Giant ovarian cysts: is a pre- and intraoperative drainage an advisable procedure?

There has been a considerable debate over the merits of a pre- or intraoperative drainage of giant ovarian cysts, which represented a very frequent approach before definitive surgery in the past. Including our presented case of a 57-year-old woman with a 49 kg mucinous cystadenoma, 19 patients with giant ovarian cysts weighing more than 40 kg were reported in the literature since 1970. An incidence of 37% of malignant and low malignant potential tumors was found. Based on a critical evaluation of the medical courses and the discussed miscellaneous advantages and complications, we conclude that a pre- and intraoperative drainage should be avoided.

Variations with age in the mechanical properties of human skin in vivo

To quantitatively assess the viscoelastic properties of human skin, an in vivo testing method has been developed and previously reported. In this method, a strain-gauged pretension device is first used to determine the natural skin tension and then to apply a predetermined tension. A suction cup device with a rectangular cross-section and semi-circular ends is then applied to the pretensioned area and the skin deflection versus negative pressure characteristic is recorded. With the basic characteristics of the skin stress field determined by the geometry of the cup as a homogeneous stress state, the stress-strain response curve is computed from the recorded data. Using a constant pressurisation rate testing mode, the back and forearm of 116 healthy male and female subjects ranging in age from two to 67 years were tested. Variations in the shape and average slope (approximate modulus) of the stress-strain curves have been investigated with changes in age and sex. It has been found that the average slope decreases through maturation, reaches a minimum between the ages of 15 and 25, and then appears to increase with advancing age. The data points begin to diverge after approximately 30 years of age. It is hypothesised that this diverging phenomenon may be a result of the cumulative effect of ultraviolet radiation on the collagen and elastin networks. An examination of the shape of the curves appears to indicate that stiffness of collagen in the dermis increases with increasing age. However, it appears that the lower portions of the curves, possibly associated with the elastin and ground substance components, undergo changes not common to every individual. It is also hypothesised that 'scatter' in the data obtained from females and the sudden change noted in the shape of the curves at puberty may be due to hormonal changes.

Prognostic value of Doppler transmitral filling patterns in patients with chronic heart failure

BACKGROUND

Chronic heart failure is a significant cause of cardiovascular morbidity and mortality. This study tested the hypothesis that restrictive filling pattern may provide useful prognostic data for identifying patients with chronic heart failure at high risk of all-cause cardiac death.

METHODS

Ninety patients with chronic heart failure [70 men and 20 women, mean age (58.1 +/- 11.6) years] were investigated and followed for (18.8 +/- 7.9) months. During this period, 14 patients died of progressive pump failure, 12 patients underwent heart transplantation, 5 patients died suddenly, and 2 patients died of acute myocardial infarction. A new criterion, the restrictive filling index (RFI), was designed to subgroup patients into a restrictive and a nonrestrictive group.

RESULTS

Patients with restrictive filling pattern had a more severe left ventricular dysfunction and a higher cardiac mortality. Analysis by the Kaplan-Meier method revealed that patients in the RFI > or = 1 and RFI < 1 groups had a cardiac events-free survival rate of 52% versus 94% at 1 year, and 27.5% versus 92% at 2 years, respectively. The multivariate Cox proportional hazard model selected RFI as the most powerful prognostic factor (chi(2) = 8.8017, P = 0.0030) for all-cause cardiac death.

CONCLUSION

These results indicate that RFI is a simple, noninvasive, and specific clinical predictor for adult chronic heart failure patients who are at a high risk for all-cause cardiac death.

