Risk factors for septic arthritis in patients with joint disease. A prospective study

OBJECTIVE: To quantify potential risk factors for septic arthritis, in order to identify a basis for prevention. METHODS: The occurrence of potential risk factors for septic arthritis in patients with joint diseases attending a rheumatic disease clinic was prospectively monitored at 3-month intervals over a period of 3 years. Potential risk factors investigated were type of joint disease, comorbidity, medication, joint prosthesis, infections, and invasive procedures. The frequencies of risk factors in patients with and those without septic arthritis were compared using multiple logistic regression analysis. RESULTS: There were 37 patients with and 4,870 without septic arthritis. Risk factors for developing septic arthritis were age > or = 80 years (odds ratio [OR] = 3.5, 95% confidence interval [95% CI] 1.4-8.6), diabetes mellitus (OR = 3.3, 95% CI 1.1-10.1), rheumatoid arthritis (OR = 4.0, 95% CI 1.9-8.3), hip and/or knee prosthesis (OR = 15, 95% CI 4.1-54.3), joint surgery (OR = 5.1, 95% CI 2.2-11.9), and skin infection (OR = 27.2, 95% CI 7.6-97.1). CONCLUSION: These findings indicate that preventive measures against septic arthritis in patients with joint diseases should mainly be directed at those with joint prostheses and/or skin infection.     

High-dose epirubicin is not an alternative to standard-dose doxorubicin in the treatment of advanced soft tissue sarcomas. A study of the EORTC soft tissue and bone sarcoma group

The activity and toxicity of single-agent standard-dose doxorubicin were compared with that of two schedules of high-dose epirubicin. A total of 334 chemonaive patients with histologically confirmed advanced soft-tissue sarcomas received (A) doxorubicin 75 mg m(-2) on day 1 (112 patients), (B) epirubicin 150 mg m(-2) on day 1 (111 patients) or (C) epirubicin 50 mg m(-2) day(-1) on days 1, 2 and 3 (111 patients); all given as bolus injection at 3-week intervals. A median of four treatment cycles was given. Median age was 52 years (19-70 years) and performance score 1 (0-2). Of 314 evaluable patients, 45 (14%) had an objective tumour response (eight complete response, 35 partial response). There were no differences among the three groups. Median time to progression for groups A, B and C was 16, 14 and 12 weeks, and median survival 45, 47 and 45 weeks respectively. Neither progression-free (P = 0.93) nor overall survival (P = 0.89) differed among the three groups. After the first cycle of therapy, two patients died of infection and one owing to cardiovascular disease, all on epirubicin. Both dose schedules of epirubicin were more myelotoxic than doxorubicin. Cardiotoxicity (> or = grade 3) occurred in 1%, 0% and 2% respectively. Regardless of the schedule, high-dose epirubicin is not a preferred alternative to standard-dose doxorubicin in the treatment of patients with advanced soft-tissue sarcomas.     

A prospective study of the risk of tuberculosis among HIV-infected patients

OBJECTIVE: To evaluate the risk of developing active tuberculosis (TB) in a cohort of HIV-1-infected patients. METHODS: Prospective longitudinal follow-up of 839 HIV-infected patients, of whom 505 (60%) were parenteral drug users and 269 (32%) homosexual men. Tuberculin skin tests were performed at baseline and annually thereafter. Prophylaxis with isoniazid (300 mg daily for 9 months) was offered to those with a positive tuberculin test (induration > or = 5 mm). Diagnosis of TB was accepted if it could be confirmed microbiologically (acid-fast bacilli seen in Ziehl-Neelsen stains or grown in Lowenstein-Jensen cultures) or pathologically (presence of caseating granulomas) and patients had consistent clinical manifestations. RESULTS: Active TB developed in 23 out of the 733 (3.1%) patients with a negative tuberculin skin test after a mean follow-up of 16 +/- 11 months (range, 2-52 months), with an estimated cumulative probability of 1.5 and 7% after 1 and 3 years, respectively (or 2.4 per 100 patient-years). None of the 87 patients with a negative tuberculin test but a positive Multitest developed TB. Conversely, 106 patients had a positive tuberculin skin test (97 at baseline and nine who converted during follow-up). Active TB developed in seven out of the 26 not receiving prophylaxis or in whom prophylaxis had to be discontinued (16.2 per 100 patient-years), in four out of 61 patients 3-27 months after having completed 9 months of prophylaxis with isoniazid (8.9 per 100 patient-years) and in none of the 19 still receiving isoniazid. When TB was diagnosed, the mean CD4 lymphocyte count of the 34 patients who developed it during follow-up was 77 +/- 103 x 10(6)/l (range, 1-400 x 10(6)/l). CONCLUSIONS: Among HIV-infected patients in whom the tuberculin skin test is negative, the risk of developing active TB is sufficient to consider prophylaxis if the CD4 count falls below 400 x 10(6)/l, at least in those patients with skin anergy living in high-risk geographical areas such as Spain. When the tuberculin skin test was positive, isoniazid (9 months) provided a 45% protection beyond the period of its administration.     

