Search

We aimed to examine family quality of life (FQOL) of Northern Israeli families having a child with a severe neurodevelopmental disability and its relation to socio-demographics. The cohort included caregivers of 70 children ages (mean ± standard deviation) 5.36 ± 3.53 years. Families were two-parent (85.7%), lived in the periphery (67.1%) and included Jews (60%), Muslims (18.6%), Druze (14.3%) and Christians (7.1%). Religiosity included: secular (38.6%), traditional (31.4%), religious (30%). Children's diagnosis included autistic spectrum disorder (41.4%), intellectual disability (21.4%), cerebral palsy (17.1%), genetic syndromes (17.1%) and sensorineural hearing loss (2.9%). Degree of support (1-minimal,5-greatest) required by the child was 3.67 ± 1.28 for physical and 3.49 ± 1.36 for communication. Primary caregivers completed the FQOL Survey. Domain scores were highest for family relations and lowest for financial well-being. Dimension scores were highest for importance and lowest for opportunities. Overall FQOL approximated average. Jewish families and residents of a major urban area reported higher and more religious families reported lower overall FQOL. Regression analysis found ethnicity contributing to overall FQOL and domain scores with residence contributing to support from services. Ethnicity and child dependence contributed to dimension scores. Northern Israeli families having a child with a severe neurodevelopmental disability report average FQOL scores. However, family and child dependence characteristics affect FQOL scores. Professionals working with these families should consider FQOL information when making recommendations.

Purpose: Estimate the reliability of the E-chart as used with Israeli school children. Design: Cross-sectional, population-based study conducted among 751 Israeli students of the Northern District, aged 6- and 7-year-olds and 13- and 14-years-old in 30 schools in 2003. Methods: Each student was screened separately by two public health nurses using the illiterate E-chart. Collected data included the students’ vision and demographic characteristics, the nurses’ professional background, and whether they referred students for medical testing. The reliabilities of vision testing and of the recommendations were determined using total, positive, and negative percentages of agreement and Kappa coefficients. Findings: Total percentage of agreement on vision (combined findings for both eyes) was 78.2% (Kappa 0.47, 95%CI 0.41–0.53). Logistic regression models to predict agreement on vision abnormality showed a higher percentage of agreement among females and 13- and 14-year-old students than among males and 6- and 7-year old students. Total agreement of 85.8% was found in referral recommendations (Kappa 0.58, 95%CI 0.51–0.65). Significant relationships were noted with student age, ethnicity, subdistrict of residence, nurse seniority, and agreement on vision findings. Conclusions: Improvement in school vision-screening reliability is needed, especially among 6- and 7-year-old students. To this end, the determinants of fair reliability should be investigated and training programs planned. Reasons for differences in the reliability of nurses’ recommendations detected among subdistricts must be further studied, together with careful supervision, to ensure better performance and adherence to PHS guidelines. Implications for nurses and nursing should be considered. Clinical Relevance: Demographic characteristics were found to predict reliability, which can guide nurses in selecting students who need more careful attention or closer supervision during vision testing.

Earlier studies indicate that high circulating levels of insulin-like growth factor-1 (IGF-1) may be associated with premenopausal breast cancer. We studied variations in the IGF-1 gene and the growth hormone (GH1) gene in relation to risk of breast cancer in 667 Ashkenazi Jewish women (321 cases, 346 controls) from a population-based case-control study in Northern Israel, and a clinical series of 331 founder BRCA mutation carriers (161 affected, 170 unaffected). All participants were tested for six polymorphisms in the IGF-1 gene and one GH1 polymorphism. Logistic regression models were used to estimate odds ratios for haplotype-specific and genotype-specific age-adjusted risks. Two common IGF-1 haplotypes (ATTCAC, GAGTGT) were found, when compared with the most prevalent haplotype ATTCGC (32.5%), to be associated with a decreased risk of breast cancer in premenopausal noncarrier women only. Age-adjusted odds ratios were 0.5 (95% confidence interval: 0.28-0.92) for ATTCAC and 0.46 (95% confidence interval: 0.24-0.89) for GAGTGT. The GH1 polymorphism did not influence the risk of breast cancer in our study population. The IGF-1 gene seems to be associated with breast cancer risk in premenopausal Ashkenazi Jewish women who are not carriers of mutations in BRCA1/2 genes.

Object Deepening sedation is often needed in patients with intracranial hypertension. All widely used sedative and anesthetic agents (opioids, benzodiazepines, propofol, and barbiturates) decrease blood pressure and may therefore decrease cerebral perfusion pressure (CPP). Ketamine is a potent, safe, rapid-onset anesthetic agent that does not decrease blood pressure. However, ketamine's use in patients with traumatic brain injury and intracranial hypertension is precluded because it is widely stated that it increases intracranial pressure (ICP). Based on anecdotal clinical experience, the authors hypothesized that ketamine does not increase—but may rather decrease—ICP. Methods The authors conducted a prospective, controlled, clinical trial of data obtained in a pediatric intensive care unit of a regional trauma center. All patients were sedated and mechanically ventilated prior to inclusion in the study. Children with sustained, elevated ICP (> 18 mm Hg) resistant to first-tier therapies received a single ketamine dose (1–1.5 mg/kg) either to prevent further ICP increase during a potentially distressing intervention (Group 1) or as an additional measure to lower ICP (Group 2). Hemodynamic, ICP, and CPP values were recorded before ketamine administration, and repeated-measures analysis of variance was used to compare these values with those recorded every minute for 10 minutes following ketamine administration. Results The results of 82 ketamine administrations in 30 patients were analyzed. Overall, following ketamine administration, ICP decreased by 30% (from 25.8 ± 8.4 to 18.0 ± 8.5 mm Hg) (p < 0.001) and CPP increased from 54.4 ± 11.7 to 58.3 ± 13.4 mm Hg (p < 0.005). In Group 1, ICP decreased significantly following ketamine administration and increased by > 2 mm Hg during the distressing intervention in only 1 of 17 events. In Group 2, when ketamine was administered to lower persistent intracranial hypertension, ICP decreased by 33% (from 26.0 ± 9.1 to 17.5 ± 9.1 mm Hg) (p < 0.0001) following ketamine administration. Conclusions In ventilation-treated patients with intracranial hypertension, ketamine effectively decreased ICP and prevented untoward ICP elevations during potentially distressing interventions, without lowering blood pressure and CPP. These results refute the notion that ketamine increases ICP. Ketamine is a safe and effective drug for patients with traumatic brain injury and intracranial hypertension, and it can possibly be used safely in trauma emergency situations.

Background: The perinatal-neonatal course of very-low-birth-weight (VLBW) infants might affect their childhood growth. We evaluated the effect of parental anthropometry and perinatal and neonatal morbidity of VLBW neonates on their childhood growth. Methods: We obtained parental anthropometry, height and weight at age 6-10.5 years of 334 children born as VLBW infants. Parental, perinatal and neonatal data of these children were tested for association with childhood anthropometry. Results: (1) Maternal and paternal weight standard deviation score (SDS) and discharge weight (DW) SDS were associated with childhood weight SDS (R 2 = 0.111, p < 0.00001); (2) Maternal and paternal height SDS, corrected gestational age (GA) at discharge, maternal assisted reproduction and SGA status were associated with childhood height SDS (R 2 = 0.208, p < 0.00001); (3) paternal weight SDS, DW SDS and surfactant therapy were associated with childhood body mass index (BMI) SDS (R 2 = 0.096, p < 0.00001). 31.1% of VLBW infants had DW SDS < -1.88, and are to be considered small for gestational age ('SGA'). One quarter of these infants did not catch up by age 6-10.5 years. Conclusion: Childhood anthropometry of VLBW infants depends on parental anthropometry, postnatal respiratory morbidity and growth parameters at birth and at discharge. Almost one-third of VLBW premature infants had growth restriction at discharge from neonatal intensive care unit (NICU), a quarter of whom did not catch up by age 6-10.5 years.

