Predictors of post-ERCP complications in patients with suspected choledocholithiasis

BACKGROUND AND STUDY AIMS

Determinants of complications after endoscopic retrograde cholangiopancreatography (ERCP) have not yet been completely characterized.

PATIENTS AND METHODS

Data were collected from an endoscopic database. Univariate analysis and multivariate logistic regression analysis were used to generate the best model of independent predictors of post-ERCP pancreatitis.

RESULTS

The database included 1239 ERCP examinations carried out to investigate suspected choledocholithiasis over a five-year period. From these, 45 patients who developed post-ERCP complications were compared to a random sample of 486 patients who had undergone an uncomplicated ERCP for suspected choledocholithiasis. Univariate analysis demonstrated significant differences between the two patient groups for the following factors: age, using a cut-off point of 59 years (27% vs. 51%, P = 0.002), pancreatic channel opacification (73% vs. 58%, P = 0.05), and absence of common bile duct stones (41% vs. 24%, P = 0.03). Using multivariate logistic regression, the best model for predicting post-ERCP pancreatitis in patients undergoing sphincterotomy included age under 59 years (P = 0.04), and absence of a common bile duct stone (P = 0.004). The model yielded probabilities of developing post-sphincterotomy pancreatitis that ranged from 2.8% if no predictor was present, to 27% when both predictors were present. Among patients in whom a sphincterotomy was not performed, the only significant independent predictor found was pancreatic channel opacification (P = 0.05).

CONCLUSION

Age under 59 years, pancreatic channel opacification, and an absence of common bile duct stones at ERCP are all independent predictors of post-ERCP pancreatitis.

Toward a dynamic topographic components model

Möcks' topographic component model (TCM) (Möcks, J. Topographic components model for event-related potentials and some biophysical considerations. IEEE Trans. Biomed. Eng., 1988a, 35: 482-484; Möcks, J. Decomposing event-related potentials: a new topographic components model. Biol. Psychol., 1988b, 26: 199-215) decomposes event-related potentials into components uniquely determined by their respective amplitude profiles across replicates, assuming a constant topography and wave shape for each component. To accommodate possible changes in the component expression across conditions, a dynamic version of TCM is investigated which further admits component modulation in time scale. Twenty test problems were synthesized, incorporating two arbitrary topographies each activated with its own arbitrary wave shape modified, across two conditions, in amplitude, onset and duration. Seventeen problems were perfectly solved, with substantial success on the remaining three, confirming that component jitter or stretching can even help component identification.

The development of an empirical psychosocial taxonomy for patients with diabetes

The main purpose of this study was to develop and to cross-validate an empirically derived psychosocial taxonomy of patients with diabetes. In the first study, 101 patients with Type I or Type II diabetes completed the Multidimensional Diabetes Questionnaire. Cluster analysis identified three clusters, labeled adaptive copers, low support-low involvement, and spousal overinvolvement. In the second study, the taxonomy was cross-validated using an independent sample of 132 patients with long-standing Type II diabetes. The results confirmed that the multivariate classification system was unique and highly accurate. External validation, using general psychological as well as diabetes-specific measures, supported the validity and distinctiveness of the patients' profiles. These findings help establish a multiaxial psychosocial taxonomy of diabetes and may have significant implications for the management of patients with diabetes.

Pediatric surgeons' activities and future plans

OBJECTIVE

The authors aim was to survey members of the Canadian Association of Paediatric Surgeons (CAPS) on their demographics, practice, and future plans.

MATERIALS AND METHODS

A questionnaire was mailed to 86 members.

