Summary
This prospective population‐based study was designed to evaluate treatment choices in patients with new manometrically diagnosed achalasia and their outcomes. Patients referred to the ...esophageal function laboratory were enrolled after a new manometric diagnosis of achalasia. Patients completed an initial achalasia symptom score validated questionnaire on their symptom severity, duration, treatment pre‐diagnosis and Medical Outcomes Study 36‐item Short‐Form (SF‐36) survey. Treatment decisions were made by the referring physician and the patient. Follow‐up questionnaires were completed every 3 months for 1 year. Patients who chose not to undergo treatment at 1‐year follow‐up completed another questionnaire after 5 years. Between January 2004 and January 2005, 83 of 124 eligible patients were enrolled. Heller myotomy was performed on 31 patients, three patients received botulinum toxin injections, and 25 patients received 29 pneumatic balloon dilatations. Twenty‐four patients chose to receive no treatment. Following treatment, patients treated with surgery, dilatation and botulinum toxin had an average improvement in achalasia symptom score of 23 +/− 12.2, 17 +/− 10.9, and 9 +/− 14, respectively. Patients receiving no treatment had worsening symptoms with a symptom score change of −3.5 +/− 11.4. Surgery and dilatation resulted in significant improvement (P < 0.01) relative to no treatment. In univariate logistic regression, symptom severity score (odds ratio OR 1.04, 95% confidence interval CI 1.00 to 1.08), sphincter tone (OR 1.04, 95% CI 1.00 to 1.09), difficulty swallowing liquids (OR 3.21, 95% 1.15 to 8.99), waking from sleep (OR 2.75, 95% 1.00 to 7.61), and weight loss (OR 5.99, 95% CI 1.93 to 18.58) were all significant in predicting that patients would select treatment. In the multivariate analysis, older age (OR 1.05, 95% CI 1.01 to 1.09) and weight loss (OR 3.91, 95% CI 1.02 to 15.2) were statistically significant for undergoing treatment. At 5 years, five (21%) of those who had initially declined treatment at 1 year ultimately chose a treatment. Patients who finally chose Heller myotomy had lower mental component dimension scores on the SF‐36 at 1 year than those who did not. This study shows that almost one third of patients with manometrically diagnosed achalasia choose not to undergo treatment within 1 year of their diagnosis. Patients who are more symptomatic appear to be more likely to undergo treatment by univariate analysis. In multivariate analysis, increasing age and weight loss are predictive of those who will undergo treatment, with weight loss having the greatest influence. Patients who choose not to undergo treatment make lifestyle changes to maintain their quality of life, and only a minority of them ultimately undergo treatment.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Landowners who seek to manage ownership transitions while preserving conservation-related values must engage in the notoriously complex process of estate planning. Most scholarship on ...conservation-based estate planning has been undertaken from landowner perspectives, seeking to understand why some succeed whereas others do not. Here, we expand this scholarship by including perspectives from professional planners. Combining their insights with past literature, we offer a framework of conservation-based estate planning that describes and normalizes key elements within stages of the process. Interview results emphasized the unique needs of conservation-based estate planning around non-monetary values, the relational nature of the planning process, and the temporal challenges and disruptive life events landowners commonly confront while planning. Our findings synthesize the extant literature, raise questions and needs for future work, and empower landowners, planners, and natural resource professionals to persevere through this difficult process and achieve their conservation-related goals from which we all benefit.