Introduction The experience of the mammography testing process and related satisfaction influence women’s willingness to undergo the test again. The study goal was to assess women’s overall satisfaction with the mammography examination service provided by participating units in the National Program for the Early Detection of Breast Cancer in Israel. Methods Between August 2003 and March 2004, a random sample of 3,295 women from 38 mammography units nationwide was drawn. Women were interviewed within 48 hours of their mammography, regarding their assessment of the examination process: discomfort, overall satisfaction, and intention to rescreen. Overall satisfaction and process items were measured on an ordinal scale ranging from 1 (lowest) to 6 (highest). Multivariate binomial regression was performed to identify significant predictors of being less satisfied and to estimate the associated relative risks with 95% confidence interval (CI). Results A response of “very satisfied” (score 6), indicating overall satisfaction with the mammography process, was reported by 77% (95% CI, 73%–80%) of the women, 19% (95% CI, 17%–21%) said they were satisfied. Willingness to rescreen was reported by 95%. Negative assessment of staff attitude was the most influential predictor of being less satisfied. Twenty-six percent of women reported experiencing very discomforting pain. This response was associated with a diagnostic test indication, and with process items directly related to the test (technician’s attitude toward the patient; information provided by her; privacy during the test). Conclusions Women’s satisfaction was high, as was intention to rescreen. The gap between intention and rescreening begs further investigations as to other types of barriers preventing women from adherence to rescreening.

Background and objective: Retinopathy of prematurity (ROP) develops mostly in very-low-birth-weight (VLBW) premature infants. Besides prematurity and hyperoxia, other variables have been brought up as risk factors for ROP. We aimed to search risk factors for ROP by comparing two groups of preemies, one with and the other without ROP. Patients and methods: During 2004–2006, 27 VLBW premature infants developed ROP (ROP group). For each neonate in the ROP group, we chose a neonate born at similar gestational age (GA) (±1week) but without ROP (control group). For each neonate of both groups, we recorded demographic, maternal, gestational, intrapartum, neonatal, interventional, growth and ophthalmologic data from patients' medical records. Results: Eleven of the tested variables were significantly different between the ROP and control groups in univariate analysis. However, only seven of these variables remained significantly different between groups when controlling each variable for GA: bronchopulmonary dysplasia (BPD, p = 0.04), duration of hospitalization (p = 0.017), high-frequency oscillatory ventilation (HFOV, p = 0.033), duration of oxygen therapy (p = 0.023), surfactant therapy (p = 0.045), inhaled steroids (p = 0.015) and systemic steroids for BPD (p = 0.007). These seven significant variables were related to respiratory morbidity and interventions. Multiple stepwise logistic regression including all significant variables in the univariate analysis showed that only systemic steroids remained significantly different between groups (p = 0.007, OR 5.42, 95% CI 1.60–18.34). Conclusion: Significantly more neonates in the ROP group received late postnatal systemic steroids as compared to controls. We speculate that steroids, by altering insulin growth factor-1 (IGF-1) and vascular endothelial growth factor (VEGF) expression, might contribute to the pathogenesis of ROP.

Background: Peptic ulcers and erosions (PU&E) are thought to be uncommon in children. Patients with early exposure to Helicobacter pylori may be at a higher risk for early onset PU&E. Children in Israel have a high prevalence and early acquisition of Helicobacter pylori (H. pylori) and have easy access to pediatric gastroenterologists and endoscopy. Our aim was to describe the prevalence and characteristics of PU&E in this population referred by Pediatric Gastroenterologists for an upper endoscopy. Methods: We conducted a retrospective study over the years January 2003–May 2006. Over these years we had information on 751 diagnostic upper endoscopies. PU&E was regarded as erosive gastritis/duodenitis or ulcer in either the stomach or duodenum. H. pylori status was assessed using rapid urease test and gastric biopsies. Results: PU&E was detected in 169 (22.5%) patients (ulcers 51 (6.8%), erosions 118 (15.7%)). One hundred twenty-four had gastric PU&E and 58 had duodenal PU&E. H. pylori was positive in 112 (66.3%). H. pylori-associated PU&E becomes common after age 10 years, with gastric PU&E presenting much earlier than duodenal disease. Most of the H. pylori-negative PU&E were idiopathic and improved symptomatically on PPI treatment. Interestingly, 43% of patients with PU&E in our cohort were either immigrants from the former Soviet Union or of Israeli Arab origin. Conclusions: PU&E appears to be common in this selected population with a relatively high incidence of gastric PU&E. H. pylori associated PU&E becomes common after age 10 years with gastric PU&E presenting much earlier than duodenal disease. Non H. pylori PU&E in children comprises approximately a third of all PU&E, are mostly idiopathic and appear earlier than H. pylori associated PU&E.

Introduction: The aim of this study was to assess the clinical significance and prognosis of a prolonged isolated elevation of serum aminotransferases without cholestasis (>3 months) in infants and young children, investigated for a variety of conditions, and to determine a protocol for their follow-up and investigation. Methods: A combined prospective-retrospective analysis of apparently healthy babies and young children with isolated elevation of serum aminotransferases of at least 1.5 times above the norm for age which persisted for at least 3 months and whose creatine phosphokinase (CK), gamma glutamyltransferase (GGT), alkaline phosphatase and bilirubin levels remained normal throughout the study duration. The children underwent the following investigations: abdominal ultrasound and infectious, metabolic and/or immunological investigation depending on the duration of the abnormality. Results: Six children were eliminated following the finding of positive cytomegalovirus (CMV) antigen in the urine. 72 children were investigated (47 males and 25 females). The duration of serum aminotransferases elevation was 3–36 months (average 12.4, median 11.5 months). The initial, maximal and final alanine aminotransferase (ALT) values were 85.5, 140.5 and 39.8 IU/l, respectively. Of seven children who had liver biopsies performed, three (42.8%) were suspected of having a glycogen storage disease which was not confirmed enzymatically. Four biopsies revealed non-specific histological changes. Conclusions: Isolated elevation of serum aminotransferases in healthy looking young children is mostly a benign condition that usually resolves within a year. If no pathology is found during routine investigation, these children can be followed conservatively. Liver biopsy does not contribute much to the diagnosis and is probably unnecessary.