RESULTS

We received 60 questionnaires (70%), with a return rate including 85% men and 15% women. Seventeen percent of the respondents do not have children, 8% did not answer the question pertaining to children, and 8% expect to have more children. Among the 75% of surgeons with children, 16% have reduced the number of hours worked, from 2 hours to more than 1 day per week, for a number of years. Younger surgeons and women are more likely to reduce their work load for their family life. Most surgeons practice in an academic (64%) or a mixed setting (25%), with only 12% involved in private practice. On average, 69% of their time is devoted to patient care; teaching and research each take an average of 10% of the surgeon's time, while 9% of their time is spent on administrative duties. Study respondents work an average of 57 hours per week, and 45 weeks per year. Age significantly influenced the number of hours worked per week, and the number of weeks worked on a yearly basis. Gender and type of practices did not significantly influence the number of hours or weeks worked, whereas location of practice did. Spouse activity also had an impact on the number of hours and weeks worked. When asked about their preference for the next 5 years, 30% of surgeons would opt for a decrease in their level of activity, and 15% wish to retire. Irrespective of the age group or the type of practice, surgeons would prefer to decrease their level of activity. A recurring theme submitted by respondents is the need for increased time for teaching and research and less administrative work. Finally, 60% of surgeons were very satisfied with their work, 27% were satisfied, and 12% were unsatisfied.

CONCLUSION

Lifestyle and family commitment have an impact on pediatric surgeons' activity and should be considered when analyzing work force requirements.

The development of an empirical psychosocial taxonomy for patients with diabetes

The main purpose of this study was to develop and to cross-validate an empirically derived psychosocial taxonomy of patients with diabetes. In the first study, 101 patients with Type I or Type II diabetes completed the Multidimensional Diabetes Questionnaire. Cluster analysis identified three clusters, labeled adaptive copers, low support-low involvement, and spousal overinvolvement. In the second study, the taxonomy was cross-validated using an independent sample of 132 patients with long-standing Type II diabetes. The results confirmed that the multivariate classification system was unique and highly accurate. External validation, using general psychological as well as diabetes-specific measures, supported the validity and distinctiveness of the patients' profiles. These findings help establish a multiaxial psychosocial taxonomy of diabetes and may have significant implications for the management of patients with diabetes.

The assessment of panic using self-report: a comprehensive survey of validated instruments

A repertoire of reliable and valid self-report instruments to assess panic and panic disorder would help both researchers and clinicians. This review presents a description and an analysis of the available instruments. Following a comprehensive search of the literature, 14 instruments with published information on reliability and validity were reviewed. The following information is reported for each instrument: brief description of the instrument and its development, mean and standard deviation for clinical and nonclinical samples, and psychometric properties. Four types of instruments are presented: general assessment and information (n = 2), severity of panic disorder (n = 2), body sensations (n = 2) and cognitive dimensions of panic (n = 8). Overall, it would seem that panic measures have moderate to excellent psychometric qualities. However, the comparison between the instruments is difficult because the amount of empirical support available varies widely from one instrument to the other.

Helicobacter pylori infection in Eastern Europe: seroprevalence in the Polish population of Lower Silesia

The Helicobacter pylori status of the population of Eastern European countries has not been explored despite the high incidence of peptic ulcer disease and gastric cancer observed in these countries. A seroprevalence study has been performed in Wroclaw, a city of Lower Silesia, Poland, to provide insight into this question. Sera were collected to obtain 50 subjects per 5 yr increment of age. A second generation ELISA kit with a high sensitivity and specificity was used. The results plotted by year of birth show a very high prevalence of H. pylori infection in all adults groups born before 1970 (80-100% positive). In the younger age groups, a dramatic decrease was observed. Because it is now known that most H. pylori infections are acquired in childhood (cohort effect), it can be predicted that the infection rate in the adult population will be much lower in the future compared with that presently observed, and it can be expected that evolution in H. pylori prevalence will have an impact on the rate of gastroduodenal diseases in Poland. Because of the high prevalence, it was not possible to identify risk factors for infection in this population.

Long-term stability of diagnosis and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adolescence. II: Postnegative distinction and childhood predictors of adult outcome

BACKGROUND

The aim of this study was to verify the presence and stability across life of the positive/negative distinction in early-onset schizophrenia (EO-SZ) through a longitudinal factor analysis of the schizophrenic dimensions, and to identify the factors predicting several indices of long-term outcome for EO-SZ.

METHOD

Forty children consecutively referred for DSM-III-R schizophrenia (SZ) in a specific catchment area comprised the sample.

