Feedback to nurse managers about staff nurses'' perceptions of their jobs

Perioperative antibiotic administration can decrease surgical morbidity, shorten hospitalization, while lowering the overall costs attributable to infections. Its use in surgery is widespread and often inappropriate. In this study, the authors evaluate the guidelines for selection and use of prophylactic antibiotics in surgical cancer patients at the Hospital of Cancer in Rio de Janeiro, Brazil. During 36 non-consecutive months, 1681 cancer patients submitted to surgical procedures were prospectively followed-up by members of the Hospital Infection Control Committee. The overall surgical site infection (SSI) and mortality rates were 17.7% and 4.8% respectively. Prophylactic antibiotics were used in 1262 elective surgeries (75.1%), and their use was not considered to be in accordance with the recommended protocol in 37.6% of the cases. The inadequate antimicrobial prophylaxis resulted in higher incidence of SSI than did prophylaxis in according to the protocol (21.7% vs. 16.4, Relative Risk 1.32; 95% Confidence Internal 1.05-1.67; p0.01). This study calls the attention for the need of a more strict and determined educational program in order to provide mechanisms for an adequate administration of prophylactic antibiotics to patients submitted to high-risk surgeries.     

Surveillance of the use of antibiotic prophylaxis in surgery

In 1991, updated recommendations for the administration of antimicrobial prophylaxis in surgery were made extensively available to all surgical wards of our hospital. Two years later we surveyed the implementation of these recommendations in our institution. Inpatients undergoing surgical procedures during a 6 month period were prospectively evaluated for the indication, type, timing and duration of antibiotic prophylaxis. On each day of the study, data of patients who underwent surgery in the previous 24-48 h were obtained and monitoring was continued for up to 5 days. Of the 215 evaluated patients 193 (90%) received prophylaxis. This rate was similar for elective and emergency surgeries. The rate of prophylaxis in surgeries for which its use is recommended was significantly higher than in surgeries where compelling data for its use are not available (96 vs. 74%, P = 0.000006). However, many and important deviations of basic principles of antimicrobial prophylaxis in surgery were found. Prophylaxis was administered systematically in some types of surgery lacking compelling data for its use. In almost 50% of the surgical procedures the first dose of antimicrobial prophylaxis was not administered at the optimal timing; prophylaxis was continued for more than 24 h in 21% of the cases, and the use of unstandardized regimens was common. Despite the availability of local guidelines, the implementation of a hospital program with regard to antibiotic prophylaxis in surgery may be difficult. Further measures should be applied to achieve this goal.     

Antimicrobial prophylaxis in colorectal surgery: a systematic review of randomized controlled trials

BACKGROUND: A systematic review was carried out to assess the relative efficacy of antimicrobial prophylaxis for the prevention of postoperative wound infection in patients undergoing colorectal surgery. METHODS: MEDLINE, EMBASE, the Cochrane Trials Register and the references cited in retrieved studies were searched to identify relevant trials published between 1984 and 1995. RESULTS: Some 147 relevant trials were identified. The quality of trials has improved over the past 12 years. The results confirm that the use of antimicrobial prophylaxis is effective for the prevention of surgical wound infection after colorectal surgery. There was no significant difference in the rate of surgical wound infections between many different regimens. However, certain regimens appear to be inadequate (e.g. metronidazole alone, doxycycline alone, piperacillin alone, oral neomycin plus erythromycin on the day before operation). A single dose administered immediately before the operation (or short-term use) is as effective as long-term postoperative antimicrobial prophylaxis (odds ratio 1.17 (95 per cent confidence interval (c.i.) 0.90-1.53)). There is no convincing evidence to suggest that the new-generation cephalosporins are more effective than first-generation cephalosporins (odds ratio 1.07 (95 per cent c.i. 0.54-2.12)). CONCLUSION: Antibiotics selected for prophylaxis in colorectal surgery should be active against both aerobic and anaerobic bacteria. Administration should be timed to make sure that the tissue concentration of antibiotics around the wound area is sufficiently high when bacterial contamination occurs. Guidelines should be developed locally in order to achieve a more cost-effective use of antimicrobial prophylaxis in colorectal surgery.     

