar fashion despite their differences in structure. In addition, acidic groove residues appear to influence the interaction of the phosphoinhibitor with the active site of PP-1.

The Boston AIDS Survival Score (BASS): a multidimensional AIDS severity instrument

OBJECTIVES

This study developed a new acquired immunodeficiency syndrome (AIDS) severity system by including diagnostic, physiological, functional, and sociodemographic factors predictive of survival.

METHODS

Three-hundred five persons with AIDS in Boston were interviewed; their medical records were reviewed and vital status ascertained.

RESULTS

Overall median (+/- SD) survival for the cohort from the first interview until death was 560 +/- 14.4 days. The best model for predicting survival, the Boston AIDS Survival Score, included the Justice score (stage 2 relative hazard [RH] = 1.25, 95% confidence interval [CI] = 0.80, 1.96; stage 3 RH = 1.76, 95% CI = 1.15, 2.70), a newly developed opportunistic disease score (Boston Opportunistic Disease Survival Score; stage 2 RH = 1.35, 95% CI = 0.90, 2.02; stage 3 RH = 2.10, 95% CI = 1.38, 3.18), and measures of activities of daily living (any intermediate limitations, RH = 1.84, 95% CI = 1.05, 3.21; any basic limitations, RH = 2.60, 95% CI = 1.44, 4.69). This model had substantially greater predictive power (R2 = .17, C statistic = .68) than the Justice score alone (R2 = .09, C statistic = .61).

CONCLUSIONS

Incorporating data on clinically important events and functional status into a physiologically based system can improve the prediction of survival with AIDS.

Genetic and environmental contributions to healthcare need and utilization: a twin analysis

OBJECTIVE

An exploratory study to examine the genetic and environmental influences on healthcare-seeking behavior for four health conditions (high blood pressure, mental health problems, joint disorders, and hearing problems).

DATA SOURCES

Data collected from 3,602 male-male twin pair members of the Vietnam Era Twin (VET) Registry.

STUDY DESIGN

Varying models for the relationship between genetic and environmental influences on health condition liability and on treatment use were tested in an attempt to explain the relative contributions of additive genetic, common, and unique environmental effects to health condition and treatment use.

DATA COLLECTION

A mail and telephone survey of general health status was administered in 1987 to VET Registry twins.

PRINCIPAL FINDINGS

Variance component estimates under the best-fitting model for the genetic component ranged from 24 percent to 52 percent for the condition status and from 42 percent to 56 percent for treatment-seeking behavior.

CONCLUSIONS

Utilization models that consider only environmental parameters will leave a large percentage of variability unexplained. Familial patterns have an impact not only on disease susceptibility but also on healthcare utilization, thereby having lifelong implications for social and fiscal constraints placed on the healthcare system. Thus, explanatory models for healthcare utilization behavior should consider the contribution of genetic factors in the decision to seek and use health services.

How do genes influence marijuana use? The role of subjective effects

This study investigated determinants of the subjective effects of marijuana and the relationship of subjective effects to marijuana use. Subjects were 8169 twins drawn from the Vietnam Era Twin Registry. Subjects who used marijuana more than five times (n = 2513) reported whether they experienced each of 23 subjective reactions. Factor analysis identified a positive (pleasant) reaction factor and a negative (unpleasant) reaction factor. Both factors were related to duration and frequency of use. Pairs in which both members used marijuana more than five times (MZ = 352 pairs; DZ = 255 pairs) were examined to assess determinants of subjective effects. Approximately one-quarter of the variance in each factor was determined by additive genetic influences; the remaining variance was determined by environmental factors that are not shared by members of a twin pair. The shared or family environment had no detectable influence on either subjective reaction factor.

Risperidone for dementia-related disturbed behavior in nursing home residents: a clinical experience

Many nursing home residents are candidates for antipsychotic pharmacotherapy for dementia-related behavioral disturbances that include physical agitation and aggression, verbal outbursts, anxiety, and depression. These patients are often resistant to or intolerant of standard neuroleptics and are usually receiving multiple medications for concurrent psychiatric or medical conditions. New medications must be carefully considered because they may interact with concurrent medications or aggravate concurrent medical problems. Low doses of risperidone may be better tolerated in the elderly because the drug poses little risk of extrapyramidal side effects or blood disorders. One hundred and nine patients with dementia-related behavioral disturbances were studied in 9 nursing homes; most initially received 0.25 to 0.5 mg of risperidone twice daily. Their behavior was recorded for up to 6 months on questionnaires completed by a nursing staff member at each home. Risperidone was well tolerated overall and nursing staff viewed it as helpful in 38 of 100 patients, moderately helpful in 26, slightly helpful in 17, and not helpful in 19.