RESULTS

Across a 14.8-year follow-up, longitudinal factor analysis identified two separate factors corresponding to the positive and negative symptom dimensions. We also observed that: the GAS rated over the last three years of adult illness and the severity of negative symptoms during the stabilised interepisode intervals in adulthood were the indices of adult outcome that were most easily predicted; and the best childhood predictors of adult outcome were premorbid functioning and severity of positive and negative symptoms during acute episodes.

CONCLUSIONS

The presence of premorbid non-psychotic behaviour disturbances (NPBD) and premorbid developmental problems was not related to severity of outcome, in contrast to the former variables.

Long-term stability of diagnosis and symptom dimensions in a systematic sample of patients with onset of schizophrenia in childhood and early adolescence. I: nosology, sex and age of onset

BACKGROUND

Little is known about the long-term outcome of schizophrenia that has its onset during childhood and early adolescence (early-onset schizophrenia, or EO-SZ). Whether or not EO-SZ is an aetiologically separate form of schizophrenia (SZ) is unresolved.

METHOD

The study was a 14.8-year follow-up, using methods such as systematic sampling, evaluation of possible non-respondent bias, consensus best-estimate diagnoses (DSM-III-R) made independently in childhood and adulthood, measures of positive and negative dimensions, of non-psychotic behaviour disturbances (NPBD) and of developmental problems before the appearance of SZ.

RESULTS

There was high stability of EO-SZ (n = 40) diagnoses (mean onset at 14.0 years) until adulthood (mean age at follow-up 28.8 years) but a lower stability of positive and negative schizophrenic dimensions. There was a poor outcome of EO-SZ, a strong over-representation of males but few gender differences, and no effect of age of onset on clinical features and outcome.

CONCLUSIONS

EO-SZ taken as a whole shows no qualitative differences to adult-onset SZ. However, a distinction through the onset of preschizophrenic developmental problems or NPBD might be a way to investigate heterogeneity within EO-SZ.

Exposure versus cognitive restructuring in the treatment of panic disorder with agoraphobia

The aim of this study was to assess the rate of change on clinical, behavioral and cognitive variables during exposure therapy and cognitive restructuring in the treatment of panic disorder with agoraphobia. A total of 28 Ss who received a diagnosis of panic disorder with agoraphobia were randomly assigned to either of two treatment conditions: exposure therapy or cognitive restructuring. Treatment conditions were kept as distinct as possible from each other. Subjects were assessed on five occasions: pretreatment, after 5, 10, and 15 (posttreatment) sessions of treatment and at a 6-month follow-up. Analyses of outcome data revealed strong and significant time effects on all measures. However, no group x time interaction reached statistical significance, suggesting that both strategies operate at the same pace. Furthermore, power analyses suggest that any difference that might exist in the rate of improvement between exposure and cognitive restructuring in the treatment of panic disorder with agoraphobia is marginal.

Technology assessment in laparoscopic general surgery and gastrointestinal endoscopy: science or convenience?

Gastrointestinal endoscopy and laparoscopic general surgery have been significantly affected by the emergence of new techniques. These two disciplines share many similarities, including the use of sophisticated and expensive technologies. Their proper assessment is essential because they are developed amidst ever-decreasing health care budgets. Gastroenterologists and general surgeons must both participate in such evaluations and feel confident in interpreting pertinent published data. The present review uses a clinician's point of view with relevant examples to discuss the methodologies adopted in technology assessment and to highlight common pitfalls encountered in study design, patient selection, timing and selection of the study, blinding, and outcome measurement. Cost and statistical considerations, as well as ethical issues, are also reviewed in the context of technology assessment.

Farmer's lung and variables related to the decision to quit farming

An exploratory strategy was used to investigate why 55% of patients with farmer's lung (FL) disease quit farming. Three groups were recruited: 47 patients with FL disease who quit farming because of the disease (FLq), 76 patients with FL disease who continued farming (FLc), and 123 control farmers without a history of FL disease. The severity of FL disease at diagnosis was similar in both groups of patients. For example, single-breath carbon monoxide diffusion capacity predicted for FLq and FLc was 64.4 +/- 28.2 and 63.9 +/- 22.0, respectively. Relying on a cognitive-behavior theory, numerous physiological, behavioral, cognitive, affective, and social variables were assessed. Results showed that the decision to quit farming was based on cognitive and behavioral motives rather than physiological factors. Subjects in the FLq group showed more negative beliefs toward FL and had more fears of FL disease. FLq subjects also reported that family members, friends, and family doctors were more inclined to consider that FL disease could stop them from farming. However, self-efficacy to continue farming despite having FL disease and perceived hindrance caused by FL disease played the most important roles in the decision to quit farming.