This prospective study assessed the relation between pain catastrophizing, response to experimental pain stimuli, and pain perceived by women after elective cesarean sections. Forty-seven women who were scheduled for elective cesarean section were enrolled in the study. Magnitude estimation to suprathreshold phasic and tonic heat pain stimuli was assessed 1 or 2 days before surgery. Women completed the Pain Catastrophizing Scale after the heat stimuli and again on the first postoperative day. During the first and second postoperative days, perception of pain intensity was assessed by visual analog scale at each analgesia request. A multiple regression analysis revealed that pain on the first postoperative day was predicted by patient response to preoperative tonic heat stimuli ( r 2 = .167, P = .008). Pain on the second postoperative day was predicted by preoperative pain catastrophizing ( r 2 = .139, P = .021). No significant association was observed between preoperative response to heat stimuli or pain catastrophizing and the patient’s analgesic consumption in the obstetrical ward. It is concluded that pain catastrophizing and response to experimental tonic heat pain correlate with post–cesarean section pain. Perspective This article presents psychological and psychophysical measures that may be of help in the prediction of post–cesarean section pain. It may therefore contribute to the treatment of the sequelae of the most common major surgical procedure performed in women in their reproductive years.

Complications of Crohn's disease (CD) lead to surgery in about 70-90% of patients. The majority of patients suffer from relapse of the disease. Colonic bacteria are essential to the development of CD. Therefore, a rationale exists in trying to prevent relapse by manipulation of gut microflora. This is feasible by treatment with probiotics or antibiotics. Synbiotic 2000 is a cocktail containing 4 probiotic species and 4 prebiotics. It is rational to pursue that it could be effective in preventing postoperative disease. We sought to check weather treatment with Synbiotic 2000 could prevent postoperative recurrence in patients with CD. This was a prospective multicenter, randomized study. Patients were randomized to active treatment or placebo in a 2:1 ratio. Follow-up consisted of endoscopic, clinical, and laboratory parameters. Thirty patients were enrolled. No differences were found between the 2 treatment groups regarding gender, age at diagnosis, age at surgery, weight, smoking status, type of disease, length of the resected segment, or medical treatment prior to surgery. No difference in either endoscopic or clinical relapse rate was found between patients treated with once daily dose of Synbiotic 2000 or placebo. In our small study, Synbiotic 2000 had no effect on postoperative recurrence of patients with CD. Larger studies in patients with the inflammatory type of CD undergoing surgery, using higher doses of probiotics cocktail might prove effective.

Therapy of Hodgkin disease (HD) is designed to prolong progression-free survival and minimize toxicity. The best regimen to achieve this has not yet been defined. A total of 108 patients with newly diagnosed HD and adverse prognostic factors were prospectively studied between 1999 and 2004. They were assigned to therapy according to defined risk stratification. Patients were defined depending on the International Prognostic Score (IPS). Those with IPS of 3 or higher received 2 cycles of escalated therapy, including bleomycin, etoposide, doxorubicin, cyclophosphamide, vincristine, procarbazine, and prednisone (BEACOPP [EB]). All others received 2 cycles of standard BEACOPP (SB). Subsequent therapy was prospectively assigned following 2 cycles according to results of early interim 67Ga or positron emission tomography/computed tomography (PET/CT). Following a positive interim scan, 4 cycles of EB were administered, whereas 4 cycles of SB were given to patients with a negative scan. The complete remission rate, the 5-year event-free survival (EFS), and overall survival (OS) rates were 97%, 85% and 90%, respectively. Relapse or progression occurred in 27% of patients with interim positive PET/CT versus 2.3% of negative scans (P < .02). Early interim fluorine-18 2-fluoro-2-deoxy-d-glucose (FDG)–PET/CT is a useful tool for adjustment of chemotherapy on an individual basis. Similar EFS and OS rates were observed for patients in both risk groups.

Purpose Termination of pregnancy is a painful procedure. Currently, there are no sufficient data regarding the best mode to reduce this pain. The aim of the study was to evaluate postabortion pain levels and to examine the analgesic effect of three different generic types of suppositories provided at the end of the surgical procedure prior to awakening from general anesthesia. Method Two hundred seventeen women were randomly assigned to four groups: indomethacin (100 mg), paracetamol (1000 mg), tramadol (100 mg), and control group with no suppository treatment. Pain levels were evaluated by VAS five times ��� 15, 30, 60, 90 and 120 min after abortion. The number of doses of rescue analgesia with dipyrone (1 g po) was recorded. Results There was a significant difference in pain levels between the four groups during the 2-h study (p Rescue analgesia was requested by 22/55 women in the control group, 10/55 in the tramadol group, 7/54 in the paracetamol group and 5/53 in the indomethacin group ( �� 2 =19.0, p Conclusion The application of a single suppository of an analgesic drug, especially indomethacin, is a simple, inexpensive and safe mode to reduce postabortion pain.

SummaryThe NETT study assessed the benefits of lung volume reduction surgery (LVRS) versus medical treatment. However, data is available only on the early outcome of LVRS (24 months). We evaluate the factors affecting the outcome at one-year and up to 6 years after LVRS.Thirty-seven patients underwent LVRS. Thirty-five patients, who survived the operation for at least one-year, were followed up to 6 years. Patients’ laboratory, clinical and scintigraphic data before surgery were reviewed retrospectively, and follow-up at one-year and at the end of data collection.Successful LVRS with improvement of FEV1⩾30% at one-year was observed in 13 of 35 patients. Five of these patients had initial FEV1 values of 23%. Combinations of age under 60 years and PDiff >23% were a favorable factor (P23%) has improved outcome.

Background During surgery, damage occurs to muscles in the area of the operation. The few studies that have examined creatine phosphokinase (CK) values after surgery have been in adults. The only study in children was after cardiac surgery. Understanding the normal enzyme pattern of change may help to differentiate malignant hyperthermia, anaesthesia-induced rhabdomyolysis and elevated CK values resulting from inherited muscle disease in cases in which these are suspected. The aim of this study was to delineate the normal rise of CK after minor and major surgery in children. Methods A total of 71 patients aged 1 month–17 yr were studied. From the cohort of 71 patients, 46 underwent elective surgery (14 major, 32 minor) and in 25 the surgery was designated as an emergency surgery (21 major, 4 minor). The anaesthesia protocol was similar for both groups with halothane induction and isoflurane maintenance. Owing to its possible effect on CK, succinylcholine was avoided during the study. Results The mean values of CK concentration before and after surgery were 63.1 iu litre −1 and 151.5 iu litre −1 , respectively. The median CK elevation (range) for the major and minor surgery groups was 43 iu litre −1 (4–647) and 10 iu litre −1 (−28 to 122), respectively ( P Conclusions CK concentrations in the major surgery group were significantly higher than the minor surgery group. This profile can contribute to the evaluation of patients who present with the possibility of malignant hyperthermia, anaesthesia-induced rhabdomyolysis and underlying muscle disease. Any rise of CK concentration above what is expected should prompt further investigation.