Pulmonary hypoplasia presented in adulthood as a chronic respiratory failure: report of two cases. Embryology, clinical symptoms and diagnostic procedures

The efficacy and safety of single-dose ceftriaxone and multiple-dose cefuroxime as antibiotic prophylaxis for pleuropulmonary surgery were compared in 160 patients undergoing thoracic surgery. 82 patients received a single-dose of 2 g ceftriaxone intravenous prior to surgery. Seventy-eight patients received 1.5 g of cefuroxime i.v. prior to surgery and 750 mg i.m. every 8 hours for the next 48 hours. Patients were observed daily for ten days postoperatively and monitored for signs of wound and systemic infections. Postoperative infections were studied in each treatment group. No adverse postoperative infections effects or laboratory abnormalities attributable to either drug were noted. Those results indicate that single-dose ceftriaxone was as effective and well-tolerated as a multiple-dose cefuroxime in preventing postoperative infections following pleuropulmonary surgery.     

放疗联合手术治疗胃癌的Meta-分析

Objective: We carried out a meta-analysis to assess the effectiveness and safety of radiotherapy combined with surgery for gastric cancer. Methods: Randomized Clinical Trials (RCTs) in which radiotherapy (preoperative, intraoperative and postoperative), was compared with surgery alone in resectable gastric cancer were identified by searching Cochrane Library (Issue 2, 2009), PubMed (Jan 1966-Jun 2009), EMBASE (Jan 1974-Jun 2009), Chinese Biomedical Literature Database (Jan 1978-Jun 2009), Chinese Science and Technology Periodicals Database (Jan 1989-Jun 2009), China National Knowledge Infrastructure (Jan 1994-Jun 2009) and Wanfang database (Jan 1997-Jun 2009) in English and Chinese languang. Two researchers assessed the quality of included randomized controlled trials (RCT) extracted data independently. The RevMan 5.0 software was used for meta-analysis. Our researchers assessed the quality of included randomized controlled trials (RCT) extracted data independently. The RevMan 5.0 software was used for meta-analysis. Results: Nine randomized controlled trials of 1 548 patients were selected for meta-analysis. Five randomized controlled trials were related with comparison of preoperative radiotherapy plus surgery with single surgery. Two randomized controlled trials were the comparative studies between surgery plus postoperative and single surgery. The meta-analysis results showed that: (1) compared with surgery alone, preoperative radiotherapy combined with surgery can increase 3 years (OR = 1.78; 95% CI 1.14-2.78, P = 0.01), 5 years (OR = 1.67; 95% CI 1.22-2.29, P = 0.001), 10 years (OR = 1.64; 95% CI 1.03-2.60, P = 0.04) survival rate and resection rate (OR = 2.15; 95% CI 1.31-3.54, P = 0.003); reduce the of tumor recurrence rate (OR = 0.59; 95% CI 0.37-0.92, P = 0.02) and metastasis rate (OR = 0.44; 95% CI 0.27-0.73, P = 0.001); (2) The tumor recurrent rates (OR = 0.19, 95% CI 0.03-1.14, P = 0.07) and tumor metastasis rate (OR = 0.09; 95% CI 0.00-1.77, P = 0.11) had no difference between single surgery group and peri-operative radiotherapy plus surgery group; (3) Postoperative radiotherapy compared with surgery alone had no significant effects on 1 year (OR = 0.83; 95% CI 0.60-1.15, P = 0.26) and 3 years (OR = 0.75; 95% CI 0.51-1.11, P = 0.15) survival rate compared with single surgery, but the 5-year survival rates (OR = 0.57; 95% CI 0.34-0.95, P = 0.03) of the patients who received surgery alone was higher than those who received combined therapy. No difference of the tumor recurrence rate (OR = 0.59; 95% CI 0.33-1.05, P = 0.07), tumor metestasis rate (OR = 0.90; 95% CI 0.51-1.59, P = 0.71) and anastomotic leak (OR = 0.98; 95% CI 0.25-3.65, P = 0.98) were observed between the two groups. Conclusion: Preoperative radiotherapy combined surgery is more rational and effective than surgery alone of gastric cancer. However, in terms of the clinical effects of perioperarive or postoperative radoiotherapy combined with surgery, much multicenter, largescale, high-quality, double-blind and rigorously designed studies would be needed than currently available in the future.     