Expression of beta hCG and alpha CG mRNA and hCG hormone in human decidual tissue in patients during tubal pregnancy

We recently showed that endometrial tissue produces hCG during the secretory phase of the menstrual cycle. Based on these findings, we hypothesized that the decidua should also be able to secrete hCG. We examined the decidualized endometrium of patients with extrauterine pregnancies. Decidual specimens were obtained for mRNA extraction and paraffin embedding from 24 patients that were between weeks 6-11 of tubal pregnancy. Tissues were evaluated and classified into one of three groups based on the endometrial differentiation that took place prior to conception: (A) high secretory transformation, (B) diminished transformation with restricted decidualization and (C) inferior endometrial proliferation. Decidual gland hCG secretion was demonstrated immunohistochemically and by Western blotting. Serum hCG levels were higher (P < 0.0001) in patients from group A than group C. mRNA expression of both the beta subunit (beta-hCG) and alpha subunit (alpha-CG) was determined by RT-PCR. Furthermore, the specificity of beta-hCG amplification was confirmed by restriction enzymes. beta-LH amplification was not found. Moreover, the degree of endometrial transformation and the level of decidualization was found to correlate with hCG hormone staining and beta-hCG mRNA expression. hCG protein in the decidua was present in the glands of the compact layer and in the spongy layer, and was more pronounced in previously transformed high secretory endometrium than in inferior endometrium. In conclusion, this study provides the first evidence that hCG is produced in the decidua of patients during extrauterine pregnancies and might play a possible paracrine role.

Absence of Yq microdeletions in infertile men

Microdeletions of the long arm of the Y chromosome (Yq) were described in men with idiopathic azoo- or oligozoospermia and seem to cause impairment of spermatogenesis. Deletion frequencies differ considerably among selected infertile men. The aim of this study was to investigate the prevalence of Yq microdeletions in patients with idiopathic infertility. Men with azoospermia or oligozoospermia resulting from endocrine or obstructive causes or with a constitutional cytogenetic anomaly were excluded. Ninety-seven patients presenting at infertility centers in Leipzig and Zurich were included in the study. Sixty-four (66%) of them were severely oligozoospermic (sperm concentrations < 5 x 10(6)/mL) and 33 (36%) were azoospermic. A sequence-tagged site (STS) PCR strategy was applied for the microdeletion screening. Thirteen STS markers spanning the whole euchromatic region of Yq were used. No Y-chromosomal microdeletion could be detected in these 97 infertile men. This result suggests a much lower Yq deletion frequency than previously thought, even among strictly selected patients with idiopathic azoo- or oligozoospermia.

What does receiving the care programme approach mean for service users?

OBJECTIVE

To explore what receiving the Care Programme Approach means for service users.

DESIGN

A qualitative study based on peer group discussion, the transcript being subjected to issues analysis to generate key themes.

SETTING

Ayrshire and Arran, West of Scotland.

SUBJECTS

Six people with severe and enduring mental illness who were receiving the Care Programme Approach. The size of the group was restricted to allow service users time to express their views. (A representative response was not being sought.)

RESULTS

Four major themes emerged from the service users: the power of user involvement, how receiving CPA can help to avert potential problems, the rights of service users, and the benefits of advocacy. These service users felt that CPA had made a real difference to their lives.

CONCLUSION

As user involvement is an integral part of CPA, it is important that we develop strategies that allow their views to shape, in a genuine way, the services being put in place to meet their needs. In Ayrshire they seem to have learned that their participation mattered.

Sphingosine-1-phosphate lyase has a central role in the development of Dictyostelium discoideum

Sphingosine-1-phosphate, a product of sphingomyelin degradation, is an important element of signal transduction pathways that regulate cell proliferation and cell death. We have demonstrated additional roles for sphingosine-1-phosphate in growth and multicellular development. The specific disruption in Dictyostelium discoideum of the sphingosine-1-phosphate lyase gene, which encodes the enzyme that catalyzes sphingosine-1-phosphate degradation, results in a mutant strain with aberrant morphogenesis, as well as an increase in viability during stationary phase. The absence of sphingosine-1-phosphate lyase affects multiple stages throughout development, including the cytoskeletal architecture of aggregating cells, the ability to form migrating slugs, and the control of cell type-specific gene expression and terminal spore differentiation. This pleiotropic effect, which is due to the loss of sphingosine-1-phosphate lyase, establishes sphingolipids as pivotal regulatory molecules in a wide range of processes in multicellular development.