Background Cardiovascular disease (CVD) prevention suffers from a major gap between clinical evidence (information) and clinical practice (implementation). Insufficient control risk factor levels and under-utilization of aspirin, statins, angiotensin-converting enzyme (ACE) inhibitors and beta-blockers are well-known examples. Methods The SaM (Screening and Monitoring) approach was devised by a family physician in order to facilitate closure of this gap. It does so by providing solutions to problems in the fields of information and implementation. A simple manipulation of the electronic medical record used in the practice serves to facilitate cyclic monitoring of patients with cardiovascular risk factors. Technological and human resources available in the primary care setting are used. The approach is described in the first part of the article. The second part presents results obtained by employing the approach on one family physician's patient population. Results The final results demonstrate a marked improvement over time in risk factor levels and use of medications in accordance with Indications. The values achieved are superior to those reported in the literature. Blood pressure in hypertensive patients 134/75 mmHg; haemoglobin A1c 7.27%; low-density lipoprotein-cholesterol in patients with CVD or diabetes, 97mg/dl; patients with CVD receiving anti-thrombotic medication, 94%; dyslipidaemic patients with CVD or diabetes receiving lipid-lowering drugs, 90%; post myocardial infarction patients receiving beta-blockers, 76%; hypertensive diabetics or patients with chronic heart failure (CHF) receiving ACE-inhibitors/angiotensin receptor blockers, 86%. Conclusions In this one-practice pilot-study, the SaM approach was employed with marked improvement in risk factor levels and use of appropriate medications. This may translate into reductions in morbidity and mortality in a larger population. Eur J Cardiovasc Prev Rehabil 12:56-62 © 2005 The European Society of Cardiology

Objectives To evaluate sound localization ability in totally deaf patients with unilateral cochlear implants and to estimate the ability to improve this function by training. Design A controlled case series. Materials and methods Nine patients with monaural cochlear implants were asked to identify the source of 50 randomly distributed sound stimuli coming from five different directions anteriorly or laterally. After some training, patients were retested. There were two control groups. One comprised nine adults with normal hearing, and the other comprised nine adults with normal hearing but one ear plugged. Results The mean initial score of the study group (maximal score 100) was 41.5 (range 23–63). Patients who had used cochlear implants longer had better sound localization ability (Spearman's correlation coefficient = 0.92). On retesting, after an average of 6.3 training sessions, their mean score improved to 66 (range 32–95), (p = 0.008). The improvement was more pronounced in postlinguals than in prelinguals (p = 0.016). Conclusions Spontaneous development of sound localization ability in totally deaf patients with unilateral cochlear implants is proportional to the time interval between implantation and initial testing. Improvement appears to be influenced by training, and to be greater in postlingual than in prelingual implantees. Copyright © 2005 Whurr Publishers Ltd.

The objective of this study was to define the variables associated with vaginal birth after cesarean section (VBAC) and to develop a scoring system for the prediction of successful VBAC. We searched our computerized database for parturients with a history of one low-transverse cesarean section (CS) who were delivered during the year 2000. Variables were categorized according to the time period in which they were obtained: (1) first prenatal visit, (2) at the onset of labor, and (3) during labor. Univariate and multiple stepwise logistic regression models were fitted to calculate odds ratios (ORs) and 95% confidence intervals (CIs). Of the 475 parturients with a history of one previous CS, 136 underwent elective CS and 339 underwent a trial of VBAC, of whom 82% were successful. Of the variables that can be obtained at the onset of labor, five were significantly associated with successful VBAC: abnormal presentation as the indication for the primary CS (OR, 7.4; 95% CI 2.8 to 19.2), a previous VBAC (OR, 7.2; 95% CI, 2.1 to 24.8), cervical dilation (OR, 2.5; 95% CI, 1.3 to 4.9), gestational age < or = 41 weeks (OR, 2.8; 95% CI, 1.1 to 7.1), and lower gestational age at the primary CS (OR, 1.2; 95% CI, 1.02 to 1.4). In the proposed VBAC score, each of the four most significant variables was assigned a score ranging between 0 and 3 based on the probability for VBAC. A score < or = 2 was associated with a success rate of 42%, a score between 3 and 6 was associated with a rate of 81%, and a score between 7 and 10 was associated with a 98% successful VBAC rate (p < 0001). The proposed VBAC score may help obstetricians when counseling their patients regarding the individual likelihood of a successful VBAC.

Osteoporosis is the most common manifestation of untreated celiac disease (CD). Bone quantitative ultrasound (QUS) has recently emerged as a new modality for bone status assessment. We evaluated bone status in children with CD using dual-energy x-ray absorptiometry and quantitative ultrasound.This cross-sectional study included 41 children (13 girls, 28 boys) aged 11.2 +/- 3.6 years with CD. All children had been diagnosed with CD for at least 1 year (mean, 5.7 +/- 4.3 years). The results of lumbar spine bone mineral density assessed by dual-energy x-ray absorptiometry and the measurements of the velocity of ultrasound wave (at distal radius and midshaft tibia sites), expressed as speed of sound in m/s, were compared between children adherent to gluten-free diet (GFD) and non-compliant children.Speed of sound z-scores at tibia were below -2 SD in 20 of 41 children (49%), whereas lumbar spine bone mineral density z-scores were below -2 SD in 4 of 41 (10%) children with CD (P = 0.0002). Only 19 of 41 children were strictly compliant to GFD. The prevalence of tibia speed of sound z-scores-2 SD was significantly higher in non-compliant children (15 of 22, 68%) compared with children on GFD (5 of 19, 26%), (P = 0.01). Children non-compliant with GFD had significantly worse tibia speed of sound z-scores (-2.3 +/- 1.8, mean +/- SD) compared with children on GFD (-1.2 +/- 1.5, mean +/- SD) (P = 0.04).Children with CD on a gluten-containing diet had higher prevalence of abnormal tibia bone SOS and lower z-scores compared with children on a GFD. These differences were not detected by spinal dual-energy x-ray absorptiometry or radius speed of sound. The value of quantitative ultrasound for screening and follow-up of children with CD should be further evaluated.

Objective To investigate whether uterine contractions at the time of a Cesarean section have an impact on future presence and location of a cervical Cesarean scar. Methods A targeted transvaginal ultrasound examination of the fetus, uterus and cervix was done in 2973 consecutive women at 14–16 weeks' gestation. The sonographer was blinded to the women's previous obstetric histories. The presence and location of a sonographic cervical hypoechogenic line, which probably represented a Cesarean scar, was recorded. Results There were 180 women with a previous Cesarean section performed before the start of uterine contractions and 173 with a Cesarean section performed during contractions in labor. The cervical hypoechogenic line was more common in sections performed during contractions (75.7% vs. 52.7%; P < 0.001) and was more distally located from the internal os (17.9 ± 9.4 vs. 14.6 ± 9.1 mm; P = 0.01). A hypoechogenic line was observed in 21/2620 women without a previous Cesarean section, representing a false-positive rate of 0.8%. Conclusion Cesarean sections, especially those done during uterine contractions, are actually performed through cervical tissue. This finding is in agreement with the physiological process of cervical effacement during contractions. Copyright © 2004 ISUOG. Published by John Wiley & Sons, Ltd.

Background: Due to the lack of a reliable way of clinically measuring dehydration, laboratory tests are usually used to improve the accuracy of clinical assessment of dehydration in children. The purpose of this study was to compare the relationship between clinical and laboratory parameters in the assessment of dehydration and to evaluate the improvement of those parameters over time. Methods: We conducted a retrospective study to assess the relationship between clinical assessment of dehydration and laboratory findings. Results: Three hundred children were eligible for the study. Twenty-six per cent of those with mild dehydration had serum urea concentrations greater than 14.3 mmol/L, compared with 38% and 5% of those with moderate or no dehydration, respectively. Urea concentration showed a good specificity, 95%. Creatinine concentrations and mean pH were similar whether or not dehydration was present. Bicarbonate and base excess concentrations decreased with the increasing severity of dehydration and were significantly greater in subjects with moderate dehydration than in those without. The sensitivity (71%) and specificity (74%) of both tests were rather poor. All groups had an abnormal anion gap, which was significantly greater in those with mild or moderate dehydration. Conclusion: This study confirms that there is a discrepancy between clinical assessment and laboratory parameters of dehydration. Urea showed good specificity, and anion gap was the most sensitive laboratory parameter for assessment of dehydration. These findings need further validation.