Perioperative antibiotic prophylaxis in abdominal surgery for hernia repair: retrospective study of 1,524 consecutive patients

In the surgical units of our Division, from January 1979 to December 1989, the infection rate in surgical groin hernia repair was much higher than expected, in comparison to other reports in the literature. In order to evaluate if correct preoperative antibiotic prophylaxis could decrease the incidence of postoperative infections (wound, urinary and respiratory tract) after abdominal wall hernia repair surgery, a total of 1,524 consecutive patients undergoing this type of procedure were reviewed between January 1990 and December 1996. The patients were divided in three different groups, according to the antibiotic prophylaxis regimen: i) group A: 606 patients (39.8%) treated with ceftriaxone; ii) group B: 408 patients (26.8%) treated with pefloxacin; and iii) group C: 510 patients (33.4%) treated with different regimens using either cephalosporins or quinolones other than ceftriaxone and pefloxacin. Only 1 surgical wound infection was observed (0.06%). The tolerability was good: no significant side effects related to antibiotic prophylaxis were recorded in our experience. In this study, even though retrospective, single-dose ceftriaxone proved to be a valid and cost-effective choice in antibiotic prophylaxis.     

Management and outcomes for black patients with acute myocardial infarction in the reperfusion era. National Registry of Myocardial Infarction 2 Investigators

Data from a national registry of myocardial infarction patients from June 1994 to April 1996 were analyzed to compare the presenting characteristics, acute reperfusion strategies, treatment patterns, and clinical outcomes among black and white patients. Blacks presented much later to the hospital after the onset of symptoms (median 145 vs 122 minutes, p <0.001), were more likely to have atypical cardiac symptoms (28% vs 24%, p <0.001), and nondiagnostic electrocardiograms during the initial evaluation period compared with whites (37% vs 31%, p <0.001). Also, blacks were less likely to receive intravenous thrombolytic therapy (adjusted odds ratio [OR] 0.76, 95% confidence intervals [CI] 0.71 to 0.80), coronary arteriography (adjusted OR 0.85, 95% CI 0.77 to 0.95), other elective catheter-based procedures (adjusted OR 0.87, 95% CI 0.78 to 0.96), and coronary artery bypass surgery (adjusted OR 0.66, 95% CI 0.58 to 0.75) than their white counterparts. Despite these differences in treatment, there were no significant differences in hospital mortality between blacks and whites.     

Pharmacokinetics and pharmacodynamics of sibrafiban (Ro 48-3657), an orally active IIb/IIIa antagonist, administered alone or in combination with heparin, aspirin, and recombinant tissue-type plasminogen activator in beagles

OBJECTIVE: The study aimed to determine the effectiveness of prophylactic medical intervention in reducing the incidence of cystoid macular edema (CME) and the effectiveness of medical treatment for chronic CME after cataract surgery. DESIGN: The study design was a systematic review and meta-analysis of published reports of randomized clinical trials (RCTs). PARTICIPANTS: Sixteen RCTs involving 2898 eyes examining the effectiveness of medical prophylaxis of CME and 4 RCTs involving 187 eyes testing the effectiveness of medical treatment of chronic CME were used in the study. INTERVENTIONS: Medical prophylaxis of treatment (cyclo-oxygenase inhibitors or corticosteroids) versus control (placebo or active treatment) was performed. MAIN OUTCOME MEASURES: Incidence of angiographically diagnosed CME, incidence of clinically significant CME, and vision were measured. RESULTS: Thirty-six articles reported testing a prophylactic medical intervention for CME after cataract surgery. The incidence of CME varied extensively across studies and was related to the study design used. Summary odds ratios (OR) indicated that prophylactic intervention was effective in reducing the incidence of both angiographic CME (OR = 0.36; 95% confidence interval [CI] = 0.28-0.45) and clinically relevant CME (OR = 0.49; 95% CI = 0.33-0.73). There also was a statistically significant positive effect on improving vision (OR = 1.97; 95% CI = 1.14-3.41). A combination of the results of the four RCTs testing medical therapy for chronic CME indicated a treatment benefit in terms of improving final visual acuity by two or more Snellen lines (OR = 2.67; 95% CI = 1.35-5.30). Assessment of the quality of the 20 RCTs included in the meta-analyses indicated problems in the design, execution, and reporting of a number of trials. CONCLUSION: A combination of the results from RCTs indicates that medical prophylaxis for aphakic and pseudophakic CME and medical treatment for chronic CME are beneficial. Because most of the RCTs performed to date have problems related to quality, a well-designed RCT is needed to confirm this result, using clinical CME and vision as outcomes.     

