New drug treatments for alcohol problems: a critical appraisal

This review considers the novel drug treatments that have been suggested to help prevent relapse or attenuate drinking in people with alcohol problems. The evidence from randomized controlled trials for the efficacy of some of the main candidates: acamprosate, naltrexone, bromocriptine, selective serotonin re-uptake inhibitors and buspirone, was examined. Important methodological problems which may have introduced bias were detected in many of the trials. These included failure to test the integrity of the double blind, excluding or estimating outcome in early withdrawals and the comparison of groups on multiple outcome measures with selective reporting of results. In addition, the generalizability of some studies was limited by the procedures used for sample selection. In view of the potential adverse effects of drug treatment it is concluded that the evidence is not strong enough to support the introduction of any of these substances into routine clinical practice at present. The review also emphasizes the importance of methodological rigour to maximize objectivity in treatment evaluation research.     

Antenatal screening for factor V Leiden mutation: a critical appraisal

Because of its acid-labile nature, omeprazole is usually administered as encapsulated enteric-coated granules. The gelatin capsule and acid-resistant coating are essential for effective drug absorption and optimal bioavailability. OBJECTIVE: This study tested the effectiveness of nonencapsulated, intact omeprazole granules in suppressing intragastric acidity when administered through a gastrostomy. METHODS: Fourteen male patients with established gastrostomies underwent a baseline 24-h intragastric pH monitoring study while off any acid-suppressing medication. Via the gastrostomy, they then received 7 days of dosing with 20 mg omeprazole as intact granules in orange juice. Twenty-four-hour intragastric pH monitoring was repeated on the seventh day. RESULTS: Mean intragastric pH during the baseline study was 1.8 (+/- SD 0.7). This pH increased to 4.9 +/- 0.8 with omeprazole granules (p < 0.0001). Median intragastric pH rose from 1.3 to 5.3 (p < 0.0001). During the baseline study, intragastric pH was above 3 for 21.2 +/- 14.1%, above 4 for 14.9 +/- 11.0%, and above 5 for 9.5 +/- 8.4% of the 24-h recording period. Corresponding values after 7 days of omeprazole were 80 +/- 15.1%, 72.5 +/- 16.3%, and 59.1 +/- 16.6% (p < 0.0001 for each comparison with pretreatment values). CONCLUSION: Omeprazole effectively suppresses intragastric acidity when given through a gastrostomy tube as nonencapsulated, intact granules.     

Anticoagulation in chronic nonvalvular atrial fibrillation: a critical appraisal and meta-analysis

OBJECTIVE: To assess the outcomes associated with warfarin treatment of patients with chronic nonvalvular atrial fibrillation (CNVAF) for prevention of primary stroke. DATA SOURCES: MEDLINE was searched for literature published from 1987 to August 1996. Search terms used were 'atrial fibrillation' and 'anticoagulants'. STUDY SELECTION: Five published randomized controlled trials concerning primary stroke prevention. DATA EXTRACTION: Data were pooled across trials to estimate the magnitude of the effect for each of nine reported end-points. The annual probability of occurrence of each outcome was calculated, including standard errors and Mantel-Haenszel significance tests with 95% CIs. DATA SYNTHESIS: In view of the lack of blinded assessment and documented low inter-rater reliability of soft neurological end-points, the analysis was limited to the relatively objective end-points of major strokes, fatal strokes, major bleeding and fatal bleeding. Warfarin did not reduce the incidence of fatal strokes to a statistically significant extent, nor was incidence of fatal bleeding increased significantly. Warfarin reduced the absolute annual incidence of major strokes in patients with CNVAF by 0.89%, while at the same time it increased the absolute annual risk of major bleeding incidents by 1.8%. Though small, these differences were statistically significant. CONCLUSIONS: On balance, the margin between expected benefit and harm for warfarin prophylaxis in patients with CNVAF is uncomfortably thin. These results and conclusions differ from those of a previously published meta-analysis of these same studies.     

Neonatal cholestasis syndrome: an appraisal at a tertiary center

OBJECTIVE: To know the magnitude, etiology and clinical profile, the efficacy of various investigations and the outcome in patients with neonatal cholestasis syndrome (NCS). DESIGN: Prospective evaluation of 60 consecutive infants with NCS (mean age 3.9 +/- 1.9 months; 49 males) over a period of 3.5 years. SETTING: Tertiary level referral gastroenterology center in North India. METHODS: Liver function tests, urine examination, serum antibodies against Cytomegalovirus (CMV), Rubella and Toxoplasma; abdominal ultrasonography, hepatobiliary scintigraphy and liver biopsy were done. In appropriate setting, laparotomy and surgical corrections were done for biliary tract disorders. RESULTS: NCS constituted 19% of pediatric liver diseases. Considerable delay in presentation was observed [mean delay, extrahepatic biliary atresia (EHBA) = 4 +/- 2.0 months, neonatal hepatitis (NH) = 2.2 +/- 1.3 months]. Thirty three (55%) infants had EHBA, 14 (23%) NH (4 CMV, 2 galactosemia, 1 urinary tract infection and 7 idiopathic), 2 (3%) paucity of intralobular bile ducts and 11 (18%) were of indeterminate etiology. Liver biopsy was the most accurate (96.4%) investigation in discriminating between EHBA and NH. Of the 18 operated infants with EHBA (portoenterostomy-15 and hepatico-jejunostomy-3), 10 were alive (mean follow up = 22.8 +/- 8.6 months) of which 4 were completely asymptomatic. CONCLUSIONS: (i) NCS is an important cause of liver disease in Indian children. (ii) It requires prompt referral, quick investigative approach and targeted management. (iii) Liver biopsy is highly accurate in differentiating EHBA and NH. (iv) infants with EHBA and compensated status of liver should undergo corrective surgery irrespective of age at presentation.     