To examine the reliability of assessment with the Catz-Itzkovich Spinal Cord Independence Measure II (SCIM II) by interview and compare the findings with assessment by observation.In a cohort, comparative study, 28 inpatients with spinal cord lesions were assessed by two nurses using the Catz-Itzkovich SCIM II (interview) and by a multidisciplinary team (observation).Total agreement between interviewers ranged from 50% to 80% (Kappa coefficients 0.40-0.60). Pearson's coefficients of the correlation between scores obtained for the various SCIM subscales by interview or observation were 0.765-0.940 (P0.0001). The differences in mean scores obtained between the interview and observation methods were small and not statistically significant for most of the subscales.The results support the reliability of the Catz-Itzkovich SCIM assessment by interview and show it to be comparable with assessment by observation. The SCIM II interview may serve as an accurate measure of daily function in patients with spinal cord injury. However, with the sample of the study being relatively small, a larger scale examination is needed to generalize the results.

In this study, in vivo dosimetic data of 67 total skin electron irradiation (TSEI) treatments were analyzed. Thermoluminescent dosimetry (TLD) measurements were made at 10 different body points for every patient. The results demonstrated that the dose inhomogeneity throughout the skin surface is around 15%. The homogeneity was better at the trunk than at the extratrunk points, and was worse when a degrader was used. There was minimal improvement of homogeneity in subsequent days of treatment.

Introduction: Osteoporosis is a major cause of morbidity in liver transplant recipients and is associated with multiple factors. Objectives: To evaluate bone mineral density (BMD), bone turnover and calcium-regulating hormones in 29 patients (17 men, 12 women) 2–12 yrs following liver transplantation for non-alcoholic liver diseases. Results: Fifteen patients (52%) were on immunosuppressive treatment with tacrolimus and 14 (48%) with cyclosporine. Eleven patients (38%) were currently on prednisone, 18 patients (62%) had stopped glucocorticoid treatment 6 months to 11 yrs prior to the study. Nineteen patients (65.5%) had decreased BMD according to WHO criteria, 17 (58.2%) at the femoral neck, 13 (44.8%) at the lumbar spine. Nineteen patients (65.5%) had a subnormal (

Polymorphonuclear leukocytes (PMN) from healthy donors were tested for stimulated release of superoxide anions after being incubated with serum of welders and of a group of unexposed individuals. These two groups were further subdivided either according to age or to smoking habits. The experiments showed that stimulated superoxide production from PMN was inhibited (P0.05) by serum from young smokers as compared to that of young nonsmokers, both from the unexposed group. Incubation of PMN with serum from elderly nonsmoking individuals decreased superoxide production as compared to incubation with serum from young nonsmoking individuals, both from the unexposed group. A decrease in superoxide production by incubation with serum of welders as compared to that of unexposed individuals was significant only when the comparison was carried out between the young, non-smoking subgroups. These findings suggest that age, smoking, and exposure to oxidants induce appearance in serum of factors that affect the PMN function

OBJECTIVE To examine the correlation between a clinical measure of function in patients undergoing rehabilitation who had recently had an ischemic stroke and to examine cardiophysiologic measures registered during effort. DESIGN A cohort study comprising a sample of consecutive patients, without a history of cardiac disease or rhythm disturbances, admitted for rehabilitation after an ischemic supratentorial stroke. All patients were examined for the FIM trade mark score and dynamic cardiophysiologic variables. Results were analyzed in relation to stroke location. Thirty-eight patients participated in the study. Ten patients had a superficial lesion, 20 had a deep brain lesion, and eight had no noticeable lesion by computed tomographic imaging. Function was measured with the FIM instrument 48-72 hr after admission and repeated at 1 wk before discharge. Electrocardiographic activity was recorded during physiotherapy treatment. The relationship between the RR and QT intervals in the electrocardiographic waveforms was found to estimate two cardiophysiologic variables, the constant (a) and the slope (b) values, reflecting the dynamic change of QT during physiotherapy effort. RESULTS Only for the subgroup of patients who sustained a deep brain lesion did the motor items in the FIM instrument on admission and discharge scores have a statistically significant relationship with the slope variable (b) and an inverse statistically significant relationship with the constant variable (a). CONCLUSIONS Deep brain infarction seems to result in a significant dysfunction of the autonomic nervous system, manifesting itself as distorted dynamic behavior of the QT interval and with impaired functional performance.

PURPOSE. To assess whether early hyperbaric oxygenation (HBO) treatment has a beneficial effect on visual results after retinal artery occlusion (RAO). METHODS. A comparative retrospective study in which medical records of all HBO-treated RAO patients in our department were reviewed and compared with matched RAO patients not treated by HBO (from a different medical center). Mean visual acuity (VA) at completion of treatment, the presence or absence of improvement in VA between admission and discharge, and the mean change in VA between admission and discharge were noted. All patients treated by HBO had treatment no later than 8 hours after the beginning of visual symptoms. RESULTS. Mean VA at discharge was 0.2981 (6/20) in the treated group and 0.1308 (6/46) in the control group (p < 0.03). In the treated group, 82.9% had an improvement in VA between admission and discharge, compared with 29.7% of the control group (p < 0.00001). Mean improvement in VA was 0.1957 in the treated group and 0.0457 in the control group (p < 0.01). Differences in outcome measures between treatment and control groups were found to reflect the difference between treated and untreated hypertensive patients. No difference was found between treated and untreated non-hypertensive patients. CONCLUSIONS. Early HBO therapy appears to have a beneficial effect on visual outcome in patients with RAO. Further large-scale prospective controlled studies are needed to confirm this. (Eur J Ophthalmol 2001; 11: 345-50)

Objectives: To investigate peripheral blood neutrophil [polymorphonuclear leukocyte (PMN)] function in a group of 23 welders compared with that in an age- and smoking habit-matched non-exposed control group. Methods: Stimulated release of superoxide anions from PMN isolated from peripheral blood of welders and of a matched group was carried out. Results: The stimulated release of superoxide anions in PMNs from welders was significantly lower (P = 0.021) than that of a control group. Smokers and older workers had a lower function of PMNs than non-smokers and younger workers. Conclusions: PMN function of welders is lower than that of controls. This effect might indicate reduced immunological defences in oxidant-exposed individuals. It is possible that PMN function might serve as a biological marker of exposure in the periodic health surveillance of welders.