Cost finding in the diagnostic imaging service

Antibiotic prophylaxis after basilar skull fractures remains controversial. Previous studies have not clearly delineated the utility of prophylactic antibiotics in this setting. We undertook this study to determine if antibiotic prophylaxis after basilar skull fractures prevented meningitis. We performed a formal systematic review of previously published studies after a computerized search with use of the MEDLINE data base (1970-1996). Fourteen studies were identified, and 12 studies met the criteria for inclusion. Study design and quality were assessed by two independent investigators with use of a predetermined protocol. A total of 1,241 patients with basilar skull fractures were included; 719 patients received antibiotics, and 522 patients did not receive antibiotics. Overall results suggest that antibiotic prophylaxis did not prevent meningitis among patients with basilar skull fractures (odds ratio [OR] = 1.15; 95% confidence interval [CI] = 0.68-1.94; P = .678). Patients with basilar skull fractures and cerebrospinal fluid leakage were analyzed separately (OR = 1.34; 95% CI = 0.75-2.41; P = .358), as were children (OR = 1.04; 95% CI = 0.07-14.90; P = 1.000). Antibiotic prophylaxis after basilar skull fractures does not appear to decrease the risk of meningitis.     

Heart rate variability in 1-day-old infants born at 4330 m altitude

BACKGROUND: Rates of low-birth-weight (LBW) infants are similar between Latina and white women, an epidemiologic paradox. However, few studies have analyzed the relationship between ethnicity, Latino subgroup, confounding variables, and LBW. METHODS: We analyzed 395070 singleton livebirths to Latina and non-Latina white women in California during 1992. Multivariate logistic regression was used to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for the risks due to Latino ethnicity and Latino subgroup for very LBW (VLBW, 500-1499 g) and moderately LBW (MLBW, 1500-2499 g) outcomes. RESULTS: Latina and white women had similar unadjusted rates of VLBW (0.7% vs. 0.6%) and MLBW infants (3.7% vs. 3.4%). After adjusting for maternal age, education, birthplace, marital status, parity, tobacco use, use of prenatal care, infant sex, and gestational age, there was no difference in the odds of VLBW infants between Latina and white women (OR, 0.93 [95% CI, 0.81-1.071). Latina women had minimally elevated odds of MLBW infants (OR, 1.06 [95% CI, 1.01-1.11]) compared with white women. By Latino subgroup, there was no difference in the adjusted odds of VLBW infants among Central and South American, Cuban, Mexican, Puerto Rican, and white women. The adjusted odds of MLBW infants were elevated among Central and South American (OR, 1.14 [95% CI, 1.05-1.25]) and Puerto Rican women (OR, 1.41 [95% CI, 1.12-1.78]), relative to white women. CONCLUSIONS: The epidemiologic paradox of LBW in Latinos is valid. New conceptual models are needed to identify Latina women who are at risk for adverse pregnancy outcomes.     

Biological control of nematode parasites of livestock in Fiji: screening of fresh dung of small ruminants for the presence of nematophagous fungi