A prospective randomized study of wound approximation with tissue glue in circumcision in children

OBJECTIVE: Bleeding and wound infection are the most common complications of circumcision. Cyanoacrylate tissue glue has been claimed to have the advantage of being haemostatic, bacteriostatic and easy to use. The purpose of this study is to assess the feasibility of using the tissue glue in approximation of circumcision wound in children. METHODOLOGY: A prospective randomized trial was carried out on 86 boys consecutively admitted into the Duchess of Kent Children's Hospital, Hong Kong. The results of wound approximation with cyanoacrylate tissue glue and suturing with interrupted 4/0 plain catgut were compared. The operations were carried out by the same surgeon using identical technique except for the wound approximation. The wound was assessed 1 day, 2 days, 3 days, 1 week and 1 month postoperatively. RESULTS: There was no statistically significant difference between the two groups in the rates of wound inflammation, infection, bleeding, dehiscence and cosmetic appearance, but the duration of operation was longer using tissue glue (19.8 min vs 16.5 min, P = 0.002). CONCLUSIONS: We conclude that tissue glue approximation of circumcision wounds in children is a feasible alternative, but it offers no extra advantage when compared to suturing.     

A prospective longitudinal study of the outdoor behaviour and symptoms of photosensitive patients

The purpose of this study was to determine the measures that photosensitive patients use to control their sun exposure. Each week from March until September 1995, 30 patients with polymorphic light eruption (PLE) and 17 patients with chronic actinic dermatitis (CAD) returned a set of reply paid postcards on which they recorded information about their outdoor behaviour and symptoms. The principal differences between the two groups were that CAD patients had a much greater incidence of symptoms despite making more use of protective measures such as covering arms, wearing hats and applying sunscreen, than patients with PLE. And that as summer approached the PLE patients spent more time outdoors, whereas there was less seasonal variation in this respect among CAD patients. Tentative conclusions drawn from mathematical modelling indicated that the incidence of rash on a particular day was influenced by ambient ultraviolet radiation and length of time spent outdoors. There were indications that wearing a hat and keeping the arms covered offered some protection, whereas use of sunscreen may actually increase the likelihood of symptoms.     

A cephalometric comparative study of the soft tissue airway dimensions in persons with hyperdivergent and normodivergent facial patterns