OBJECTIVE:To assess whether a high intake of oral iron would increase the effect of recombinant human erythropoietin (rHuEPO) on hemoglobin synthesis. METHODS:We studied 30 preterm infants (gestational age 29±1.8 weeks, birth weight 1161±200 g, at age of 28±10 days) who were randomly assigned to receive either 8 mg/kg per day ( n=15) or 16 mg/kg per day of oral iron during a course of rHuEPO therapy (900 μg/kg per week) for a duration of 4 weeks. Both groups were comparable in regard to clinical and laboratory data at the time of enrollment. RESULTS:rHuEPO caused a significant increase in reticulocyte count in the low- and high-dose iron groups, 17.1±5.3 to 34.7±9.2 and 16.3±3.3 to 42.5±5.6 (10 9/l), respectively ( p

Gastrointestinal symptoms such as nausea, abdominal pain, and bloating are frequent complaints of patients with Parkinson's disease (PD). It has been postulated that impaired gastrointestinal function may contribute to the development of motor fluctuations such as delay on and no on in patients with PD. Gastrointestinal impaired function and symptoms may be associated with the disease itself or secondary to levodopa treatment. Thus, we assessed gastric emptying (GE) and gastric motility in PD patients to examine the association between clinical status and gastric function. GE and antral contraction (frequency and amplitude) were evaluated by scintigraphy in 29 patients with mild PD (Hoehn and Yahr [HY] stage 1.0-2.0); 22 patients with moderate PD (HY stage 2.5-3.0); and 22 healthy volunteers, following the ingestion of a labeled standard meal. Gastric emptying (mean +/- SD of T(1/2)) and antral contraction were not significantly different between patients with mild PD (63.4 +/- 28.8 minutes) and moderate PD (54.7 +/- 25.5 minutes). In the control group, GE was 43.4 +/- 10.8 minutes (range 29.0 - 61.0 minutes). The prevalence of delayed emptying (61 minutes) was not significantly different in patients with mild disease (48.3%) as compared with patients with moderate disease (36.4%). Antral contraction, both frequency and amplitude, were not significantly different between patients with mild and moderate PD throughout the entire 100 minutes of the study. Untreated patients (n = 28) had mean GE T(1/2) of 59 +/- 30.6 minutes. Patients with smooth response to levodopa showed slower GE (n = 10; 73.6 +/- 25.3 minutes), while treated patients with motor response fluctuations when tested at the on state (n = 13), had much faster GE (49.3 +/- 16.2 minutes). This shortened GE in the on state was similar to the GE of normal volunteers. We conclude that gastric emptying time in patients with PD was delayed compared with control volunteers. It was even slower in patients treated with levodopa. This effect of levodopa treatment was reversed to pseudonormalization (normal GE) at the advanced stages of the disease, when patients developed motor response fluctuation. Other clinical features of PD were not associated with delayed gastric emptying.

Despite widespread use of the automatic blood pressure (BP) measuring device OMRON M4, there is little formal validation on its accuracy. A study was conducted to assess the accuracy of the OMRON M4 compared with the true indirect BP measured by mercury sphygmomanometer (MS). A rapid method for the evaluation of automatic blood pressure measurement devices (READ) was applied for this study. The READ is based on numerous BP measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Blood pressure measurements were done in supine position for 10 min followed by head-up tilt for 30 min and again supine for 10 min. The automatic device (AU) and the MS were connected to one arm-cuff by means of a T connector. A stethoscope with dual sets of ear-pieces was used for duplicate MS measurements (MS1 and MS2). The MS1, MS2 and AU measurements were taken simultaneously in a blinded manner. Three units of the automatic instrument were evaluated. An average of 111 measurements per unit were performed, every BP category being present in >/=15 MS measurements. The differences between MS1 and MS2 measurements (DeltaBP: MS1-MS2) were utilized to assess the consistency of true indirect BP and the differences between AU and MS measurements (DeltaBP:AU-MS2) were utilized to assess the accuracy of the AU. The following characteristics of the OMRON M4 were assessed: (1) grade of accuracy, (2) aberration pattern, (3) consistency of the aberration-pattern, and (4) correlation between levels of BP and DeltaBP: AU-MS. For MS paired readings, 92-100% of systolic and 99-100% of diastolic readings fell within 5 mm Hg difference range, that is consistent with a British Hypertension Society grade A of both. For AU compared to MS2, 29-64% of systolic and 73-94% of diastolic readings fell within 5 mm Hg and 49-86% of systolic and 86-99% of diastolic readings fell within 10 mm Hg and the devices qualified C, D and C, respectively. All devices exhibited irregular and inconsistent aberration patterns, making the design of correction formulas impractical. In conclusion, the OMRON M4 device did not meet the requirements of the British Hypertension Society and, therefore, cannot be recommended for clinical use.

To assess the transverse cerebellar diameter (TCD) in preterm and term neonates with normal growth or growth restriction.TCD was sonographically measured after birth in 404 neonates born between 23 and 42 weeks of gestation. The study included two groups: Group 1: 334 appropriately grown for gestational age (AGA) neonates (both birthweight (BW) and head circumference (HC) were between the 3rd and 97th centiles), which were subdivided into two subgroups according to the HC measurements. Group 2: 70 small for gestational age (SGA) neonates (BW3rd centile), were further divided into three subgroups according to HC measurements.In Group 1 of AGA neonates, a linear growth function was observed between the TCD and GA (R = 0.914, P0.00001, TCD = 0.279 + 0.142 X GA), and between TCD and HC (R = 0.886, P0.00001, TCD = -0.333 + 1.777 X HC). The percentage of neonates with normal TCD (or =10th centile) was more than 85% of the AGA and asymmetric SGA subgroups, and 60.7% of the microcephalic SGA subgroup (P0.02).This study provides normative data of neonatal TCD across gestational age. TCD measurement via sonography is a new adjunctive criterion for objectively assessing gestational age in infants when a precise determination of gestational age is necessary. This is very important since utility of the TCD is effective for both AGA and asymmetric SGA infants.

The method for rapid evaluation of automatic blood pressure (BP) measurement devices (READ) is based on numerous BP measurements at rest and during a standardised postural challenge in a small number of subjects with a wide range of BPs. The present study proposes additional parameters of the READ for in-field validation of automatic BP measurement devices. BP measurements were done in supine position for 10 min followed by head-up tilt for 30 min and again supine for 10 min. BPs were determined simultaneously by automatic (AU) and mercury sphygmomanometric (MS) measurements on the same arm. The BP differences DeltaBP:AU-MS were calculated. Three units of the Colin BP-8800 and the Datex-Engstrom Cardiocaptrade mark II were evaluated. Based on DeltaBP(AU-MS), the grade of accuracy, aberration patterns and correlates of accuracy were assessed for each unit. Per unit, an average of 121 measurements were done, every BP category being met in >/=20 MS measurements. In general, the AU systolic BP values were higher than MS systolic BP values (mean systolic DeltaBP = 1.26 +/- 17.1 mm Hg) and AU diastolic BP values were lower than MS diastolic BP values (mean diastolic DeltaBP = -12.31 +/- 7.8 mm Hg). All units classified into category D of the British Hypertension Society grading system and exhibited inconsistent aberration patterns, making design of correction formulas impractical. Inaccuracy of the instruments was independent on mode of measurement, posture, magnitude of the BP and heart rate, early or late measurements from beginning of the head-up tilt test, and prolonged use of the unit. The READ permitted to identify rapidly the degree of accuracy of automatic BP measuring devices. Identification of the aberration pattern of an instrument could be the basis for calculating equations for correction of the measured BP. Further studies will show which parameters of the READ may expose specific defects of the instruments. Journal of Human Hypertension (2000) 14, 37-42.

