Physical abuse among depressed women

BACKGROUND: The evidence-based approach to medical care involves the explicit use of evidence on the magnitude of the effects of interventions to inform diagnostic and treatment decisions. This article critiques current mainstream guidelines on the management of hypertension in the elderly (aged 60 years and over) and presents an alternative evidence-based approach. METHODS: Three major national and international guidelines for the management of hypertension from the United Kingdom (UK), the United States (US) and from a joint World Health Organisation/International Society of Hypertension (WHO/ISH) Working Party were appraised and the evidence on which they were based was reviewed. The relevant evidence was also assessed to determine the likely magnitude of risks and benefits of anti-hypertensive treatment in older people and an alternative approach to making treatment decisions, based on the New Zealand guidelines for the management of hypertension, is described. RESULTS: Hypertension management guidelines from the UK, US and WHO/ISH made similar recommendations about which elderly patients should be treated, although there were some ambiguities in their advice. Treatment recommendations were based primarily on blood pressure levels which were set at about 160 mm Hg systolic and/or 90 mm Hg diastolic. The threshold levels were based mainly on the cut-off blood pressure levels used in randomised trials of anti-hypertensive drug treatment, rather than the estimated magnitude of treatment benefit. Each of the guidelines acknowledged the important effect of associated cardiovascular disease (CVD) risk factors on the likely benefits of treatment, but did not expand on the magnitude of this effect. No patient-specific estimates of the likely absolute benefits of treatment were provided in any of the guidelines. In contrast the New Zealand guidelines for the management of hypertension recommend the use of explicit estimates of absolute CVD risks and benefits to inform treatment decisions. They were designed to provide practitioners with estimates of the likely absolute risk of CVD in patients with different risk factor profiles and with estimates of the absolute benefits of treatment. The New Zealand guidelines recommend that drug treatment be considered in patients with a 5-year risk of CVD of about 10-15% or more; approximately 25 patients with a 10-15% risk would require treatment for 5 years to prevent one CVD event. As elderly patients are generally at higher absolute CVD risk than younger people, the New Zealand recommendation give priority to the treatment of older patients. In order to take account of differences in life expectancy and the medical costs of caring for elderly people, absolute risk-based guidelines can be improved by incorporating potential years of life gained from treatment and the cost-effectiveness of treatment expressed as $/quality adjusted life years gained. Preliminary analyses indicate that the cost-effectiveness of treatment is generally greatest in patients in their 60s and early 70s. Treatment in younger people is not usually very cost-effective because of their low absolute risk of CVD and the cost-effectiveness of treatment in people over about 75 years declines because of the increasing cost of non-CVD morbidity. CONCLUSIONS: The explicit assessment of absolute CVD risks and likely treatment benefits in patients with hypertension can usefully inform treatment decisions and provide a more rational basis for initiating therapy than blood pressure levels alone. This approach highlights the generally greater CVD risk and potential treatment benefits in older compared with younger hypertensive patients. The absolute risk-based approach can be further enhanced by providing decision makers with patient-specific data on the potential life years gained from treatment and its cost-effectiveness. (ABSTRACT TRUNCATED)     

Paracetamol poisoning in the north east of England: presentation, early management and outcome

1. Paracetamol is increasingly involved in self-poisoning in the United Kingdom and remains a common cause of fatal poisoning. 2. To document the epidemiology and early management of paracetamol poisoning data were collected on consecutive patients with suspected paracetamol poisoning presenting to 6 hospitals in the North East of England over 12 weeks in 1994. 3. There were 400 presentations (attendance rate 1.14/10(3) population/yr) involving 343 persons (45% male). Paracetamol concentrations at 4 h correlated weakly with reported paracetamol dose (R = 0.49, P < 0.0001) and were similar comparing those treated and not treated by gastric decontamination. 4. In 38 (9%) cases paracetamol concentrations were above the appropriate nomogram treatment line, including 3% and 20% of patients who reported ingesting less than and more than 12 g respectively. In 21 patients acetylcysteine treatment was deferred until admission to the ward, the mean delay involved was 2.8 h. 5. One patient died, from arrhythmias caused by co-ingested dothiepin. 6. Paracetamol poisoning is common. Most cases do not have potentially toxic plasma paracetamol concentrations, but those who do often present late and antidotal treatment may be delayed inappropriately.     