PURPOSE: This study was performed to compare the dimensions of the nasopharynx, oropharnynx, and hypopharynx of persons with hyperdivergent and normodivergent facial types, and to determine whether any variations exist. PATIENTS AND METHODS: Lateral cephalometric records of a population with a normodivergent facial pattern (n = 23) and a group with a hyperdivergent facial pattern (n = 27) as evidenced by increased mandibular plane angle were used to compare the soft tissue airway dimensions. Statistical analysis consisted of Student's t-tests, Wilcoxon rank sums, and chi2. Statistical significance was set .05. RESULTS: Overall the hyperdivergent group had a narrower anteroposterior pharyngeal dimension than the normodivergent control group. This narrowing was specifically noted in the nasopharynx at the level of the hard palate and in the oropharynx at the level of the tip of the soft palate and the mandible. In addition, the posterior pharyngeal wall had a thinning at the level of the inferior border of the third cervical vertebrae, and there was a more obtuse palatal angle. The tongue was also positioned more inferiorly and posteriorly in the hyperdivergent group, as evidenced by the increased distance between the hyoid bone and the mandibular plane and the increased distance between the soft palate tip and the epiglottis. The hyperdivergent group had more retruded maxillary and mandibular apical bases and a higher Class II skeletal discrepancy. CONCLUSIONS: The narrower anteroposterior dimension of the airway in hyperdivergent patients may be attributable to skeletal features common to such patients, that is, retrusion of the maxilla and the mandible and vertical maxillary excess. Other features, such as an obtuse soft palate and low-set hyoid, also may be contributory factors. The relatively thin posterior pharyngeal wall observed in hyperdivergent patients might be a compensatory mechanism.     

The safety and efficacy of transcatheter arterial chemoembolization in the treatment of patients with hepatocellular carcinoma and main portal vein obstruction. A prospective controlled study

BACKGROUND: Transcatheter arterial chemoembolization (TACE) has been contra-indicated for the treatment of patients with hepatocellular carcinoma (HCC) and main portal vein (MPV) obstruction because of the potential risk of hepatic insufficiency resulting from ischemia after TACE. The current controlled study was undertaken to assess the safety, efficacy, and predictive factors of favorable response to TACE in patients with HCC and MPV obstruction with good hepatic function and adequate collateral circulation around the MPV. METHODS: Of a total of 47 patients, 31 were treated with TACE, and 16 who declined the procedures were untreated controls. Thirty-six patients (77%) had diffuse-type HCC and 11 (23%) had nodular-type HCC. During the first week after TACE immediate postprocedural complications were evaluated, and the development of hepatic insufficiency as a late complication was assessed at the end of the fourth week. The cumulative survival rate was estimated by the Kaplan-Meier method, and predictors of better prognosis were obtained by univariate and multivariate analyses. RESULTS: Although no patients showed clinical evidence of hepatic insufficiency as an immediate complication, transient fever and abdominal pain were common. Progressive hepatic insufficiency developed at the fourth week; however, there was no difference between the treated and untreated groups. The survival time of treated patients was statistically no longer than that of untreated patients. In the univariate analysis, tumor type and size, the pattern of iodized oil uptake in the tumor, and the presence of iodized oil uptake in the tumor thrombi at the MPV significantly influenced the prognosis. Tumor type, whether treated or not, was the most important prognostic factor patients with nodular-type HCC had significantly longer survival time (median, 11 months) than those with diffuse-type HCC (median, 4 months). Regarding the efficacy of TACE, there was no statistical difference in survival between treated and untreated diffuse-type HCC patients. In comparison, with nodular-type HCC it seemed that survival time was longer for TACE-treated patients (median, 30 months) than for untreated patients (median, 7 months). CONCLUSIONS: TACE may be a safe modality for the treatment of patients with HCC and MPV obstruction, provided that the patients have good hepatic function and collateral circulation around the MPV. However, TACE was not efficacious in the treatment of diffuse-type HCC. The authors recommend TACE for treating nodular-type HCC because of the potential benefit of prolonged survival.     

A prospective evaluation of the safety and efficacy of methohexital in the emergency department