Proteomic analysis of a developmentally regulated secretory vesicle

Secretion of spore coat proteins from the prespore secretory vesicles (PSVs) in Dictyostelium discoideum is a signal mediated event that underlies terminal cell differentiation, and represents an important case of developmentally regulated secretion. In order to study the biochemical mechanisms that govern the regulated fusion of the PSVs with the plasma membrane and the subsequent secretion of their cargo, we purified this organelle from prespore cells. Analysis of protein extracts of highly purified PSVs indicated that, in addition to the cargo of structural spore coat proteins, many more proteins are associated with the PSVs. Their identification is paramount to the understanding of the mechanism of regulated secretion in this system. In this study we have taken the first comprehensive proteomic approach to the analysis of an entire, previously uncharacterized, organelle, with the goal of identifying the major proteins associated with the PSVs. We show that in addition to the structural spore coat proteins, the PSVs contain the enzymes needed for proper spore coat assembly (thioredoxin 2 and 3), regulatory proteins which we predict receive and transduce the developmental signal for secretion (rab7 GTPase, PI-3 kinase, NDP kinase and the calcium binding proteins calfumirin-1 and calreticulin) as well as proteins that interact with the cytoskeleton to mediate movement of the PSVs to the plasma membrane (actin binding proteins coactosin and profilin 1). In addition, the results suggest that proteins can play multiple roles in the cell, and that protein function can be dictated in part by subcellular localization. The identification of the PSV proteins is allowing us to develop testable hypotheses about the roles of these proteins within the functional context of developmentally regulated secretion.

Transcript mapping and processing of mitochondrial RNA in Dictyostelium discoideum

The circular mitochondrial genome of Dictyostelium discoideum has a size of 55,564 base pairs. We present here a complete and detailed transcription map of the mitochondrial DNA. Eight major, polycistronic transcripts encoding polypeptides, ribosomal RNAs and interspersed transfer RNAs were identified in Northern hybridization studies. Most of these polycistronic transcripts are subsequently processed into smaller mono-, di- or tricistronic RNAs. In some cases, the maturation involves endonucleolytic cleavage of the transcripts using transfer RNAs as excision signals. Primer extension experiments mapped the 5' ends of the transcripts, which may represent transcription initiation sites. Two of the polycistronic transcripts were found to be overlapping. Based on sequence alignments of the potential transcription start sites, a short oligonucleotide consensus initiation sequence has been identified which does not reveal any significant sequence homologies to known promoter regions from other organisms.

Measuring stroke patients' health status in the early post-stroke phase using the SF36

This paper aims to explore the self-perceived health status of stroke patients, the factors that contribute to the perception and the relevance of the findings to researchers and practitioners. Outcomes were measured at one, three and six months post-stroke for 153 stroke patients and pre-morbid characteristics were gathered from GPs. Health status was measured using the Short Form 36 (SF36). Stroke patients' health status was significantly worse than a general population for four health dimensions (physical functioning, role physical, vitality and social functioning). Regression analyses with the SF36 profile scores as dependent variables revealed one model where associations between independent and dependent variables were relatively strong (physical functioning), the remaining seven models yielded weak associations. Self-perceived health status was not strongly related to impairment, disability or cognitive function. There are implications for researchers and practitioners across a range of professions. Researchers should aim to identify factors that explain stroke patients' perception of their own health and the impact of their perception on rehabilitation. Practitioners should consider the possible effects of low vitality on treatment concordance.

Intakes of most nutrients remain at acceptable levels during a weight management program using the food exchange system

OBJECTIVE

The purpose of this study was to determine if the food exchange system allows subjects' nutrient intake to remain at recommended levels during a weight-loss program.