Correlates of sleep problems among men: the Vietnam Era Twin Registry

The Vietnam Era Twin (VET) Registry includes 14,800 male twins born 1939-55 and in military service in 1964-75. A mailed health survey including the Jenkins Sleep Questionnaire was sent to 11,959 members and 8,870 (74.2%) provided responses on the frequency of sleep problems in the previous month. Prevalence of those experiencing conditions at least 1 day per month was 67.2% for waking often, 61.5% for waking tired/worn out, 48.1% for trouble falling asleep and 48.6% for awakening early. Ordinal logistic regression analysis was used to estimate sleep problems from demographic, behaviour and lifestyle characteristics, and morbid conditions. Black (vs. white) race, older age, church/religious group participation, social support, employment, cigarette smoking, light physical activity, and strenuous physical activity were associated with lower risk of one or more sleep problems. Eleven morbid conditions with a prevalence of 1% or more, coffee consumption, heavy alcohol consumption, and Framingham Type A behaviour pattern were associated with a higher risk of sleep problems. These analyses suggest that sleep problems may be one of the mechanisms relating reduced quality of life to many physical and behavioural characteristics. Fortunately, a number of the risk factors associated with sleep problems are lifestyle characteristics which, if modified, may reduce sleep problems.

Anatomical variation in the rudimentary horns of a unicornuate uterus: implications for laparoscopic surgery

A case of laparoscopic excision of a rudimentary horn is presented. The anatomical features of this case are contrasted with others in the published literature. A 23 year old nulligravida presented with severe dysmenorrhoea and a pelvic mass. At laparoscopy a unicornuate uterus with a rudimentary horn was identified. The patient had stage III endometriosis. The rudimentary horn was attached to the unicornuate uterus by a band of tissue. The blood supply was identified within this band of tissue. The rudimentary horn was removed laparoscopically with no complications. There are two anatomical variations in the attachment of the rudimentary horn to the unicornuate uterus. Knowledge of both types is important to avoid complications such as bleeding and possible compromise of myometrial wall thickness.

The treatment of relapsed or refractory intermediate grade non-Hodgkin's lymphoma with autologous bone marrow transplantation followed by cyclosporine and interferon

In an effort to decrease the relapse rate following autologous bone marrow transplantation for non-Hodgkin's lymphoma, patients were given cyclosporine and interferon following autologous marrow transplantation. Forty patients with intermediate grade non-Hodgkin's lymphoma that was relapsed or refractory to standard chemotherapy underwent autologous marrow transplantation. The preparative regimen consisted of cyclophosphamide 6.8 g/m2, etoposide 1600 mg/m2, and carmustine 400 mg/m2 over 4 days followed by reinfusion of bone marrow. Intravenous cyclosporine was started on day -1 as a 16 mg/kg loading dose followed by 3.6 mg/kg/day for 28 days after transplant. Patients were begun on alpha-interferon (starting dose, 0.5 million units s.c. every other day) following platelet engraftment (median day 24 post-transplant) and continued on 1.5 million units s.c. daily for 2 years. Regimen-related toxicities resulted in four (10%) deaths. Twenty-one (53%) patients developed marked erythema of the palms, soles, and arms. Biopsies of the erythema were consistent with grade I GVHD. Patients who did not develop rashes were not biopsied. The erythema persisted for a median of 10 days and resolved in all cases without treatment. Visceral GVHD was not apparent. All patients have been followed for a median of 24 months (range 12-54 months). To date, only five patients (13%) have relapsed after bone marrow transplant. Multivariant analysis could not identify risk factors for relapse post-transplant. Disease-free survival of all patients is 77% (95% confidence interval, 67-93%). The results of this pilot study suggest that the administration of cyclosporine and interferon may decrease the relapse rate of relapsed/refractory non-Hodgkin's lymphoma following autologous bone marrow transplantation.

Identification of a cohort of male and female twins aged 65 years or more in the United States

In this paper, a method with which to identify a national cohort of elderly twins is proposed. Record linkage algorithms were developed and applied to the > 30 million records contained in the Medicare beneficiary file. The matching algorithm for male/male pairs used race (black or white), last name, date of birth, and state of issuance of the Social Security number. Female/female and male/female pairs were selected with matching on race, date of birth, and the first seven digits of the Social Security number to compensate for the absence of maiden names. A stratified random sample of same-sex and opposite-sex white and black pairs (six groups) were selected and surveyed for determination of the actual prevalence of twins. On the basis of these results, the authors conclude that this method could identify an estimated 18,308 male/male, 7,544 female/female, and 204 male/female pairs of twins aged 65 years or more. This would be the largest sample of older twins ever assembled in the United States and represents a significant new resource for epidemiologic studies of the aging population.