OBJECTIVE: Knowledge of a possible correlation between distal polyps found at screening sigmoidoscopy and proximal colonic lesions is important for deciding whether to perform total colonoscopy or not. PATIENTS: A prospective analysis of 2439 consecutive patients with colorectal polyps. Of these, 304 were asymptomatic subjects who underwent complete colonoscopy for screening and were found to have adenomatous or hyperplastic polyps in the distal colorectum. RESULTS: Ten (15%) out of 65 patients with distal hyperplastic polyps only and 86 (36%) out of 239 with distal adenomatous polyps were found to have adenomatous polyps in the proximal colon as well (P < 0.001). The frequency of synchronous proximal adenomas in patients with small (< or = 5 mm) or large distal adenomas (> 5 mm) was comparable (37% and 35%, respectively). However, patients with small distal adenomas had significantly smaller proximal adenomas (P = 0.004) containing less villous component (P = 0.017) than those with large distal adenomas. Neither the patient's age nor the presence of multiple distal adenomas increased the prevalence of proximal adenomas. CONCLUSION: Hyperplastic polyps found on rectosigmoidoscopy do not indicate a need for a complete colorectal examination, as 15% of patients with distal hyperplastic polyps will have proximal adenomatous polyps, a figure that is comparable with that of asymptomatic patients having no distal polyps, either hyperplastic or adenomatous. When only small distal adenomas are found at screening sigmoidoscopy in asymptomatic persons the decision to do a total colonoscopy should be based on individual considerations, as in such cases only small polyps are to be expected in the proximal colon.     

A prospective study of primary and secondary risk factor management in stroke patients

Stroke is a common event which often results in death or major loss of independence with immense human and financial costs, so identification of patients at risk, and prevention of stroke at the individual and population levels, is a high clinical and health priority. From August 1993 to July 1994, 468 stroke patients admitted to our hospital were assessed for the presence of stroke risk factors. All patients were followed up in hospital, and on discharge or death all hospital records were reviewed. We show that many risk factors remain uncorrected in stroke patients and that preventive measures are less than ideal at the community and hospital levels alike.     

A prospective study of Clostridium difficile infection and colonization in pediatric oncology patients

BACKGROUND: Tumescent liposuction has proven to be an extremely safe and effective method of liposuction. However, the infusion of tumescent anesthesia can take 1 hour or more to complete. OBJECTIVE: To document the types, dosages, and routes of administration of premedication utilized by four experienced tumescent liposuction surgeons. To determine if infusion rates for tumescent anesthesia are affected by types of premedication. METHODS: Four experienced liposuction surgeons were asked to review their most recent 100 tumescent liposuction patients with respect to types and dosages of premedication and routes of administration. Data were also provided on corresponding infusion pump settings and infusion rates. Volumes of tumescent anesthesia and corresponding volumes of fat aspirated were also collected on the same 400 patients. RESULTS: Infusion of tumescent anesthesia could be performed more rapidly in patients who were given greater amounts of premedication. Volumes of tumescent anesthesia infused were generally two or more times the volume of fat aspirated. Patients could be infused with less premedication if slow infiltration was employed. CONCLUSION: Infusion rates for tumescent anesthesia can be increased of greater amounts of premedication are given. However, this must be balanced against the safety of the premedication.     

A prospective study of prognostic value of type IV collagenase activity in colorectal cancer tissue

The purpose of this prospective study was to evaluate the prognostic value of the type IV collagenase (IVase) activity in colorectal cancer tissue on disease-free and overall survival in 31 colorectal cancer patients. The clinicopathologic factors studied for prognostic value were age, tumor location, tumor differentiation, preoperative serum levels of carcinoembryonic antigen, Dukes' stage, and IVase activity in colorectal cancer tissue. IVase activities in colorectal cancer tissue were significantly higher in the group of patients with recurrences than in the group without recurrences (P = 0.019). Patients with high IVase activity in colorectal cancer tissue had a significantly shorter disease-free survival (P = 0.0016) and overall survival (P = 0.022) time than those with low IVase activity. Univariate and multivariate analysis showed that significant prognostic factors for disease-free survival were Dukes' stage (P = 0.029, P = 0.046, respectively) and IVase activity status (P = 0.0016, P = 0.0026, respectively). With respect to overall survival, only IVase activity status provided significant predictive value in multivariate analysis (P = 0.041). This prospective study suggests that IVase activity is a valuable prognostic factor in colorectal cancer patients.     

Phase II study of rapid-scheduled etoposide in paediatric soft tissue sarcomas

Twenty three patients with paediatric soft tissue sarcomas who had relapsed or refractory disease were treated with a rapid schedule of intravenous etoposide (100 mg/m2 daily on three consecutive days, weekly over 3 weeks). The regimen was well tolerated with predictable myelotoxicity. In 19 patients with rhabdomyosarcoma, there was a response rate of 42%. This appears to be better than previously reported with conventional three weekly schedules. These data indicate that for rhabdomyosarcoma, as for some other tumours, a divided dose regimen may be the optimal schedule and is worthy of further evaluation.     

