A scoring system for the assessment of bowel and lower urinary tract symptoms in women

OBJECTIVE

To develop a simple scoring system for a validated 22-item questionnaire used to assess bowel and urinary dysfunction in women.

SETTING

A urogynaecology clinic, a functional bowel clinic, a district general hospital and a general practice.

POPULATION

One hundred and one women referred with functional bowel and/or urinary symptoms and 131 asymptomatic controls.

METHODS

A user manual has been prepared. Individual responses to questions are categorised into normal and abnormal and odds ratio tests applied to reflect their sensitivity.

RESULTS

Scoring methods have been detailed, and appropriate and sensitive cutoff points defined.

CONCLUSIONS

The use of this validated questionnaire is now aided by a user manual, facilitating health care evaluation research into the effects of pelvic surgery on pelvic floor symptomatology. A simple scoring system is provided, making the questionnaire a valuable and accessible research tool.

Views of elderly patients on cardiopulmonary resuscitation before and after treatment for depression

OBJECTIVE

To investigate elderly patients decision to accept cardiopulmonary resuscitation (CPR) before and after treatment for depression.

METHODS

A Prospective cohort study set within a specialist psychiatrist hospital for the elderly. The subjects were 50 consecutively admitted day and in-patients with depression. Changes in the acceptability of CPR between baseline and end of treatment for depression together with patient characteristics were measured and compared.

RESULTS

49 patients completed the study; all but one of the 17 patients who initially declined CPR accepted once recovered and none who initially accepted later changed their minds (p=0.0001.

CONCLUSIONS

The study demonstrates that depressed elderly people frequently decline CPR but accept after recovery from depression. The presence of depression should be specifically considered if an elderly person unexpectedly declines CPR.

Nutritional status classification in the Department of Veterans Affairs

The Department of Veterans Affairs (VA) Nutrition Status Classification scheme uses clinical data that are routinely collected on admission or shortly thereafter for quick inpatient nutrition screening. In this scheme, patients are assigned to 1 of 4 classification levels according to 7 individual indicators. The indicators include nutrition history, unintentional weight loss as a percent of usual body weight, percent of ideal body weight, diet, diagnosis, albumin, and total lymphocyte count. After ratings (1 to 4) are assigned to each of the 7 indicators, overall nutritional status for each patient is determined by an algorithm. The VA classification system includes many of the same criteria used in other nutritional status classifications. Where it differs is in the greater emphasis on the use of objective criteria and in the rigorous evaluation of reliability and validity that went into its development. Because of these extra measures, the VA classification can be used for prioritizing workload, as well as for determining staff requirements and for comparing workload and productivity across health care facilities. So that others might benefit from using this system, this article provides information on how the classification scheme was developed and explains how it is used.

Preferential retention of codon 72 arginine p53 in squamous cell carcinomas of the vulva occurs in cancers positive and negative for human papillomavirus

We have sought to determine the basis for preferential loss of the codon 72 proline (72P) rather than the arginine (72R) allele in squamous cell carcinoma of the vulva with loss of heterozygosity (LOH) in p53. The proportion of cases containing human papillomavirus (HPV) 16 was not statistically different among individuals with either 72RR or 72RP in the germ line (P > 0.99), but p53 LOH was significantly more common in individuals heterozygous 72RP than in 72RR individuals (P = 0.04). LOH more commonly involved the 72P allele in both HPV-positive and HPV-negative cancers. Our results imply that preferential loss of the 72P allele in vulval squamous cell carcinoma occurs by HPV-dependent and -independent mechanisms.

The use of an anabolic steroid (nandrolone decanoate) to improve nutritional status after esophageal resection for carcinoma

Anabolic steroids increase appetite and muscle mass. This randomized, double-blind trial investigates any nutritional benefits of anabolic steroid in patients after surgery for esophageal cancer. Forty patients were recruited: 19 patients had five injections of 50 mg nandrolone decanoate and 21 patients received placebo over 3 months, starting 1 month after surgery. Measurements of body weight, mid-arm muscle circumference (MAMC) and appetite were taken over a 6-month period. Nutrition was optimized by dietary advice and by esophageal dilatation if required. Percent ideal weight, percent ideal MAMC and appetite score did not show significant differences between steroid and placebo groups, but there was a trend to an increase over 6 months for percent ideal MAMC in the test group. With this protocol, we have experienced minimal side-effects. However, we have not demonstrated any therapeutic benefit with low-dose steroid. An increased dose schedule over a longer period might produce a significant response.

What is the optimal distal resection margin for esophageal carcinoma?

BACKGROUND

Whereas a proximal resection margin of 12 cm is recommended for complete resection of esophageal cancer, the extent of distal resection is unclear.

METHODS

We examined distal resection margins in a consecutive series of patients who underwent esophagectomy for squamous cell carcinomas (n = 50), primary esophageal adenocarcinomas (n = 100), and adenocarcinomas of the cardia (n = 39), in whom all macroscopic tumor was judged to be completely resected.