OBJECTIVE: To assess risk factors and outcomes associated with nuchal cord at birth. STUDY DESIGN: A population-based, case-control study was conducted using linked birth and hospitalization records. Three thousand newborns were randomly selected from all singleton births with nuchal cord as noted on the birth record (n = 5,426) in King County, Washington, 1992-1993. For comparison, 3,000 controls were randomly selected from the 46,952 unaffected singleton births. RESULTS: An increased risk of nuchal cord was associated with induction of labor (odds ratio [OR] adjusted for maternal age and parity 2.0, 95% confidence interval [CI] 1.7-2.3), African American infant race (OR 1.3, 95% CI 1.0-1.6), primiparity (OR 1.2, 95% CI 1.0-1.5) and male sex (OR 1.2, 95% CI 1.0-1.3). After exclusion of selected obstetric complications, the risk of nuchal cord associated with induction of labor increased (OR 2.4, 95% CI 2.0-3.0). Nuchal cord was associated with increased risks of fetal distress (OR 2.7, 95% CI 2.1-3.4), meconium staining (OR 2.1, 95% CI 1.7-2.6), five-minute Apgar score < 7 (OR 1.6, 95% CI 1.1-2.4) and assisted ventilation < 30 minutes (OR 1.9, 95% CI 1.4-2.6). Although hospital charges for newborns with nuchal cord were slightly greater than for those without (P = .02), hospital lengths of stay did not differ significantly. CONCLUSION: Induction of labor was identified as an independent risk factor for nuchal cord. Certain adverse perinatal outcomes are increased in neonates with nuchal cord. However, neonates with nuchal cord do not have significantly longer neonatal hospital stays, and thus the adverse effects of nuchal cord may be transient.     

Prolonged surgery increases the likelihood of admission of scheduled ambulatory surgery patients

STUDY OBJECTIVE: To identify variables influencing the likelihood of unanticipated admission following scheduled ambulatory surgery. DESIGN: Retrospective case-controlled chart review study. SETTING: A large academic tertiary care hospital. PATIENTS: 8,549 ASA physical status I, II, III, and IV patients who underwent scheduled ambulatory surgery in 1991. MEASUREMENTS AND MAIN RESULTS: Of the 8,549 patients, 216 were admitted, with complete medical record information available for 167 of the admitted patients. The most common reasons for admission among the 167 were surgical (43%), anesthetic (28%), and medical (17%) complications. Odds for admission following long surgery (of at least 60 minutes) were 7.5 times (p < 0.001) greater than following short surgery (under 60 minutes). Among long cases, independent variables influencing admission were: general anesthesia [odds ratio 20.8; 95% confidence interval (CI) 4.4 to 45.6], and monitored anesthesia care or regional anesthesia (combined odds ratio 8.3; 95% CI 1.7 to 40.8). ASA physical status and patient age did not significantly influence admission rate for long cases. For short cases, patients over 65 years (odds ratio 5.6; 95% CI 2.6 to 12.0), ASA physical status III or IV (odds ratio 4.8; 95% CI 2.0 to 11.6), use of general anesthesia (odds ratio 4.7; 95% CI 1.5 to 14.2), and monitored anesthesia care or regional anesthesia (odds ratio 3.1; 95% CI 1.0 to 10.1) independently influenced the likelihood of admission. Type of surgery and gender had no detectable effect on admission. CONCLUSIONS: Surgery duration of 60 minutes or longer was the most important predictor of unanticipated admission following scheduled ambulatory surgery.     

Self-reported rectal bleeding in a United States community: prevalence, risk factors, and health care seeking

OBJECTIVE: Little data on rectal bleeding in the U.S. population are available. We therefore sought to assess the prevalence of different types of rectal bleeding, their association with potential risk factors including other colonic symptoms, and predictors of health care seeking in a U.S. community. METHODS: We used a crossectional survey by mail, applying a previously validated self-report symptom questionnaire. Our population comprised an age- and gender-stratified random sample of Olmsted County, Minnesota residents aged 20-64 yr. RESULTS: In total, 1643 responded (77%). Rectal bleeding was reported by 235 subjects (age- and gender-adjusted prevalence, 15.5 per 100; 95% confidence interval [CI], 13.6-17.4); 218 found blood on wiping, 74 noted blood coating the stools, and 46 reported dark blood mixed in the stools. The prevalence of rectal bleeding was significantly higher in younger persons (18.9%, 20-40 yr vs 11.3% > 40 yr; p < 0.001). By stepwise logistic regression analysis, constipation (odds ratio [OR] = 3.03; 95% CI, 2.09-4.41) and diarrhea (OR = 1.90; 95% CI, 1.25-2.84) were independent predictors of rectal bleeding. Among those with rectal bleeding, 13.9% (95% CI, 9.6-19.1%) had visited a physician for bowel problems in the prior yr; only a history of abdominal surgery was an independent predictor of physician visits but this explained just 15.9% of the deviance. CONCLUSIONS: In otherwise healthy young and middle-aged persons, approximately one in seven have a history of rectal bleeding and this is more frequent in younger people; only a minority seek health care and this is not related to symptom status.     