Introduction The Short Anxiety Screening Test (SAST), an easily administered rating scale, was developed to standardize the detection of anxiety disorder in the elderly, even, and especially, in the presence of depression. The instrument also included somatic complaints, often the manifestation of anxiety in the elderly. Failure to relate to the anxiety component in depression may result in the initial failure of antidepressant therapy. Objective To validate the SAST in the elderly, especially in the presence of depression. Design The SAST was validated against a psychiatric evaluation in consecutive patients attending a geriatric service, both inpatient and outpatient. The initial validity of the SAST was tested in all the sample and subsequently in the subgroups of depressed and non-depressed. Setting An urban geriatric service in Israel. Patients One hundred and fifty medical inpatients and outpatients, 95 females, aged 70 years and older. Measures Psychiatric evaluation of modified Anxiety Disorders Interview Schedule for DSM-IV as criterion standard for anxiety and depression, SAST for anxiety and short Zung Interview-Assisted Depression Rating Scale for depression. Results By the psychiatrist's evaluation, 40.7% suffered from anxiety. Mean SAST scores in the presence and absence of anxiety were significantly different (25.3 and 20.1; p

We propose a rapid method for the evaluation of automatic blood pressure measurement devices (READ) in response to the claim to simplify the validation of those devices. The READ is based on numerous blood pressure (BP) measurements at rest and during a standardised postural challenge in a small number of subjects who exhibit a wide range of BPs. Automatic (AU) and mercury sphygmomanometric (MS) brachial BP were measured simultaneously in a blinded manner. An average of 30 measurements per patient were done in 10-min while in a supine position, followed by 30 min in head-up tilt and again supine for 10 min. Two Collin-8800 automated oscillometric devices were tested with the aid of the READ in 15 adults. The consistency of the MS standard was demonstrated by duplicate MS measurements showing minimal inter-observer differences consistent with class A of the British Hypertension Society (BHS) grading system. AU-to-MS differences of 447 measurements were mean systolic deltaBP = 1.1 +/- 11.4 mm Hg and mean diastolic deltaBP = -13.36 +/- 8.9 mm Hg, classifying into category D of the BHS. Both tested instruments, each subject, each phase of the tilt test (supine I, tilt, supine II) and each mode of measurement (at 5-min intervals or continuously) equally qualified as 'D'. We conclude that the READ permitted us to identify quickly and at low expense a grossly inaccurate automatic BP measuring device. Further studies will show whether the READ can be efficient as a pre-validation test, post-validation test, and for assessment of ambulatory BP measuring devices.

Purpose: To assess practices and attitudes of Israeli physicians with regard to adolescent health. Methods: Questionnaires were sent to a sample of 1050 Israeli physicians specializing in pediatrics (P) family practice (FP), and internal medicine (IM). They were requested to report their experience, perceived skills, and desire for further training regarding 16 adolescent health items grouped under four topics: medical, sexuality, risk behavior, and psychosocial problems. A scoring system was applied to assess their report. Attitudes toward confidentiality in the same topics were also surveyed. Results: Questionnaires were received from 306 (29%) physicians, of whom 42% were P, 35% were FP, and 29% were IM. The majority (96%) of respondents included adolescents in their practice, and adolescents comprised 33%, 17%, and 11% of the registered patient population of the P, FP, and IM, respectively. The mean scores for practice, perceived skills, and desire for further training were generally low. Analysis of variance revealed significant differences among the three physicians groups in all surveyed topics, resulting from the low scores of the IM group. A diversity regarding confidentiality was noted, in that younger FP were most willing to keep health issues confidential. Conclusions: Physicians in Israel have limited experience and perceive themselves to be underskilled in dealing with adolescent health issues. Training programs in adolescent health need to be developed to meet the needs of physicians in Israel.

Thirty-six term neonates born after maternal intrapartum fever, with premature rupture of membranes18 hours and unknown maternal group B Streptococcus status had blood samples for complete blood count, C-reactive protein, culture, and 16S rRNA gene polymerase chain reaction amplification. Only 2 neonates were symptomatic and none had leukopenia, C-reactive protein1.0 mg/dL, bacteremia, or positive polymerase chain reaction.

Objective To construct nomograms of the size of the fetal orbit and lens during gestation. Subjects The study group included 349 normal pregnant women at 14–36 weeks' gestation. Methods Routine biometric measurements were obtained in all the participants; these included biparietal diameter, head and abdominal circumferences, measurements of the long bones and the diameters of the fetal orbit and lens. The orbital and lens circumference measurements were also related to gestational ages. Results A linear growth function was observed between gestational age (GA) and orbital diameter (r = 0.94; p < 0.00001; y = −0.66 + 0.5 × GA), orbital circumference (r = 0.94; p < 0.00001; y = −2.1 + 1.5 × GA) and orbital area (r = 0.94; p < 0.00001; y = −98.1 + 8.3 × GA). Significant correlation was also found between femoral length (FL) and orbital diameter (r = 0.95; p < 0.00001; y = 3.3 + 1.9 × FL), orbital circumference (r = 0.95; p < 0.00001; y = 10.3 + 5.9 × FL) and orbital area (r = 0.93; p < 0.00001; y = −28.2 + 32.2 × FL). A linear growth function was observed between orbital circumference and biparietal diameter (r = 0.94; p < 0.00001) and head circumference (r = 0.95; p < 0.00001). A linear growth function was also observed between gestational age and the diameter of the lens (r = 0.89; p < 0.00001; y = 0.88 + 1.4 × GA) the circumference of the lens (r = 0.89; p < 0.00001; y = 2.78 + 0.4 × GA) and the area of the lens (r = 0.89; p < 0.00001; y = −7.95 + 1.0 × GA). The correlation was found between the ratios of the diameters, circumferences and areas of the lens and the orbit. Conclusions These results provide normative data of the growth of the fetal orbit and lens and may aid future studies relating to fetal eye anomalies. Copyright © 1998 International Society of Ultrasound in Obstetrics and Gynecology

This pilot study surveyed Israeli adolescents' preferences regarding health services as a preliminary step for a national survey. A total of 444 students filled a questionnaire including demographics, personal health data, and preferences regarding 31 statements on health care, based on a Philadelphia questionnaire. Factors of most significant impact in seeking health care were cleanliness, integrity, respectfulness, knowledge, and competence. The 10 top statements important to Israeli teens included 9 of the 11 top statements of the Philadelphia teens. Future research may demonstrate change in outcome if adolescents' desires were attended based on a cultural adapted questionnaire.

Immediate breast reconstruction with the tissue expander is now established as an accepted procedure after mastectomy, and large series have been published concerning the technique and its complications. Unfortunately, only scarce information is available regarding the long-term aesthetic results and patient satisfaction achieved by immediate reconstruction using tissue expansion. In this study, we reviewed 52 patients who had undergone immediate breast reconstruction using the tissue expander with a follow-up of at least 1 year after completion of the reconstruction. We developed an objective assessment of patient satisfaction, aesthetic results, and the factors affecting them. The results show remarkable concordance of assessment by patient, surgeon, and independent observer: All gave good scores for aesthetic appearance (6.4 to 7.4 on a scale of 1 to 10). A total of 92.3 percent of patients rated their satisfaction as good to excellent. Symmetry was the main parameter influencing the patients' score, while the surgeon's score also was affected by the quality of the inframammary fold and capsular contracture. Breast size, chemotherapy, complications, time interval, and additional procedures had no relation to either scoring or patient satisfaction.