Type A behavior and aspirations: A study of parents' and children's goal setting.

Although Type A behavior is recognized as an independent risk factor for coronary heart disease, little is known about its antecedents. In order to learn more about the achievement-striving component of Type A, this study investigated both children's goal setting and their parents' aspirations. Type A children did not have higher aspirations than did Type B children for their performance on an experimental task. Examination of parental aspirations as correlates of Type A scores in two samples of children indicated that mothers did not report different aspirations for their Type A and Type B children. However, fathers did report setting high goals for their Type A sons and perceived that these goals were not attained by them. Paternal aspirations were not consistently related to Type A behavior in daughters. These findings suggest that the father may play an important role in the development of Type A behavior in sons. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

A prospective study of unplanned endotracheal extubation in intensive care unit patients

OBJECTIVE: To evaluate incidence, factors associated with unplanned endotracheal extubation (UEE), and prognostic factors for reintubation. DESIGN: A prospective study over a 32-mo period. SETTING: A 16-bed general intensive care unit of a tertiary university hospital. PATIENTS: Adult subjects undergoing endotracheal intubation for >48 hrs. INTERVENTIONS: Observation of patients who presented unplanned extubation. MEASUREMENTS AND MAIN RESULTS: Over the 32-mo period, there were 59 episodes of UEE in 55 patients (frequency 7.3%). Deliberate self-extubation occurred in 46 episodes (77.9%), while there were 13 episodes (22.1%) of accidental extubation. Twenty-seven (45.8%) episodes occurred in patients who were receiving full mechanical ventilatory support and 32 (54.2%) episodes occurred during the weaning period from mechanical ventilation. Reintubation was required in 27 (45.8%) episodes of UEE. The need for reintubation after UEE was 36.9% in deliberate self-extubation patients and 76.9% in accidental extubation patients (p = .01). Only 15.6% (5/32) of patients who presented UEE during weaning required reintubation, while reintubation was mandatory in 81.5% (22/27) of patients who presented UEE during full mechanical ventilatory support (p < .001). A multiple logistic regression analysis was performed to determine the variables independently associated with the need for reintubation: days of mechanical ventilation were significantly associated with the need for reintubation, and weaning was associated with no need for reintubation. The model correctly classified the need for reintubation in 84.7% (50/59) of cases. CONCLUSIONS: Reintubation in UEE patients strongly depends on the type of mechanical ventilatory support. The probability of requiring reintubation if UEE occurs during full ventilatory support is higher than if UEE occurs during weaning. These data suggest that some patients are under mechanical ventilation longer than necessary.     

A prospective comparison of four study designs used in assessing safety and effectiveness of drug therapy in hypertension management

The objective of the study was to compare prospectively the impact of study design on drug therapy safety and effectiveness data obtained in hypertension management. The main study was a randomized controlled clinical trial of four different prospective study designs used in postmarketing assessment involving 1008 primary care practices in nine Canadian provinces. Two thousand nine hundred sixty-four patients with mild to moderate hypertension received an angiotensin converting enzyme (ACE) inhibitor daily for 14 weeks in one of four postmarketing studies--a randomized double-blind clinical trial (RCT) (10 to 40 mg fosinopril daily v 5 to 20 mg enalapril daily), two structured open label trials of 10 to 40 mg fosinopril daily (one with free drugs), or an unstructured open label trial of 10 to 40 mg fosinopril daily. Patient demographic and baseline characteristics, systolic and diastolic blood pressures, adverse events reported, and data quality were recorded as the outcome measures. The results showed that the RCT patients were titrated to higher doses of ACE inhibitor than patients in the open studies, P < .008; patients in the open studies were more likely to receive adjuvant diuretic therapy, P < .008. The decrease in blood pressure was similar for patients in all four studies, mean decrease in systolic BP was between 18 and 20 mm Hg, mean decrease in diastolic BP was between 11 and 13 mm Hg. Fewer patients in the unstructured open trial reported adverse events than patients in the RCT; a 55% relative reduction in reported adverse events (P < .008) was associated with the unstructured trial. There were also fewer drug-related adverse events per patient reported in the unstructured study (17 per 100 patients) than in the other studies (27 to 41 per 100 patients), P < .008. Physician preference for rounding off blood pressure measurements to 0 or 5 occurred most often in the unstructured open trial (P < .008). In conclusion, despite differences in dose titration and in the use of adjuvant therapy, antihypertensive drug therapy effectiveness observed in an RCT may be similar to uncontrolled postmarketing studies. Open trials with scheduled follow-up visits are as effective in detecting severe adverse events as RCT, but postmarketing studies with unstructured schedules of follow-up are insufficient in identifying drug-related adverse events and have poorer quality data.     