Evaluation of status of tuberculin skin sensitivity test among medical students

BACKGROUND: The role of lipoproteins as markers of peripheral arterial disease (PAD) is not well defined. METHODS: We measured both lipid and non-lipid risk factors in 51 male patients with angiographically proven PAD and in 56 control subjects. The independent association of risk factors with PAD was evaluated by means of a multiple logistic regression analysis. RESULTS: The levels of cholesterol bound to high density lipoprotein (HDLc) and to its subfraction HDL2 were lower and triglycerides were higher in patients than in control subjects (1.0 +/- 0.3 vs 1.2 +/- 0.3, p < 0.003; 0.4 +/- 0.2 vs 0.5 +/- 0.3, p < 0.03; and 1.8 +/- 1.2 vs 1.3 +/- 0.7, p < 0.02, respectively). Total cholesterol and LDLc levels were similar in both groups. In the multiple logistic regression analysis that was done with lipid parameters, a statistically significant association of triglycerides (OR = 1.73; CI95% = 1.06-2.80) and HDLc (OR = 0.15; CI95% = 0.05-0.50) with PAD was observed, while HDL subfractions and apolipoproteins were not significantly associated. In the multiple logistic regression analysis that was done with non-lipid parameters, hypertension (OR = 5.35; CI95% = 1.86-15.4) and smoking (packs-year) (OR = 1.04; CI95% = 1.10-1.06) were the only significantly associated with PAD. When lipid and non-lipid parameters were included in the regression analysis, a statistically significant association between hypertension, smoking and HDLc with PAD was observed. CONCLUSIONS: Among lipid risk factors, a low HDLc and high triglycerides, and among non-lipid risk factors hypertension and smoking, are significantly and independently associated with lower limb arteriopathy.     

A case report of jejunal carcinoma in a patient with tuberous sclerosis]

It remains uncertain if law enforcement officers experience an elevated cardiovascular disease morbidity and, if so, whether their profession contributes to this incidence. Consequently, the self-reported incidence of cardiovascular disease (CVD) (coronary heart disease, myocardial infarction, stroke, coronary artery bypass graft surgery, angioplasty) and CVD risk factors (age, diabetes, elevated body mass index (> or = 27.8 kg.m-2), hypercholesterolemia, hypertension, tobacco use) in 232 male retirees, > or = 55 years of age, from the Iowa Department of Public Safety were compared with 817 male Iowans of similar age. CVD incidence was higher in the law enforcement officers than the general population (31.5% vs 18.4%, P < 0.001). Using multiple logistic regression, factors found to be associated with CVD included the law enforcement profession (odds ratio [OR] = 2.34; 95% confidence interval [95% CI] = 1.5-3.6), hypercholesterolemia (OR = 2.37; 95% CI = 1.7-3.3); diabetes (OR = 2.22; 95% CI = 1.4-3.6), hypertension (OR = 1.79; 95% CI = 1.3-2.5), tobacco use (OR = 1.67; 95% CI = 1.07-2.6), and age (OR = 1.06; 95% CI = 1.03-1.08). These results suggest that employment as a law enforcement officer is associated with an increased cardiovascular disease morbidity and this relationship persists after considering several conventional risk factors.     

Sudden infant death syndrome: risk factor profiles for distinct subgroups

The authors investigated risk profiles of sudden infant death syndrome (SIDS) as a function of age at death. A case-control study carried out in the Tyrol region of Austria enrolled 99 infants who died of SIDS between 1984 and 1994 and 136 randomly selected controls. Early and late SIDS (< 120 days of age vs. > or = 120 days) were defined according to the clear-cut bimodal age-at-death distribution. Inadequate antenatal care, low parental social and educational level, and the prone sleeping position were risk conditions that applied to both early and late SIDS. A marked seasonal variation (winter preponderance) was the most outstanding feature of late SIDS. A gestational age of < 37 weeks (odds ratio (OR) = 8.4, 95% confidence interval (CI) 2.6-26.0), repeated episodes of apnea (OR = 5.7, 95% CI 1.2-27.0), low birth weight (< 2,500 g) (OR = 3.4, 95% CI 1.1-11.0), a family history of sudden infant death (OR = 2.9, 95% CI 1.1-7.5), and maternal smoking during pregnancy (OR = 2.2, 95% CI 1.0-4.5) were associated with early SIDS. This study identified two distinct subgroups of SIDS infants characterized by different risk conditions and ages at death. These results underline a multiple-cause hypothesis for SIDS etiology which involves a genetic predisposition, immaturity in the first months of life, and environmental factors acting at various ages.     