The study was planned to obtain the dimensions of the fetal nose width and nostril distance during normal pregnancy as a basis for further studies and for identification of deviations in growth. The study group included 302 healthy pregnant women at 14-40 weeks' gestation. Routine biometric measurements were obtained from all the participants, including biparietal diameter, head and abdominal circumferences, measurements of the long bones and dimensions of the fetal nose width and nostril distance. The nose width and nostril distance were also calculated for each gestational age. A linear growth relationship was observed between nose width and gestational age (r = 0.88; p < 0.0001; y = 0.27 + 0.57 x gestational age), biparietal diameter (r = 0.92; p < 0.0001; y = 0.41 + 0.23 x biparietal diameter), head circumference (r = 0.91; p < 0.00001; y = 0.85 + 0.63 x head circumference), femoral length (r = 0.91; p < 0.0001; y = 3.18 + 0.26 x femoral length) and humeral length (r = 0.73; p < 0.0001; y = 1.94 + 0.11 humeral length). A linear growth function was also observed between nostril distance and gestational age (r = 0.54; p < 0.00001; y = 2.77 + 0.15 x gestational age), biparietal diameter (r = 0.71; p < 0.00001; y = 1.83 + 0.08 x biparietal diameter), head circumference (r = 0.70; p < 0.00001; y = 1.99 + 0.2 x head circumference), femoral length (r = 0.75; p < 0.00001; y = 2.49 + 0.09 x femoral length) and humeral length (r = 0.91; p < 0.00001; y = 1.89 + 0.32 x humeral length). A linear growth relationship was found between nose width and nostril distance (r = 0.71; p < 0.00001; y = 1.81 + 0.31 x nose width). These results provide normative data of the fetal nose width and nostril distance in various dimensions and across gestational age. In addition, the data offer the potential for prenatal diagnosis of nose and nostril abnormalities.

OBJECTIVE: To improve the accuracy of cytologic diagnosis in breast lesion aspirates that are cytologically suggestive of fibroadenoma (FA), exhibiting proliferating epithelial elements and bare nuclei but devoid of the typical stroma. STUDY DESIGN: A retrospective study was conducted. All available cases (89) that were aspirated and reported as suggestive of FA between 1981 and 1991 and were later biopsied were studied, and various morphologic criteria were analyzed in each smear. A control group consisted of 43 cases that were cytologically diagnosed as FA and confirmed histologically. RESULTS: Two criteria contributed to the cytologically suggestive diagnosis of FA. The presence of numerous multilayered fragments of proliferating glandular epithelium improved the positive predictive value (PPV) for FA on the suggestive smear from 67.4% to 88.3%, and the presence of numerous bare nuclei in the background improved it to 88.9%. The combined presence of both criteria improved the PPV even further, to 91.7%. CONCLUSION: When an aspirate from a breast lesion is cytologically suggestive of FA despite the absence of the typical stroma, a PPV of 91.7% can be achieved, provided that the epithelial elements include many multilayered fragments and that the background consists of numerous bare nuclei.

Erythropoietin (rHuEPO) therapy has been shown to be beneficial in preventing and treating anaemia of prematurity and to decrease the need for blood transfusions. There is, however, only scanty data on the effect of rHuEPO therapy on iron metabolism. We studied 29 preterm infants (age 34 +/- 14 days) who were randomly assigned to receive either rHuEPO 900 U kg-1 week-1 with 6 mg kg-1 day-1 of iron for 4 weeks (n = 15) or no therapy. The following parameters were evaluated and compared between and within groups at the beginning, during and at the end of the study: Haematocrit (SI), reticulocytes (10(9) micrograms l-1), serum ferritin (microgram 1-1) and iron (mumol l-1). The results were as follows. At the baseline, erythropoietin levels were similar in both groups: 7.2 +/- 5.6 versus 6.2 +/- 3.2 mU ml-1 (NS). In the treated infants the haematocrit remained stable during the study and was significantly higher than in the control group by the end of the study: 0.34 +/- 0.03 versus 0.28 +/- 0.05 (p = 0.001). rHuEPO therapy increased the reticulocyte count from 130 +/- 70 to 430 +/- 200 (p = 0.0002). However, rHuEPO therapy depleted both serum ferritin and iron levels from 321 +/- 191 to 76 +/- 58 micrograms l-1 (p = 0.04) and from 18 +/- 5 to 13 +/- 4 mumol l-1 (p = 0.03), respectively. We conclude that rHuEPO therapy prevented anaemia and its sequelae; however, serum ferritin and iron levels were depleted. We suggest that the effect of rHuEPO may be further increased by higher iron supplementation.

To assess the reliability of bone scintigraphy, a random sample of 100 bone scans was reviewed twice by each of two physicians. Observer variation in the description and interpretation of bone scintigrams varied by diagnosis. Good to excellent κ values were obtained for inter- and intraobserver variation in relation to metastasis or normal scans. For degenerative bone disease, as well as the specific agreement on major pathologies other than metastases, κ values were found to be moderate. The agreement on the need for further radiographic studies was poor to moderate. The interpretation of bone metastases or normal scintigrams was found to be more reliable in a research setting than in the usual clinical framework, and the latter requires improvement. The interpretation of bone scintigraphy as consistent with degenerative changes is not reliable. The diagnosis should be evaluated by radiography.

The objective of the study was to explore the relationships between rehabilitation outcomes in elderly patients admitted to a rehabilitation hospital following a surgically treated hip fracture and independent variables. Prefracture function, and independent patients' variables and particulars regarding the fracture were recorded. Functional and mental status as well as motivation and co-operativeness were assessed on admission to rehabilitation, during rehabilitation and six months after discharge. Data were transferred to structured questionnaires for analysis. A total of 112 patients with a mean age of 74.8 years, made up of 75% females and 25% males, were admitted consecutively for rehabilitation after a surgically treated hip fracture sustained in a fall, during a two-year period (1989-91). Of these, 11 patients (9.8 per cent) died during rehabilitation; 86% of the 101 survivors returned to their prefracture residence, but 25% of survivors had not attained their prefracture functional status by discharge. Motivation, co-operativeness and unimpaired mental function on admission to rehabilitation were found to be the most important determinants of satisfactory outcomes. It was concluded that attention should be paid to the elderly person who has sustained the fracture and not only to the fracture itself. Motivation and co- operativeness should be constantly monitored during the rehabilitation process.

Variation in arterial pressure and plethysmographic waveforms has been shown to be predictors of cardiac output response to fluid challenge. The objective of this study was to evaluate the ability of arterial and plethysmographic waveform variables to predict hypotension during blood loss.Patients undergoing autologous haemodilution were studied. After anaesthesia induction, blood was withdrawn in steps of 2% of estimated circulating blood volume (ECBV). Arterial and plethysmographic waveforms were recorded and analysed offline at each step of blood withdrawal.Thirty-four (29%) out of 118 studied patients tolerated 20% ECBV withdrawal without hypotension. Patients who tolerated 20% ECBV withdrawal were younger than those who did not [mean (sd): 53.8 (11.1) vs 62.7 (10.7); P0.0001]. Patients with hypertension developed hypotension earlier than healthier patients did. There were no differences at the baseline in arterial and plethysmographic waveform variables between those who did and those who did not tolerate 20% of ECBV withdrawal. All values of variables increased significantly from the baseline after the withdrawal of 4% of ECBV (P0.005). There were no changes in heart rate (HR), 73 (12) at the baseline and 76 (13) after 20% of ECBV withdrawal (P=0.4).Arterial and plethysmographic waveform variables were augmented with increasing blood loss in all patients. Older patients, patients who received anti-hypertensive drugs, or both developed hypotension earlier than others. Baseline values were weak predictors of hypotension during stepwise blood withdrawal. No clinically significant increase in HR was observed, regardless of tolerance of arterial pressure to blood withdrawal.