Electromyograph biofeedback as a relaxation technique: A critical appraisal and reassessment.

A review of the frontalis EMG biofeedback (BF) literature demonstrates that EMG BF compares favorably with other relaxation procedures, although some reviewers have prematurely concluded that alternative relaxation treatments are preferable on a cost–benefit basis. Previous statements about the efficacy of BF have oversimplified the data, however, and have failed to recognize sufficiently that reliable effects are associated with different relaxation procedures and specific trait dimensions operating for certain groups of Ss. Definitive statements regarding the efficacy of EMG BF and other relaxation treatment modalities need to acknowledge the full complexity of the data and await further research on specific person–treatment interactions. (3 p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Halo and performance appraisal research: A critical examination.

The different conceptual and operational definitions of halo are reviewed, and problems when using halo as a dependent measure in performance rating research and practice are pointed out. Four major points are emphasized: (1) There is no agreed on conceptual definition of halo; (2) the different conceptual definitions of halo are not systematically related to different operational definitions (i.e., measures) of halo; (3) halo measures may be poor indexes of rating quality in that different halo measures are not strongly interrelated and halo measures are not related to measures of rating validity or accuracy; and (4) although halo may be a poor measure of rating quality, it may or may not be an important measure of the rating process. The utility of assessing halo to determine the psychometric quality of rating data is questioned. Halo may be more appropriately used as a measure to study cognitive processing, rather than as a measure of performance rating outcome. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

The role of cognition in depression: A critical appraisal.

Examines 5 broad areas of cognitive functioning: expectations and evaluations of performance, perception of environmental information, recall of information, cognitive biases, and attributional processes. A review of the literature suggests that neither A. T. Beck's (1967, 1976) nor the learned helplessness model of depression has a strong empirical base. Depressed persons present themselves negatively on a variety of measures, but less consistently than either model suggests. Differences between depressed and nondepressed persons with respect to extralaboratory experiences and self-presentational strategies remain viable alternative explanations for those results that have been obtained. In addition, specificity to depression has not been demonstrated consistently for any measure of cognitive bias or distortion. Attention is given to conceptual and methodological difficulties in unambiguously establishing what people think, in demonstrating biased or distorted cognitive processes, and in testing hypotheses about the fundamental role of cognition in depression. (4? p ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Optimal exposure of the proximal abdominal aorta: a critical appraisal of transabdominal medial visceral rotation

PURPOSE: Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. METHODS: One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). RESULTS: There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed. CONCLUSIONS: Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.     

Children of alcoholics: A critical appraisal of theory and research.

Review of book, Kenneth J. Sher (Au.) Children of Alcoholics: A Critical Appraisal of Theory and Research. Chicago: University of Chicago Press, 1991, 256 pp., ISBN 0-87630-604-0. Reviewed by Ken C. Winters. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Ophthalmoplegia, hemiparesis and cheiro-oral syndrome in basilar artery migraine

A patient with migraine developed ophthalmoplegia, hemiparesis and cheiro-oral syndrome on the left side. T2-weighted MRI showed infarcts in the tegmentum of bilateral midbrains and right pons but no lesion in the cerebral or cerebellar hemisphere. Infarction in the tegmentum of brainstem secondary to the involvement of perforating arteries has not been reported in basilar artery migraine until now.     

Criminal behavior of discharged mental patients: A critical appraisal of the research.

Because of continuing debate on the dangerousness of mental patients between mental health representatives and community members, a critical appraisal of the available evidence is presented. Epidemiological, prospective studies of arrests and convictions among discharged mental patients are compared with those evaluating arrests and convictions of the general public; changes over time are also examined. Patients with arrest records prior to hospitalization were found to have arrest rates after discharge that far exceeded those of the general public or of other patients. As the number of patients with prior records has increased over time, postdischarge rates for patients considered as a single group have increased accordingly, although patients without prior records continue to have postdischarge arrest rates equal to or lower than those of the general public. Implications for community psychiatry programs are discussed. (28 ref) (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Acute myeloid leukemia in the elderly: a critical review of therapeutic approaches and appraisal of results of therapy