Vascular determinants of epilepsy: the Rotterdam Study

PURPOSE: To investigate the relation between vascular determinants and epilepsy in an elderly population. METHODS: This is a cross-sectional, community-based, case-control study. The total study population was comprised of 4,944 subjects, 65 of whom had epilepsy which conformed to International League Against Epilepsy (ILAE) criteria. Vascular determinants that were evaluated included a history of stroke or myocardial infarction, peripheral vascular disease, hypertension, serum total cholesterol and left ventricular hypertrophy. Multivariate logistic regression analysis was used to calculate prevalence odds ratios (OR), adjusted for age and gender, as a measure of the strength of the associations. RESULTS: A history of stroke was strongly associated with lifetime epilepsy (OR 3.3; 95% CI [Confidence Interval] 1.3-8.5), as well as with late-onset epilepsy (OR 3.1; 95% CI 0.9-10.6). All vascular determinants were associated with lifetime epilepsy and late-onset epilepsy, with odds ratios >1. When stroke patients were excluded, the odds ratios were statistically significant for the relationships between total cholesterol and late-onset epilepsy (OR 1.3, 95% CI 1.0-1.6) and left ventricular hypertrophy and late-onset epilepsy (OR 2.9, 95% CI 1.0-8.6). Furthermore, presence of any of these vascular indicators was twice as common among subjects with late-onset epilepsy as compared with subjects without epilepsy (OR 2.0, 95% CI 0.9-4.2), and this was statistically significant when stroke patients were excluded (OR 2.1, 95% CI 1.0-4.7). CONCLUSIONS: These results suggest that there may be a relationship between vascular factors and the risk of late-onset epilepsy, apart from the relationship that exists through clinically overt stroke.     

Prevalence of risk factors in spontaneous intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage

OBJECTIVE: To evaluate whether differences exist in the occurrence of modifiable risk factors between aneurysmal subarachnoid hemorrhage and spontaneous intracerebral hemorrhage, since these stroke subtypes have frequently been combined in epidemiological studies and labeled hemorrhagic stroke. DESIGN: Cross-sectional survey. SETTING: Helsinki University Central Hospital in Helsinki, Finland. PATIENTS: One hundred fifty-six consecutive patients with spontaneous intracerebral hemorrhage aged 16 to 60 years (96 males and 60 females) and 281 patients with aneurysmal subarachnoid hemorrhage (145 males and 136 females) who were admitted to an emergency department. MAIN OUTCOME MEASURES: Prevalence of several health habits, previous diseases, and medication of patients with spontaneous intracerebral hemorrhage were compared with that of patients with subarachnoid hemorrhage using multiple logistic regression. RESULTS: Hypertension (odds ratio [OR], 2.6; 95% confidence interval [CI], 1.6-4.3), diabetes mellitus (OR, 26.4; 95% CI, 3.1-221.6), alcohol intake within the preceding week (for 1-150 g of alcohol: OR, 2.0; 95% CI, 1.1-3.6; for 151-300 g of alcohol: OR, 1.7; 95% CI, 0.8-3.8; and for > 300 g of alcohol: OR, 4.4; 95% CI, 2.1-9.1), and anticoagulant treatment (OR, 21.8; 95% CI, 2.3-207.3) were all significantly more common, but current cigarette smoking (OR, 0.3; 95% CI, 0.2-0.5) was less common in patients with intracerebral hemorrhage than in those with subarachnoid hemorrhage simultaneously after adjustment for sex, age, and body mass index. In males, hypertension (OR, 2.3; 95% CI, 1.1-4.5) and alcohol intake (for > 300 g/wk: OR, 5.8; 95% CI, 2.2-15.7) were more common, but current smoking (OR, 0.2; 95% CI, 0.1-0.4) was less common in patients with intracerebral hemorrhage than in those with subarachnoid hemorrhage after adjustment for age, body mass index, and diabetes mellitus. In females, hypertension (OR, 2.9; 95% CI, 1.4-5.8) and anticoagulant treatment (OR, 10.0; 95% CI, 1.0-100.2) were more common in patients with intracerebral hemorrhage after adjustment for age and body mass index. In univariate statistics, patients with intracerebral hemorrhage were also older, more often had previous symptoms of cerebral ischemia, and had higher values for body mass index and gamma-glutamyltransferase than did those with subarachnoid hemorrhage. CONCLUSIONS: Hypertension, diabetes mellitus, anticoagulant treatment, and amount of alcohol taken within 1 week seem more commonly to be associated with intracerebral hemorrhage than with subarachnoid hemorrhage, which is, however, associated more frequently with cigarette smoking.     