DESIGN

Subjects in an intervention were prescribed an energy-restriction diet and exercise program lasting 32 weeks, and nutrient intake was measured prestudy and after 12, 16, and 32 weeks.

SUBJECTS/SETTING

Healthy but overweight and obese premenopausal women (n = 219) were recruited at 6 university sites into community-based weight loss programs. One hundred fifteen women completed all aspects of the study.

INTERVENTION

Energy intake was set at 0.8 x resting metabolic rate (RMR) for weeks 1 through 12, 1.0 x RMR for weeks 13 through 20, and 1.2 x RMR for weeks 21 through 32. Energy intake was based on food exchange tables, with the number of food exchanges adjusted to encourage a distribution of 55% carbohydrate, 30% fat, and 15% protein. Subjects increased their daily walking distance to 3.2 km above prestudy levels.

MAIN OUTCOME MEASURES

Nutrient intake was measured from four 3-day food records.

STATISTICAL ANALYSES PERFORMED

Repeated measures analysis of variance, with specific time point changes assessed from paired t tests adjusted for multiple comparisons.

RESULTS

Body mass decreased by a mean +/- SD of 6.7 +/- 3.2 kg at week 12 and 7.8 +/- 6.2 kg by week 32. Walking distance increased by an average of 17.2 +/- 10.0 km/week during the first 12 weeks, and 12.4 +/- 12.4 km/week during the last 20 weeks. Despite a 23% to 36% reduction in energy intake during the study, intake of most nutrients was maintained. Intake of vitamin E, calcium, iron, and zinc decreased significantly from prestudy levels during the first 16 weeks of the intervention, but not at week 32.

APPLICATIONS/CONCLUSIONS

Intake of most nutrients can remain at recommended levels when overweight and obese women follow the American Diabetes Association/American Dietetic Association food exchange system during a community-based weight-loss program.

What is the association between the different components of stroke rehabilitation and health outcomes?

OBJECTIVES

To describe the rehabilitation input stroke patients received from health professionals during the early post stroke period and to explore possible associations between health outcomes and these rehabilitation inputs.

DESIGN

Community-based study with prospective identification of stroke patients from a random sample of 24 general practices stratified by geographical area and practice size.

SETTING

Ayrshire and Arran Health Board area, West of Scotland.

INTERVENTIONS

All physiotherapy, occupational therapy, dietetics, podiatry, speech and language therapy and community nursing inputs given to stroke patients in the course of normal treatment were recorded.

OUTCOME MEASURES

Barthel Index and Medical Outcomes Study Short Form-36 (SF-36). Both recorded at one, three and six months post stroke.

RESULTS

Of the 152 people providing data, more had received physiotherapy than any other rehabilitation input at all three follow-ups (81%, 47%, 39%), with occupational therapy being the next most common service (65%, 44%, 25%). Amount of rehabilitation input was significantly negatively correlated with health outcomes measured at each discrete time point: those patients with the poorest outcomes received greatest input. However, regression analysis of change in outcome scores showed that increasing amounts of rehabilitation input were significantly associated with a reduction in disability, particularly between one and three months post stroke.

CONCLUSIONS

Not only have we shown that those stroke patients with poorest outcomes received most rehabilitation input, but, from analysis of the individual rehabilitation inputs, we have identified some rehabilitation inputs that significantly predict improved outcomes. This suggests that there would be merit in further investigation of these associations.