Dietary vitamin C, beta-carotene and 30-year risk of stroke: results from the Western Electric Study

The relations of dietary antioxidants vitamin C and beta-carotene to 30-year risk of stroke incidence and mortality were investigated prospectively in the Chicago Western Electric Study among 1,843 middle-aged men who remained free of cardiovascular disease through their second examination. Stroke mortality was ascertained from death certificates, and nonfatal stroke from records of the Health Care Financing Administration. During 46, 102 person-years of follow-up, 222 strokes occurred; 76 of them were fatal. After adjustment for age, systolic blood pressure, cigarette smoking, body mass index, serum cholesterol, total energy intake, alcohol consumption, and diabetes, relative risks (and 95% confidence intervals) for nonfatal and fatal strokes (n = 222) in highest versus lowest quartiles of dietary beta-carotene and vitamin C intake were 0.84 (0.57-1.24) and 0.71 (0.47-1.05), respectively. Generally similar results were observed for fatal strokes (n = 76). Although there was a modest decrease in risk of stroke with higher intake of beta-carotene and vitamin-C intake, these data do not provide definitive evidence that high intake of antioxidant vitamins decreases risk of stroke.

The influence of familial and non-familial factors on the association between major depression and substance abuse/dependence in 1874 monozygotic male twin pairs

The co-occurrence of major depression (MD) with alcohol and illicit substance abuse/dependence (A/D) has been repeatedly observed. However, prior research has been unable to determine whether or not the co-occurrence is a result of familial vulnerability or non-familial influences. The present study examines the association of the lifetime diagnosis of MD with alcohol, cannabis, amphetamine, cocaine, and sedative A/D (DSM-III-R criteria) before and after controlling for familial factors in a non-clinical sample of 1874 middle aged, monozygotic male twin pairs. A lifetime diagnosis of MD was significantly associated with lifetime diagnosis of alcohol and illicit substance A/D prior to accounting for familial factors (odds ratios: 1.8-4.5). After employing a co-twin analytical technique to control for familial factors, a lifetime diagnosis of MD remained significantly associated only with lifetime diagnoses of cannabis, amphetamine and sedative A/D (odds ratios: 2.3-10.9). These results suggest that the association between MD and alcohol A/D is influenced by familial factors. In contrast, the association between MD and illicit substances of A/D is largely explained by non-familial factors.

Burnout and its correlates in emergency physicians: four years' experience with a wellness booth

OBJECTIVE

To measure the degree of burnout among emergency physicians (EPs) and to identify and rank predictive factors.

METHODS

Using the Maslach Burnout Inventory as well as a 79-item questionnaire, a cross-sectional survey was conducted for physician registrants at the Annual Scientific Assemblies of the American College of Emergency Physicians from 1992 to 1995. Degrees of burnout were stratified into low, moderate, and high ranges. Univariate and stepwise multiple regression analyses were conducted to identify and rank correlates to burnout scores.

RESULTS

Of 1,272 registrants taking the inventory, 60% registered in the moderate to high burnout ranges. Twenty-one correlates were identified. These were classified broadly in terms of negative perceptions of self, negative practice habits and attitudes, and unhealthy lifestyles. The most highly ranked correlates were: self-recognition of burnout, lack of job involvement, negative self-assessment of productivity, dissatisfaction with career, sleep disturbances, increased number of shifts per month, dissatisfaction with specialty services, intent to leave the practice within 10 years, higher levels of alcohol consumption, and lower levels of exercise. Age and years of practice were not significant predictors of burnout. Projected attrition rates were 7.5% over 5 years and 25% over 10 years.

CONCLUSIONS

Elevated levels of burnout exist among a substantial percentage of surveyed EPs. However, there is evidence for a "survivor" category of practitioners for whom burnout either does not develop or is a reversible process. The projected attrition rate over 5 and 10 years appears to be no greater than that of the average medical specialty.

Cycle of abuse and psychopathology in cleric and noncleric molesters of children and adolescents

Sexual abuse in childhood is frequently reported among sex offenders and has been hypothesized to be one of a number of psychological factors etiologically related to perpetration of child molestation in adulthood. In the current study we examine a sample of cleric and noncleric admitted child molesters and normal control subjects in their exposure to sexual abuse in childhood and current psychopathology. Odds ratios for the association between exposure to sexual abuse and child molestation were obtained while adjusting for group differences in demographic and psychological characteristics. Results indicated exposure to sexual abuse in childhood was associated with becoming a child molester for both cleric and noncleric offenders (p < .0002). Nonclerics indicated more severe psychopathology than clerics. Sexual abuse in childhood is one of many risk factors for becoming a perpetrator of child molestation in adulthood for both cleric and noncleric child molesters. Noncleric offenders demonstrated more sociopathy and mental disorder in general while cleric offenders indicated more sexual conflictedness, suggesting different psychoetiologies of offending among cleric and noncleric child molesters.