A case-control study of multiple myeloma and occupation

Lifetime job histories from a population-based, case-control study were analyzed to investigate the relationship between multiple myeloma and employment in various occupations and industries. Interviews were obtained from 89% (692) of eligible incident cases and 83% (1683) of eligible controls. An elevated risk was observed among persons ever employed as painters [odds ratio (OR) = 2.1, 95% confidence interval (CI) = 1.2-3.6], particularly for those employed for 10 or more years (OR = 4.1, 95% CI = 1.8-10.4). A small excess risk was observed among agricultural workers employed for 10 or more years (OR = 1.3, 95% CI = 1.0-2.2), with a higher relative risk observed among farm laborers (OR = 1.8, 95% CI = 1.0-4.0). Among agricultural workers who reported having been highly exposed to pesticides, the OR was 5.2 (95% CI = 1.6-21.1). Some evidence, based on smaller numbers, was also found to support an association with firefighting and employment in the petroleum- and coal-products manufacturing industries. Little evidence was found to support the previously noted association with wood exposure, and no evidence for an association with employment in the rubber or petroleum refining industries was found. This study lends further support to previously reported associations between multiple myeloma and employment among painters and agricultural workers.     

Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma

OBJECTIVE: The purpose of the study was to identify factors associated with an increased risk of complications after partial-thickness or full-thickness glaucoma surgery. DESIGN: A retrospective, cohort analysis. PARTICIPANTS: A total of 24,206 Medicare patients who were older than 65 years of age and who were enrolled in Medicare in 1994 underwent partial-thickness or full-thickness glaucoma surgical procedures in 1994. INTERVENTION: The authors obtained data on all glaucoma surgery claims to the Health Care Finance Administration in 1994 and analyzed complication rates using hierarchical logistic regression, separately smoothing four sets of regression coefficients (state-level effects, systemic and ocular diagnoses, prior ocular surgeries, and concomitant ocular surgeries). MAIN OUTCOME MEASURE: Patients were classified as having complications if their records showed at least one of the following occurrences after surgery: retinal detachment repair, endophthalmitis, scleral fistula revision-repair, or cyclodestruction. RESULTS: The risk of complications was greater for full-thickness procedures than for partial-thickness procedures (odds ratio [OR] = 1.51; 95% confidence interval [CI] = 1.07, 2.12). Compared to glaucoma surgeries performed without an additional intraocular procedure, glaucoma surgery with prior phacoemulsification (OR = 0.51; 95% CI = 0.35, 0.74) was associated with lower complication rates, as was glaucoma surgery with prior argon laser trabeculoplasty (OR = 0.62; 95% CI = 0.44, 0.88). A concomitant vitrectomy (OR = 1.86, 95% CI = 1.35, 2.56) was associated with greater odds of a complication. The mean follow-up of subjects was 184 days (standard deviation, +/- 107), whereas the mean time to a complication was 49 days (standard deviation, +/- 63). CONCLUSION: The risk of an early postoperative complication after full-thickness procedures appears to be greater than that after partial-thickness procedures. Concomitant intraocular procedures performed in conjunction with glaucoma surgery, such as a vitrectomy, can substantially increase the risk of retinal detachment repair, endophthalmitis, scleral fistula revision-repair, and/or cyclodestruction.