American cutaneous leishmaniasis in Guyana, South America

The 185 patients who presented at the dermatology clinic of Georgetown Public Hospital, Guyana, between 1992 and 1998, with skin ulcers indicative of American cutaneous leishmaniasis (ACL) were retrospectively reviewed. The laboratory-confirmed cases of ACL were identified and the corresponding data were analysed for risk factors such as age, gender, areas of residence and of possible exposure to the causative agent (Leishmania braziliensis guyanensis), ethnic origin, longevity of the ulcers, and treatment regimes prior to the definitive diagnosis. Eighty-one (43%) of the 185 subjects were confirmed to be infected with Le. b. guyanensis. Although 53 (66%) of the cases lived in or close to the capital city, Georgetown, most of the cases had travelled to (and probably been infected in) region X in the interior of Guyana (32%) or regions VII (23%), VIII (23%), IX (11%), VI (5%), I (3%) or III (3%), usually because they were involved in the mining (41%) or lumber (21%) industries, the army or hunting. Almost all (95%) of the cases were male and most (58%) were aged 20-39 years. In general, the cases had had their skin lesions for many days before presenting for treatment: 46% for 1-5 weeks and 3% for > 6 months. Prior to presentation at the clinic, many of the cases had attempted to cure themselves, using local herbal remedies (37%), antibiotics and antifungal remedies (39%), other creams (5%), household chemicals (9%) or miscellaneous remedies such as lead salts (especially lead sulphate) and battery acid, all without success. Recommendations are made for an epidemiological study of active ACL among forest workers, eco-tourists and residents of high-risk areas. Diagnostic centres need to be sited in the regions most at-risk, particularly in or near environments in which the main vectors - sandflies such as Lutzomyia umbratilis, Lu. anduzei and Lu. whitmani - are known to be prevalent.

[The Leipzig University Gynecologic Clinic (Trier Institute) from its establishment in 1810 to 1945]

At the beginning of the 19th century the childless couple Trier gave a plot of land to Leipzig University with the impost of founding a maternity hospital (Accoucheur Institute) and demand to take their family name as clinic name. The institute was erected in 1810 and later (1892) extended as a department of obstetrics and gynecology. The Women's Clinic of the University ("Triersches Institut") developed very favorably through the 19. and 20. century, including the difficult time of national socialism and the years after World War II. This is documented by it's expansion with several enlargements and new buildings. The institution acquired a remarkable national and international reputation due to prominent scientific and clinical results of the famous professors working at the place such as Jörg, Credé, Zweifel, Stoeckel, Sellheim and Robert Schroeder.

Significance of fever in Jamaican patients with homozygous sickle cell disease

OBJECTIVE

To investigate the cause and outcome of high fever in Jamaican children with homozygous sickle cell disease.

DESIGN

Retrospective review of febrile episodes in a three year period (1 September 1993 to 31 August 1996).

SETTING

Sickle cell clinic, an outpatient clinic in Kingston run by the Medical Research Council Laboratories (Jamaica).

PATIENTS

Patients with homozygous sickle cell disease under 17 years of age presenting with an axillary temperature >/= 39.0 degrees C (102.4 degrees F).

MAIN OUTCOME MEASURES

Diagnosis, death.

RESULTS

There were 165 events in 144 patients (66 (45.8%) boys) with a median age of 6.1 years. Bacteraemia was found in 10 (6.1%) events (three Streptococcus pneumoniae, two Haemophilus influenzae type b, two Salmonella sp, one Escherichia coli, one Enterobacter sp, and one Acinetobacter sp), and urinary tract infections in four (2.4%). All cultures of cerebrospinal fluid were sterile. Acute chest syndrome occurred in 36 (21.8%) events. A painful crisis was associated with 45 (27.3%) events and was the only pathology identified in 20 events (12.1%). Hospital admission was necessary in 66 cases including all those with bacteraemia and 31 with acute chest syndrome. There were two deaths: a 5 year old boy with septic shock associated with H influenzae septicaemia, and a 3 year old boy with the acute chest syndrome.

CONCLUSIONS

Painful crisis and acute chest syndrome were the most common complications associated with high fever, but other important associated features included bacteraemia and urinary tract infection. Enteric Gram negative organisms accounted for 50% of positive blood cultures.

Assessment of body composition change in a community-based weight management program

OBJECTIVE

The purpose of this study was to validate the use of the leg-to-leg bioelectrical impedance analysis (BIA) system in assessing change in body composition over 32 weeks in overweight and obese women participating in a community weight management program.