RESULTS

Microscopic tumor was found at a 3-cm distal resection margin for one multifocal squamous cell carcinoma. Positive distal resection margins were seen in 12% (12 of 100 patients) of primary esophageal adenocarcinomas (median, 2 cm versus 4 cm if negative; p = 0.002, Wilcoxon) and 28% (11 of 39 patients) of cardia adenocarcinomas (median, 1 cm versus 3 cm if negative; p = 0.02, Wilcoxon). Although pathologic stage was shown to be the only significant predictor of overall survival (Hazard ratio [HR] 1.8; 95% confidence interval 1.2 to 2.6; p = 0.007), there was a trend toward reduced postoperative survival for patients with histologically positive distal resection margins, in particular for patients with cardia adenocarcinomas (median, 15.4 months versus 5.7 months if negative; p = 0.0001).

CONCLUSIONS

To achieve consistently negative distal resection margins, we recommend resection of at least 5 cm of macroscopically normal foregut below the distal margin of the primary tumor.

A study of five candidate genes in Parkinson's disease and related neurodegenerative disorders. European Study Group on Atypical Parkinsonism

OBJECTIVE

To determine whether reported genetic association of polymorphisms in the CYP2D6, CYP1A1, N-acetyltransferase 2 (NAT2), DAT1, and glutathione s-transferase M1 (GSTM1) genes with PD were evident in a population of 176 unrelated patients with sporadic PD and to extend these findings to other disease groups (familial PD [n = 30], ALS [n = 50], multiple system atrophy [n = 38], progressive supranuclear palsy [n = 35], and AD [n = 23]).

METHODS

A combination of allele-specific PCR and analysis of restriction fragment length polymorphisms were performed.

RESULTS

We genotyped 1,131 individuals. After matching each patient with a control subject by age, sex, ethnicity, and geographic origin, there was no association of any allele/genotype with any of the six disease groups. There was an increased frequency of NAT2 slow acetylators in the ALS group compared with controls (70% versus 50%; OR 2.33 [95% CI, 1.03 to 5.30]), but this was not significant after adjusting for multiple testing.

CONCLUSIONS

This is one of the most extensive candidate gene studies performed in PD and the first time that some of these loci have been studied in multiple system atrophy and progressive supranuclear palsy. In contrast with previous studies, we found no role for these polymorphisms in the etiology of PD, ALS, multiple system atrophy, progressive supranuclear palsy, or AD.

MRI study of regional variations of pharyngeal wall compliance in cats

Upper airway compliance indicates the potential of the airway to collapse and is relevant to the pathogenesis of obstructive sleep apnea. We hypothesized that compliance would vary over the rostral-to-caudal extent of the pharyngeal airway. In a paralyzed isolated upper airway preparation in cats, we controlled static upper airway pressure during magnetic resonance imaging (MRI, 0.391-mm resolution). We measured cross-sectional area and anteroposterior and lateral dimensions from three-dimensional reconstructed MRIs in axial slices orthogonal to the airway centerline. High-retropalatal (HRP), midretropalatal (MRP), and hypopharyngeal (HYP) regions were defined. Regional compliance was significantly increased from rostral to caudal regions as follows: HRP < MRP < HYP (P < 0.0001), and compliance differences among regions were directly related to collapsibility. Thus our findings in the isolated upper airway of the cat support the hypothesis that regional differences in pharyngeal compliance exist and suggest that baseline regional variations in compliance and collapsibility may be an important factor in the pathogenesis and treatment of obstructive sleep apnea.

Observer variability among colposcopists from the West Midlands region

OBJECTIVE

To assess variation in diagnoses and management decisions among colposcopists when presented with cervical images; to see the impact of the referral cytology report on diagnostic accuracy.

DESIGN

A two-part video questionnaire study.

PARTICIPANTS

Colposcopists from West Midlands Region.

METHODS

Twenty cervical images displaying a range of transformation zones from normal through varying abnormalities up to cervical intraepithelial neoplasia (CIN) grade 3 were shown on video tape together with basic patient information. Two sets of videos were made, the second being identical to the first other than including the referral cytology. Participants recorded their diagnoses and management decisions on prepared questionnaires. The two sets of videos were viewed several weeks apart.

RESULTS

Completed questionnaires to both videos were received from 30 colposcopists. Diagnostic accuracy improved with knowledge of the cervical cytology result in cases of CIN 2/3 (chi 2 = 19.45, P < 0.0001) but not where the histology was CIN 1 or less (chi 2 = 2.64, P = 0.10). Overall interobserver agreement improved slightly from kappa = 0.169 to kappa = 0.212 when the cytology was revealed. While only 2.6% of cases of CIN 2/3 would have been under-managed after the second questionnaire, 37.5% cases where the abnormality did not amount to CIN would have been overtreated.

CONCLUSION

There is considerable inter-observer variability and variation in diagnostic accuracy in scoring cervical images particularly at the lower end of the spectrum of abnormality which has the potential to lead to over-treatment. We rely considerably on the cervical cytology result in forming a diagnosis. We recommend that a see-and-treat approach be abandoned when the referral smear shows minor abnormalities. The study has implications for both training and audit in colposcopy.