A randomized prospective trial comparing 45 and 90-ml oral sodium phosphate with X-Prep in the preparation of patients for colonoscopy

Incontinentia pigmenti is an uncommon genodermatosis that occurs in female infants. The characteristic dental defects are partial anodontia and the presence of some peg-shaped teeth. This report describes a patient with incontinentia pigmenti who exhibited multiple missing teeth in both arches. The patient had malpositioned teeth and decreased occlusal vertical dimension associated with the missing teeth. Orthodontic treatment was required for prosthetic purposes. The dental anomalies of incontinentia pigmenti and the treatment procedure are presented.     

Immunohistochemical study of proliferating mesenchymal spindle cells in heterogenous soft tissue lesions

Clinics associated with psychology training programs have potential to generate important research data. The expectation that research be experimental in nature has limited the pursuit of research in training clinics. This type of efficacy study is not feasible in most clinics, where too much variation occurs as a result of training and administrative demands. Numerous process-outcome studies have been effectively conducted in training clinics. This article reviews some of these studies, identifies problems related to research in training clinics, and makes recommendations for the development of an enhanced research agenda for training clinics.     

A longitudinal cephalometric study of the soft tissue profile of short- and long-face syndromes from 7 to 17 years

The longitudinal growth and development of the soft tissue drape for boys and girls with long and short vertical patterns was examined from age 7 to 17 years. The sample was taken from the Denver Growth Study and consisted of 32 subjects who were selected on the basis of their percentage of lower anterior vertical face height. All subjects were of northern European ancestry, and none had undergone orthodontic treatment. The sexual dimorphism was evident as anticipated for several soft tissue measurements. The boys showed continued growth through age 16 years in contrast to the girls who attained the adult size of the soft tissue integument around 14 years. A significant difference between vertical facial patterns was reported for all soft tissue variables with the exception of the soft tissue thickness at A point and the upper lip height. The boys and girls with long vertical patterns exhibited a thicker and longer soft tissue drape for the most variables when compared with those with short facial patterns. These soft tissue differences are believed to be compensatory mechanisms in long-face subjects, which may attempt to mask the vertical dysplasia, thereby producing a more normal facial profile. Individual growth assessments revealed that the perioral soft tissues follow a pattern similar to that of the mean group patterns. The subjects with long vertical facial patterns experienced their pubertal growth spurt earlier than the short-face subjects. This may have clinical implications in the timing of orthodontic intervention and treatment.     

Multivariate analysis of prognostic factors in 75 patients with soft tissue sarcoma

Traditionally, patients who received minor gynecology surgery remained in the hospital for a few days, during which time post-operative care was given by nurses. However, since patients are now often discharged the same day, the responsibility for this care has been transferred to the patients and their families. Because the nursing staff of the Gynecology Day Surgery Unit at the Royal Victoria Hospital believes there is a need for patient-monitoring after discharge and CLSCs do not offer services for this generally healthy clientele, they developed, with the head nurse and the assistant head nurse, a post-operative telephone follow-up program. This idea stemmed from the general need to adapt care as a result of the increase in day surgery. In addition to extending care beyond the hospital walls and improving its quality, this program has increased the job satisfaction of the nurses involved.