DESIGN

Intervention, with subjects prescribed an energy-restriction diet and exercise program for 32 weeks and body composition measured pre-study and after 12 and 32 weeks.

SUBJECTS AND SETTING

Overweight and obese premenopausal women (n=201) with no overt disease were recruited at six sites into community-based weight loss programs. One hundred and twenty-four women completed all aspects of the study.

INTERVENTION

Energy intake was set at 0.8 x resting metabolic rate (RMR) for weeks 1 through 12, 1.0 x RMR for weeks 13 through 20 and 1.2 x RMR for weeks 21 through 32. Energy intake was based on a food exchange table, with the number of food exchanges adjusted to encourage a percent distribution of 55% carbohydrate, 30% fat and 15% protein. Subjects increased their daily walking distance by 3.2 km above pre-study levels.

MEASURES OF OUTCOME

Underwater weighing, seven skinfolds, and leg-to-leg BIA tests were used to assess body composition.

RESULTS

A 3 x 3 repeated measures ANOVA revealed no significant difference in detecting change in FFM at 12 and 32 weeks among underwater weighing, BIA and skinfold, (F(4,492)=1.73, p=0.141) (decrease in FFM of 1.0+/-3.3 kg, 1.7+/-2.2 kg, and 1.4+/-3.3 kg respectively, 32 weeks).

CONCLUSIONS

The leg-to-leg BIA system provides a valid measure of body composition change in overweight premenopausal women during a 32-week community-based weight loss program.

Clinical teaching: maintaining an educational role for doctors in the new health care environment

CONTEXT AND OBJECTIVES

Good clinical teaching is central to medical education but there is concern about maintaining this in contemporary, pressured health care environments. This paper aims to demonstrate that good clinical practice is at the heart of good clinical teaching.

METHODS

Seven roles are used as a framework for analysing good clinical teaching. The roles are medical expert, communicator, collaborator, manager, advocate, scholar and professional.

RESULTS

The analysis of clinical teaching and clinical practice demonstrates that they are closely linked. As experts, clinical teachers are involved in research, information retrieval and sharing of knowledge or teaching. Good communication with trainees, patients and colleagues defines teaching excellence. Clinicians can 'teach' collaboration by acting as role models and by encouraging learners to understand the responsibilities of other health professionals. As managers, clinicians can apply their skills to the effective management of learning resources. Similarly skills as advocates at the individual, community and population level can be passed on in educational encounters. The clinicians' responsibilities as scholars are most readily applied to teaching activities. Clinicians have clear roles in taking scholarly approaches to their practice and demonstrating them to others.

CONCLUSION

Good clinical teaching is concerned with providing role models for good practice, making good practice visible and explaining it to trainees. This is the very basis of clinicians as professionals, the seventh role, and should be the foundation for the further development of clinicians as excellent clinical teachers.

In-training assessment - its potential in enhancing clinical teaching

CONTEXT

In-training assessment (ITA) has established its place alongside formative and summative assessment at both the undergraduate and postgraduate level. In this paper the authors aimed to identify those characteristics of ITA that could enhance clinical teaching.

METHODS

A literature review and discussions by an expert working group at the Ninth Cambridge Conference identified the aspects of ITA that could enhance clinical teaching.

RESULTS

The features of ITA identified included defining the specific benefits to the learner, teacher and institution, and highlighting the patient as the context for ITA and clinical teaching. The 'mapping' of a learner's progress towards the clinical teaching objectives by using multiple assessments over time, by multiple observers in both a systematic and opportunistic way correlates with the incremental nature of reaching clinical competence.

CONCLUSIONS

The importance of ITA based on both direct and indirect evidence of what the learner actually does in the real clinical setting is emphasized. Particular attention is given to addressing concerns in the more controversial areas of assessor training, ratings and documentation for ITA. Areas for future research are also identified.