Objective: To examine the relation between fitness and fibrinogen, white blood cell count, uric acid and metabolic syndrome across levels of adiposity in apparently healthy, nonsmoking men. Design: ...Cross-sectional study of 4057 men from the Aerobics Center Longitudinal Study examining the age-adjusted resting levels and risk of having a clinically significant elevation of fibrinogen, white blood cell count, uric acid and metabolic syndrome score across nine fitness-body fatness combinations. Fitness categories (low fitness, moderately fit or high fitness) were based on a maximal treadmill test. Body mass index (BMI) <25.0 was classified as normal weight, BMI 25.0 but <30.0 as overweight and BMI 30.0 as obese. Results: Fitness (inversely) and BMI (directly) were independently related to the age-adjusted values of all four variables (P for trend P<0.0001 for each). For all four variables, the greatest age-adjusted risk of having a clinically relevant value was found in the low fitness-obese category and the lowest age-adjusted risk was found in the high fitness-normal weight group. Conclusion: Fibrinogen, white blood cells, uric acid and metabolic syndrome score are independently related to both fitness (inversely) and fatness (directly). Within levels of fatness, risk for significant elevations in fibrinogen, white blood cells, uric acid and metabolic syndrome score is lower for the higher fitness groups.
The Kinzua Quality Deer Cooperative (KQDC) was established in 2000 to test new approaches to stewardship of white-tailed deer and forest habitat on a 30000 hectare landscape in northwest ...Pennsylvania, USA. Partners included land managers, scientists, educators, tourism promoters, and hunters. KQDC goals were adaptive management of the deer herd, improved habitat quality and deer herd attributes, and sustained hunter participation. The KQDC's tools included novel Pennsylvania Game Commission programs, habitat management, monitoring of deer and habitat, and hunter outreach. Over the first decade, deer densities in KQDC declined by 50%. Deer weight and antler characteristics improved. Browse impact on woody seedlings declined. Herbaceous indicator plants improved. The need to fence regeneration harvests declined. Hunter participation met KQDC goals for deer density and impact. The authors, research scientists and participants in the cooperative, report the results of this case study here including outcomes from ecological research and monitoring and observations of the KQDC itself.
Chlamydia pneumoniae has been identified in coronary atheroma, but concomitant serum antibody titers have been inconsistently positive and unavailable before the detection of early or advanced ...atherosclerotic lesions.
This retrospective investigation was performed on premortem serum specimens and autopsy tissue from 60 indigenous Alaska Natives at low risk for coronary heart disease, selected by the potential availability of their stored specimens. Serum specimens were drawn a mean of 8.8 years (range, 0.7 to 26.2 years) before death, which occurred at a mean age of 34.1 years (range, 15 to 57 years), primarily from noncardiovascular causes (97%). Coronary artery tissues were independently examined histologically and, for C pneumoniae organism and DNA, by immunocytochemistry (ICC) and polymerase chain reaction (PCR) with species-specific monoclonal antibody and primers. Microimmunofluorescence detected species-specific IgG, IgA, and IgM antibody in stored serum. C pneumoniae, frequently within macrophage foam cells, was identified in coronary fibrolipid atheroma (raised lesions, Stary types II through V) in 15 subjects (25%) and early flat lesions in 7 (11%) either by PCR (14, 23%) or ICC (20, 33%). The OR for C pneumoniae in raised atheroma after a level of IgG antibody > or =1:256 >8 years earlier was 6.1 (95% CI, 1.1 to 36.6) and for all coronary tissues after adjustment for multiple potential confounding variables, including tobacco exposure, was 9.4 (95% CI, 2.6 to 33.8).
Serological evidence for C pneumoniae infection frequently precedes both the earliest and more advanced lesions of coronary atherosclerosis that harbor this intracellular pathogen, suggesting a chronic infection and developmental role in coronary heart disease.
The authors hypothesize that environmental values derive from a sense of connectivity with nature. Connectivity describes a perception of sameness between the self, others, and the natural world. The ...experience of connectivity involves dissolution of boundaries and a sense of a shared or common essence between the self, nature, and others. Connectivity with nature differs theoretically and operationally from other explanations of environmental values, including cultural bias, postmaterialism, and social altruism. The authors describe their development of a sociometric scale to operationalize connectivity with nature. Based on data from a mail survey of Pennsylvania landowners, the authors use multiple regression analyses to determine the extent to which connectivity with nature predicts and explains environmental concern and behavior in the presence of standard sociodemographic variables. Survey respondents reported a high level of connectivity with nature, and connectivity retained a significant and positive relationship to environmental concern and environmental behavior in multiple regression models. Implications of these findings are advanced.
