A patient with severe angina will often be eligible for either angioplasty (PTCA) or bypass surgery (CABG). Results from eight published randomised trials have been combined in a collaborative ...meta-analysis of 3371 patients (1661 CABG, 1710 PTCA) with a mean follow-up of 2·7 years. The total deaths in the CABG and PTCA groups were 73 and 79, respectively, with a relative risk (RR) of 1·08 (95% Cl 0·79-1·50). The combined endpoint of cardiac death and non-fatal myocardial infarction occurred in 169 PTCA patients and 154 CABG patients (RR 1·10 0·89-1·37). Amongst patients randomised to PTCA 17·8% required additional CABG within a year, while in subsequent years the need for additional CABG was around 2% per annum. The rate of additional non-randomised interventions (PTCA and/or CABG) in the first year of follow-up was 33·7% and 3·3% in patients randomised to PTCA and CABG, respectively. The prevalence of angina after one year was considerably higher in the PTCA group (RR 1·56 1·30-1·88) but at 3 years this difference had attenuated (RR 1·22 0·99-1·54). Overall there was substantial similarity in outcome across the trials. Separate analyses for the 732 single-vessel and 2639 multivessel disease patients were largely compatible, though the rates of mortality, additional intervention, and prevalent angina were slightly lower in single vessel disease. The combined evidence comparing PTCA with CABG shows no difference in prognosis between these two initial revascularisation strategies. However, the treatments differ markedly in the subsequent requirement for additional revascularisation procedures and in the relief of angina. These results will influence the choice of revascularisation procedure in future patients with angina.
Objective To establish the feasibility of infrared thermal imaging as a reproducible, noninvasive method for assessing changes in skin temperature within the supraclavicular region in vivo. Study ...design Thermal imaging was used to assess the effect of a standard cool challenge (by placement of the participant's feet or hand in water at 20°C) on the temperature of the supraclavicular region in healthy volunteer participants of normal body mass index in 3 age groups, 3-8, 13-18, and 35-58 years of age. Results We demonstrated a highly localized increase in temperature within the supraclavicular region together with a significant age-related decline under both baseline and stimulated conditions. Conclusion Thermogenesis within the supraclavicular region can be readily quantified by thermal imaging. This noninvasive imaging technique now has the potential to be used to assess brown adipose tissue function alone, or in combination with other techniques, in order to determine the roles of thermogenesis in energy balance and, therefore, obesity prevention.
Despite a high initial response rate to first-line platinum/paclitaxel chemotherapy, most women with epithelial ovarian cancer relapse with recurrent disease that becomes refractory to further ...cytotoxic treatment. We have previously shown that the E3 ubiquitin ligase, EDD, a regulator of DNA damage responses, is amplified and overexpressed in serous ovarian carcinoma. Given that DNA damage pathways are linked to platinum resistance, the aim of this study was to determine if EDD expression was associated with disease recurrence and platinum sensitivity in serous ovarian cancer. High nuclear EDD expression, as determined by immunohistochemistry in a cohort of 151 women with serous ovarian carcinoma, was associated with an approximately two-fold increased risk of disease recurrence and death in patients who initially responded to first-line chemotherapy, independently of disease stage and suboptimal debulking. Although EDD expression was not directly correlated with relative cisplatin sensitivity of ovarian cancer cell lines, sensitivity to cisplatin was partially restored in platinum-resistant A2780-cp70 ovarian cancer cells following siRNA-mediated knockdown of EDD expression. These results identify EDD as a new independent prognostic marker for outcome in serous ovarian cancer, and suggest that pathways involving EDD, including DNA damage responses, may represent new therapeutic targets for chemoresistant ovarian cancer.
Objective The objective of the study was to evaluate the impact of an electronic health record (EHR) on documentation completeness and patient care in a labor and delivery unit. Study Design We ...conducted a pre- and postintervention study to compare documentation quality and workflow before and after EHR implementation. Documentation was compared using χ2 and Fisher's exact tests. Objective observers measured workflow activities across all shifts before and after EHR implementation and activities were compared using Kruskal-Wallis tests and analysis of covariance. Results Paper admission records were significantly more likely to miss key clinical information such as chief complaints (contractions, membrane status, bleeding, fetal movement, 10-64% vs 2-5%; P < .0001) and prenatal laboratory results and history (Varicella, group B Streptococcus, human immunodeficiency virus, 26-66% vs 1-16%, P < .0001). Both direct patient care and computer activities increased after EHR implementation (2 vs 12 and 12 vs 17 activities/shift, respectively, P < .0001). Conclusion The introduction of an obstetric EHR improved documentation completeness without reducing direct patient care.
Background Recent evidence suggests that hydrogen sulfide is capable of mitigating the degree of cellular damage associated with ischemia-reperfusion injury (IRI). Methods This study evaluated the ...potential utility of hydrogen sulfide in preventing IRI in skeletal muscle by using in vitro (cultured myotubes subjected to sequential hypoxia and normoxia) and in vivo (mouse hind limb ischemia, followed by reperfusion) models to determine whether intravenous hydrogen sulfide delivered after the ischemic event had occurred (pharmacologic postconditioning) conferred protection against IRI. Injury score and apoptotic index were determined by analysis of specimens stained with hematoxylin and eosin and terminal deoxynucleotide transferase-mediated deoxy-uridine triphosphate nick-end labeling, respectively. Results In vitro, hydrogen sulfide reduced the apoptotic index after 1, 3, or 5 hours of hypoxia by as much as 75% ( P = .002), 80% ( P = .006), and 83% ( P < .001), respectively. In vivo, hydrogen sulfide delivered after the onset of hind limb ischemia and before reperfusion resulted in protection against IRI-induced cellular changes, which was validated by significant decreases in the injury score and apoptotic index. The timing of hydrogen sulfide delivery was crucial: when delivered 20 minutes before reperfusion, hydrogen sulfide conferred significant cytoprotection ( P < .001), but treatment 1 minute before reperfusion did not provide protection ( P = NS). Conclusions These findings confirm that hydrogen sulfide limits IRI-induced cellular damage in myotubes and skeletal muscle, even when delivered after the onset of ischemia in this murine model. These data suggest that when given in the appropriate dose and within the proper time frame, hydrogen sulfide may have significant therapeutic applications in multiple clinical scenarios.