Behavioral and biochemical effect of chronic treatment with D-1 and/or D-2 dopamine agonists in MPTP monkeys

Monkeys developed a severe parkinsonian syndrome after intravenous administration of (MPTP). L-DOPA/carbidopa (D-1 and D-2) or bromocriptine (D-2) treatment relieved the parkinsonian symptoms, whereas SKF 38393 (D-1) was ineffective. No dyskinesia was seen in monkeys receiving bromocriptine or SKF 38393 as opposed to the L-DOPA-treated animals, in which the dyskinetic response appeared to increased with time. MPTP induced a significant increase (25%, P less than 0.01) in the number of [3H]spiperone binding sites (Bmax) in the caudate nucleus and in putamen. The Bmax of spiperone binding in the L-DOPA-treated monkeys was on average 18% lower (P less than 0.01) than that of the animals treated with MPTP alone. The Bmax for the bromocriptine-treated group was 29% (P less than 0.01) less than that in the MPTP-treated group or 11% (P less than 0.05) less than that in the L-DOPA-treated monkeys. The SKF 38393 treatment induced a 23% (P less than 0.01) decrease in the Bmax as compared to that of animals treated with MPTP alone, and no significant change compared to the L-DOPA- or bromocriptine-treated animals. These results suggest that stimulation of D-1 and D-2 dopamine receptors can differently influence the mechanisms controlling dopamine agonist-induced dyskinesia in MPTP-treated monkeys.

Tizanidine versus baclofen in the treatment of spasticity in patients with multiple sclerosis

Tizanidine (Sirdalud) was compared to baclofen (Lioresal) in a randomized, double-blind, cross-over trial. Each medication was introduced over a three week titration period and then maintained at the highest tolerated dose for five weeks. The two treatment phases were separated by a one week drug withdrawal and a two week washout period. Sixty-six patients entered the trial and forty-eight completed both treatment phases. At the end of the trial, neurologists and physiotherapists thought that baclofen was superior on the basis of perceived efficacy and tolerance (p less than or equal to 0.05). Although the efficacy of tizanidine or baclofen was judged as good to excellent by 24 and 39% of patients respectively, this difference was not statistically significant. Muscle weakness was the most common adverse effect. This was significantly more troublesome in patients treated with baclofen. Somnolence and xerostomia were more common in patients treated with tizanidine. Both baclofen and tizanidine appear to be useful adjuncts in the treatment of spasticity in patients with multiple sclerosis. Preference of either drug is tempered principally by side-effects.

A comparison of bromocriptine (Parlodel) and levodopa-carbidopa (Sinemet) for treatment of "de novo" Parkinson's disease patients

Fifty-one patients were enrolled in a double-blind, parallel group, multicentre study conducted to assess short-term efficacy and tolerance of bromocriptine (Parlodel) or L-DOPA/carbidopa (Sinemet) in patients never treated with amantadine, ergot alkaloids or L-DOPA-based drugs. An attempt to use the lowest effective dose was made. The responder rate for each group was approximately 78%; the mean daily dose for responders was 22.5 mg of bromocriptine or 250 mg of L-DOPA/carbidopa. The overall clinical improvement in each group was 62% (bromocriptine) and 55% (L-DOPA/carbidopa) for neurological assessment and 36% (bromocriptine) and 31% (L-DOPA/carbidopa) for functional disability. Comparison between groups did not show any significant difference for both neurological and disability assessments. The most frequent side effect was nausea (L-DOPA, N = 3; bromocriptine, N = 6).