HIGH levels of speech recognition have been achieved with a new sound processing strategy for multielectrode cochlear implants. A cochlear implant system consists of one or more implanted electrodes ...for direct electrical activation of the auditory nerve, an external speech processor that transforms a microphone input into stimuli for each electrode, and a transcutaneous (rf-link) or percutaneous (direct) connection between the processor and the electrodes. We report here the comparison of the new strategy and a standard clinical processor. The standard compressed analogue (CA) processor presented analogue waveforms simultaneously to all electrodes, whereas the new continuous interleaved sampling (CIS) strategy presented brief pulses to each electrode in a nonoverlapping sequence. Seven experienced implant users, selected for their excellent performance with the CA processor, participated as subjects. The new strategy produced large improvements in the scores of speech reception tests for all subjects. These results have important implications for the treatment of deafness and for minimal representations of speech at the auditory periphery.
Suboptimal cochlear implant (CI) electrode array placement may reduce presentation of coded information to the central nervous system and, consequently, limit speech recognition.
Generally, mean ...speech reception scores for CI recipients are similar across different CI systems, yet large outcome variation is observed among recipients implanted with the same device. These observations suggest significant recipient-dependent factors influence speech reception performance. This study examines electrode array insertion depth and scalar placement as recipient-dependent factors affecting outcome.
Scalar location and depth of insertion of intracochlear electrodes were measured in 14 patients implanted with Advanced Bionics electrode arrays and whose word recognition scores varied broadly. Electrode position was measured using computed tomographic images of the cochlea and correlated with stable monosyllabic word recognition scores.
Electrode placement, primarily in terms of depth of insertion and scala tympani versus scala vestibuli location, varies widely across subjects. Lower outcome scores are associated with greater insertion depth and greater number of contacts being located in scala vestibuli. Three patterns of scalar placement are observed suggesting variability in insertion dynamics arising from surgical technique.
A significant portion of variability in word recognition scores across a broad range of performance levels of CI subjects is explained by variability in scalar location and insertion depth of the electrode array. We suggest that this variability in electrode placement can be reduced and average speech reception improved by better selection of cochleostomy sites, revised insertion approaches, and control of insertion depth during surgical placement of the array.
Barrett's esophagus is a useful model for the study of carcinogenesis, as the metaplastic columnar epithelium that replaces
squamous esophageal epithelium is at elevated risk for development of ...adenocarcinoma. We examined telomere length and chromosomal
instability (CIN) in Barrett's esophagus biopsies using fluorescence in situ hybridization. To study CIN, we selected centromere and locus-specific arm probes to chromosomes 17/17p ( p53 ), 11/11q (cyclin D1), and 9/9p ( p16 INK4A), loci reported to be involved in early stages of Barrett's esophagus neoplasia. Telomere shortening was observed in
Barrett's esophagus epithelium at all histologic grades, whereas CIN was highest in biopsies with dysplastic changes; there
was, however, considerable heterogeneity between patients in each variable. Alterations on chromosome 17 were strongly correlated
with telomere length ( r = 0.55; P < 0.0001) and loss of the 17p arm signal was the most common event. CIN on chromosome 11 was also associated with telomere
shortening ( r =0.3; P = 0.05), although 11q arm gains were most common. On chromosome 9p, arm losses were the most common finding, but chromosome
9 CIN was not strongly correlated with telomere length. We conclude that CIN is related to telomere shortening in Barrett's
esophagus but varies by chromosome. Whether instability is manifested as loss or gain seems to be influenced by the chromosomal
loci involved. Because telomere shortening and CIN are early events in Barrett's esophagus neoplastic progression and are
highly variable among patients, it will be important to determine whether they identify a subset of patients that is at risk
for more rapid neoplastic evolution. (Cancer Epidemiol Biomarkers Prev 2006;15(8):1451–7)
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