Occupational health (OH) practitioners need to be confident in identifying and managing mental health problems in the workforce.
To evaluate the effectiveness of a one-day workshop in improving the ...knowledge, attitude and confidence of OH practitioners in detecting and managing depression, anxiety, suicide risk, alcohol misuse and drug abuse.
Interactive mental health workshops for 164 OH practitioners held in five regions in England were evaluated by self-administered questionnaire. Data were collected immediately prior to the workshop (T1), immediately after the workshop (T2) and 4 months following the workshop (T3).
At T1, the response rate was 97% (159/164), 90% at T2 and 63% at T3. The mean improvement in participants' knowledge was 8% (95% CI 6-10) at T2 compared with T1. The biggest improvement was in participants with no previous training in the management of common mental health problems in the workplace, mean improvement 9% (95% CI 6-12). Participants' confidence improved in all areas assessed at T2, and the improvement in confidence compared with that at baseline was sustained at 4 months (T3). Participants reported using the knowledge gained in clinical practice in all topic areas covered. Use of knowledge gained at the workshop was significantly higher in those who had had previous training in managing common mental health disorders.
This one-day interactive workshop was a feasible and effective method of improving OH professionals' confidence, knowledge and application of skills in practice in key areas of mental health.
Common mental disorders are the leading cause of sickness absence but are frequently misdiagnosed and undertreated. It is against this background that a specialist occupational psychiatry clinic was ...established at a London teaching hospital.
To explore the nature of patients and complaints seen in the clinic and investigate whether this form of service provision reached patients who may have otherwise been missed in the gap between primary and secondary care.
We reviewed the case notes of 51 consecutive new clinic assessments using a data extraction form, gathering information on socio-demographic and occupational details; the nature, duration and severity of symptoms as assessed by Health of the Nation Outcome Scale (HoNOS); diagnosis; prior treatment and the outcome of the clinic appointment.
Only half of those seen in the new clinic were currently on sick leave. The most common diagnosis was depression with most having symptoms lasting longer than 9 months. Sixty-five per cent had a medium or high HoNOS rating. Although 75% had received treatment from their general practitioner, the majority remained functionally impaired, and only 31% had been seen in secondary care.
Specialist occupational psychiatry clinics do not replicate the work already being done by standard mental health services. Patients referred to a new specialist clinic within an occupational health department had chronic, debilitating psychiatric illnesses, which in many cases had failed to respond adequately to primary care treatment and were at risk of falling into the gap between primary and secondary services.
Background Obesity is an increasing public health problem. A small number of studies have examined the relationship between obesity and sickness absence, with mixed results, particularly regarding ...short-term sickness absence. Aims To determine if obesity is associated with short- and long-term sickness absence and to investigate the mechanisms that may underlie any association. Methods Cross-sectional (n = 1489) and prospective (n = 625) analyses were conducted on staff from London Underground Ltd. All participants underwent regular clinical examinations that involved their height and weight being measured, obesity-related medical problems being diagnosed and psychiatric disorders being identified. The number of days taken for short- (<10 days in an episode) and long-term sickness absence were recorded by managers on an electronic database. Results There was a positive linear association between employees’ body mass index (BMI) and the number of days’ work missed due to sickness absence on both cross-sectional and prospective analyses (P < 0.001). Obesity was a risk factor for both short- and long-term sickness absence. Obese individuals typically took an extra 4 days sick leave every year. The majority of the increased risk for long-term sickness absence appeared to be mediated via co-morbid chronic medical conditions. The excess short-term sickness absence was not explained by obesity-related medical problems, psychiatric disorders or workplace factors. Conclusions Obese employees take significantly more short- and long-term sickness absence than workers of a healthy weight. There is growing evidence to support employers becoming more involved in tackling obesity.
Hypothesis This study retrospectively reports the results of 81 patients with proximal humeral fractures that were treated operatively. We hypothesized that treatment of these injuries through a ...standardized technique of precountored locked plating and supplemental tension band suture fixation would result in improved clinical outcomes. Materials and methods All patients were evaluated with a minimum follow-up of 1 year. Clinical assessment was performed postoperatively with American Shoulder and Elbow Surgeons (ASES) scores and active range of motion measurements. Radiographic parameters assessed included Neer fracture pattern, fracture union, hardware failure, the presence of avascular necrosis, and medial calcar length and stability. Fractures were classified as 4-part in 14 (17%), 3-part in 41 (51%), and 2-part in 26 (32%). Results The average ASES score was 80 (range, 27-100). The final range of motion averaged 131° of anterior elevation and 41° of external rotation. Fracture union was achieved in all patients, and there were no tuberosity failures. Complications included intraarticular screw penetration in 3 (3.7%) and avascular necrosis in 5 (6.2%). Discussion Locked plating and supplemental tension band fixation can lead to fracture union and favorable outcomes. Restoration of the medial calcar and supplemental suture fixation may decrease the incidence of hardware-related complications.
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