In the elderly, acute myeloid leukemia (AML) is characterized by a poorer prognosis than in younger patients, due to either host related factors (poor performance status, co-morbid diseases, organ function impairment) or the biology of leukemia itself (high incidence of adverse cytogenetic abnormalities, high frequency of preceding myelodysplastic syndromes, intrinsic resistance to cytotoxic drugs). Current therapeutic results are mostly unsatisfactory and studies reporting high rates of complete remission are probably influenced by selection biases as suggested by the low rate of elderly patients inclusion into cooperative trials. Availability of intensive support including hematopoietic growth factors could stimulate clinicians to manage an increasing number of elderly patients with AML with aggressive programs. However, chemotherapy in the elderly is difficult, costly and usually associated with high morbidity and mortality rate. Therefore, all efforts should be made to identify those subset of elderly patients in whom aggressive treatment may result in a true improvement of disease free and overall survival. The critical analysis of our five years experience, as reported here, seems to suggest that older AML patients displaying unfavourable prognostic factors at diagnosis (i.e., adverse karyotype and high serum LDH levels), but clinically eligible for intensive chemotherapy, do not actually benefit from an aggressive approach. A blind attempt to treat these patients aggressively may be associated with a life threatening toxicity not counterbalanced by an actual survival advantage. We suggest therefore that aggressive treatment should be reserved for elderly AML cases in whom the presence of good prognostic factors at diagnosis predicts that the loss of some patients due to toxicity may be balanced by the achievement of a substantial proportion of long term survivors. Finally, given the biological and clinical heterogeneity of elderly AML patients, a more precise prognostic categorization of these patients would be particularly useful in interpreting future therapeutic results.     

A critical appraisal of the role of triangulation in nursing research

Proopiomelanocortin (POMC) is the precursor for a number of biologically active peptides such as adrenocorticotropic hormone (ACTH), alpha-melanocyte-stimulating hormone (alpha-MSH) and beta-endorphin. It is well known that these peptides are involved in the stress response in fish as well as in mammals. We have cloned two different carp POMC cDNAs called, POMC-I and POMC-II. The nucleotide sequences of 955 bp for POMC-I and 959 bp for POMC-II share 93.5% identity in their cDNAs, and the deduced amino acid sequences (both 222 amino acids) are 91.4% identical. In the ACTH and beta-MSH domain, two amino acid substitutions are found, whereas alpha-MSH and beta-endorphin are identical. For beta-MSH, the serine replacement (in POMC-I) by a glycine (in POMC-II) results in a putative amidation site Pro-X-Gly for POMC-II. We used RT-PCR to show that both POMC mRNAs are expressed in the hypophysis, hypothalamus and other parts of the brain of a single fish. Furthermore, in a phylogenetic tree based on POMC sequences the divergence of carp POMC-I and -II from tetraploid animals (salmon, trout and xenopus) is demonstrated.     

A critical appraisal of intelligent testing with the WISC-III: Introduction to the series.

This special issue is intended to provide professionals and other members of the policy-shaping community with information from which judgments concerning the appropriate role of IQ testing in the delivery of school psychological services can be formed. In Kaufman's (1994) most recent rendition of his intelligent testing series, Intelligent testing with the WISC-III, he devotes a major section of the first chapter to his presumed defense of IQ testing against criticisms that have emerged within the school psychology literature. Are the inferences derived by Kaufman's methods of WISC-III test interpretation of sufficient quality to support their use in professional problem solving and decision making? Are they reliable? Are they accurate? Do they contribute to beneficial outcomes for children? These are guiding questions that represent underlying themes for this special issue. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Febrile morbidity in severe and critical ovarian hyperstimulation syndrome: a multicentre study

The objective of this study was to define the incidence of febrile morbidity and its causes in severe and critical ovarian hyperstimulation syndrome (OHSS). For this purpose, we reviewed the medical records of all OHSS patients hospitalized in 16 out of 19 tertiary medical centres in Israel between January 1987 and December 1996. Febrile morbidity was defined as at least one episode of temperature rise above 38 degrees C lasting > or =24 h. A total of 2902 patients (3305 hospitalizations) with OHSS was identified, of whom 196 had severe, and 13 critical, OHSS. Among the 209 patients investigated the incidence of febrile morbidity was 82.3%, of which 20.5% was attributed to urinary tract infection, 3.8% to pneumonia, 3.3% to upper respiratory tract infection, 2.0% to intravenous line phlebitis, 1.0% to cellulitis at an abdominal puncture site, 1.0% to postoperative wound infections and 0.5 % to gluteal abscess at the site of progesterone injection. Non-typical organisms were frequently isolated, such as Pseudomonas, Proteus, Klebsiella and Enterobacter species. No infectious aetiology was found in 105 patients (50.2%). Hypoglobulinaemia was recorded in most patients, while ascitic and pleural fluids aspirated from these patients contained high globulin concentrations. We conclude that infection-related febrile morbidity in severe and critical OHSS is high, and may be attributed to some degree of immunodeficiency associated with loss of plasma globulins to the third space. However, non-infection-related febrile morbidity is even higher and may be attributed to endogenous pyrogenic mechanisms.