Multiple cerebellar infarction due to vertebral artery obstruction and bulbar symptoms associated with vertical subluxation and atlanto-occipital subluxation in ankylosing spondylitis

Ankylosing spondylitis (AS) results in disease-specific inflammation at the site of ligamentous insertion into the bone. Atlantoaxial joint subluxation and vertical subluxation of the axis may occur as a consequence of instability resulting from the inflammatory process. Spontaneous anterior atlantoaxial subluxation is a well recognized complication in about 2% of patients with AS, and presents with or without signs of spinal cord compression. Vertical subluxation may follow anterior or posterior subluxation. It was noted in 3-8% of patients with rheumatoid arthritis, but is an exceedingly rare complication of AS. Moreover, it has never been reported that multiple cerebellar infarction and bulbar symptoms developed spontaneously due to atlanto-occipital subluxation and vertical subluxation in a patient with a long [corrected] history of AS. We describe a man with AS who developed multiple cerebellar infarction due to vertebral artery obstruction and bulbar symptoms associated with atlanto-occipital subluxation and vertical subluxation.     

Characteristics of a fast transient outward current in guinea pig trigeminal motoneurons

A fast transient voltage dependent outward current (TOC) in trigeminal motoneurons (TMNs) was studied in guinea pig brainstem slices by use of sharp electrodes in combination with single electrode voltage clamp techniques. In solutions containing TTX, low Ca2+/Mn2+ and 20 mM TEA this current activated around -55 to -60 mV from holding potentials negative to resting potential, obtained its peak amplitude within 5 ms and decayed as a single exponential with a time constant of 6-8 ms. Half maximal values for inactivation and activation were -72 and -37 mV, respectively. Bath application of 5 mM 4-AP suppressed this current by approximately 90% and eliminated the early depolarizing transient membrane rectification observed in response to a constant depolarizing current pulse, prolonged the action potential duration, and reduced the threshold voltage and delay to onset of the action potential. It is suggested that this current resembles the typical A-current observed in many CNS neurons and, as a result of its voltage and time dependent properties, could contribute to control of motoneuronal discharge and timing of burst onset during rhythmical jaw movements. Therefore, any cellular models of masticatory activity should include the properties of this current.     

Administering amphotericin B--a practical approach

Despite the introduction in recent years of novel antifungal agents, the potency and broad spectrum of activity of amphotericin B have ensured that it remains the treatment of choice for most deep-seated mycoses. However, this agent is not without significant toxicity, particularly in patients who are already seriously ill and/or who are receiving other potentially nephrotoxic drugs. We review the various routes by which amphotericin B can be administered, focusing mainly on the intravenous route. The use of more rapid infusion rates, lipid-complexed preparations, sodium supplementation in salt-depleted patients and strategies to reduce the incidence of infusion-related reactions and nephrotoxicity are also considered. Finally, detailed recommendations for the administration of amphotericin B are provided.     

Composite finger metacarpophalangeal joint reconstruction in combined second and third free toe-to-hand transfers

Composite metacarpophalangeal joint reconstruction using the toe proximal phalanx and the metacarpal head, with a capsular repair, is an option during free toe transfer procedures for absent fingers. Eleven composite metacarpophalangeal finger joint reconstructions were performed in four patients concurrent with combined second and third toe-to-hand transfer. The average follow-up period was 5 years. Postoperative assessment included range of motion, stability, radiographic changes, and pain. The average range of motion was 52 degrees, average ulnar stress deviation was 14 degrees. No patients complained of pain. Composite metacarpophalangeal joint reconstruction should be considered in free toe-to-hand procedures when metacarpal head articular cartilage is preserved.     

Plan and operation of the 1995 National Survey of Family Growth

OBJECTIVES: This report describes how the 1995 National Survey of Family Growth (NSFG) was designed, planned, and implemented. The NSFG is a national survey of women 15-44 years of age designed to provide national estimates of factors affecting pregnancy and birth rates and the health of women and infants. Planning for the 1995 NSFG began in 1990 at a formal conference with the survey's data users. Suggestions for substantial changes and improvements in the survey were made there and carried out by NSFG staff and the NSFG contractor--the Research Triangle Institute (RTI). METHODS: The survey was converted from paper and pencil interviewing to Computer-Assisted Personal Interviewing (CAPI) to improve the quality, consistency, and timeliness of the data. At the same time, event histories of the respondent's work, education, family background, cohabitation, and sexual partners were added to lend explanatory power to the survey. These changes made the interview and the CAPI program long--average interview length was 103 minutes--and complex, but the CAPI program worked very well. RESULTS: About 260 female interviewers were trained for 7 days in January 1995. These interviewers completed a total of 10,847 interviews with women 15-44 years of age, for a response rate of 79 percent. This report describes how the survey was planned and designed and how the data were collected, edited, and processed for public use. This report may be of interest to NSFG data users and to those planning other computer-assisted surveys.     

Numerical Study of Three Different Approaches to Simulate Nanofluids Flow and Heat Transfer in a Microtube

In this paper, Eulerian, mixture and single phase models are used to simulate laminar and turbulent forced convective flow of SiO₂‐EG nanofluid in a microtube. The comparison between the three approaches and other formula shows that for laminar and turbulent flow the single phase model shows higher heat transfer enhancement and is more precise in comparison to the other Eulerian and mixture models.