Treatment of spasticity with tizanidine in multiple sclerosis

Spasticity is a frequent and often disabling symptom in MS patients. Current drugs used as antispastic agents include Dantrolene Sodium, Baclofen and Diazepam. Tizanidine (5-chloro-4-(2imidazolin-2 yl amino)-2,1,3-benzothialdiazole) is a new antispasticity agent that has purported central action. A double blind placebo controlled trial was performed to study the efficacy of this drug in MS patients. Sixty-six patients entered an eight week therapeutic trial and fifty-nine completed the trial. Patients were assessed at 0, 2, 3 and 8 weeks of therapy for clinical effects. Electrophysiologic tests were performed at 0 and 8 weeks. A statistically significant benefit was noted in spastic muscle groups in the legs with concomitant significant reduction in hyperactive stretch reflexes and ankle clonus. Side effects most frequently cited included dry mouth and drowsiness. Two patients developed elevated liver function test that decreased with cessation of therapy. Other clinical details, side effects and electrophysiologic data will be presented. Tizanidine appears to reduce clinical spasticity and hyperreflexia in MS patients although no change in functional status was detected. Tizanidine may well serve as an alternate antispastic agent, alone or in combination with other agents.

Optimum symptomatic control of Parkinson's disease with dopaminergic therapy

This paper presents a review of the literature on the therapeutic action and the side effects of the two main dopaminergic agents: L-DOPA/decarboxylase inhibitor (L-DOPA/DI) and bromocriptine (Parlodel used either as monotherapy or in combination in patients with Parkinson's disease. The combination of L-DOPA/DI and bromocriptine gives the best therapeutic efficacy (49% improvement) in the total score (bradykinesia, rigidity and tremor). However, treatment by monotherapy or combination gives the same pattern of activity: greatest improvement in tremor, followed by rigidity and bradykinesia. Improvement observed in the short term is not sustained over longer periods of time for monotherapy with either drug. The short-term side effects are similar for each treatment, whereas long-term complications (dyskinesia, end-of-dose deterioration and on-off phenomenon) appear only when levodopa is used, alone (high incidence) or in combination with bromocriptine (low incidence). The overall optimum treatment is obtained with a combination of L-DOPA/DI and bromocriptine.

Bromocriptine in the management of end of dose deterioration in Parkinson's disease

Thirty-three patients with advanced Parkinson's disease complicated by end of dose deterioration were treated with bromocriptine. The drug was slowly increased so that by treatment week 24 the mean daily dose of bromocriptine was 22mg and levodopa had been decreased by an average of 15 percent. The majority of improvement in daily fluctuations and Parkinsonian disability score was documented by 8 weeks, at which time the mean daily bromocriptine dose was only 12mg. End of dose deterioration was reduced in 78 percent of the patients (mean 43% improvement). Total Parkinsonian disability score was decreased by 33 percent. Adverse effects were minimal; the most common was mild transient early treatment nausea which occurred in 15 percent of the patients. The slow introduction of small doses of bromocriptine, combined with minimal levodopa reduction, can give Parkinsonian patients significant improvement in end of dose deterioration.

Biochemical properties and kinetic parameters of dihydroxyphenylalanine--5-hydroxytryptophan decarboxylase in brain, liver, and adrenals of cat

Biochemical properties and kinetic parameters of nonpurified dihydroxyphenylalanine-5-hydroxytryptophan decarboxylase extracted from brain and two peripheral organs, liver and adrenals, were studied in the cat. This study shows that decarboxylase activity in brain is lower than in peripheral organs and that 5-hydroxytryptophan can be decarboxylated without exogenous addition of pyridoxal-5'-phosphate (PLP). However, the addition of PLP substantially increases the enzyme activity. Excess of coenzyme (greater than 60 muM) induces inhibition in adrenals and liver but not in the central nervous system (CNS). The observed inhibition might be related to the presence of a tetrahydroisoquinoline derivative formed in the medium. Differentiation between mechanisms of action of decarboxylase in the CNS and peripheral organs is suggested.

Letter: Test for reovirus-like agent

Cranial sonography is an established procedure for the detection of neonatal intracranial hemorrhage. A 3 year experience in imaging such infants is reviewed. Representative examples are presented to comprehensively illustrate the spectrum of sonographic appearances of intracranial hemorrhage and its complications from the initial hemorrhage to resolution. Diagnostic problems in the initial staging of the grade of hemorrhage and in evaluating subsequent ventricular changes are addressed.