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BACKGROUND: The objective was to determine the contribution of transfusion in the past to the risk of current infection with hepatitis B or C among patients attending a large hospital for endoscopic procedures. STUDY DESIGN AND METHODS : Blood samples had been tested for hepatitis markers by routine methods. Patients completed a comprehensive risk factor questionnaire and results were analyzed using computer software. RESULTS : Twenty-seven percent of the 2120 participants in the study received transfusions in the past. There was no increase in prevalence of hepatitis B among those transfused. Compared with nontransfused participants, recipients of blood before the implementation of hepatitis C virus (HCV) screening in 1990 had a 4.6-fold increased risk of HCV infection, whereas those transfused with screened blood had a 3-fold increased risk. The difference between the odds ratios for patients before and after screening was not significant. CONCLUSIONS: Because screening has almost completely eliminated HCV from the blood supply, our finding of a continuing association of HCV infection with transfusion was unexpected. It implies that there are significant other nosocomial risks for hepatitis C transmission associated with the clinical situations where patients received blood. These should be actively investigated.

China has made tremendous progress in its economic development in the past two decades. Accompanying this economic development has been an evident shift in the modes of transport, from walking and cycling to the use of motorcycles and, increasingly, four-wheel vehicles. Such changes are likely to have also produced changes in the patterns and numbers of road traffic injuries, including increases in motorcycle injuries. However, such changes have not been well documented. The work described in this paper sought, therefore, to document the changes in motorcycle ownership, motorcyclist mortality and injury rates in China since 1987.National traffic ownership and injury data from 1987 to 2001 were obtained from the National Bureau for Traffic Administration. Additionally, traffic ownership and injury records from 1997 to 2001 were collected from local police offices from 20 counties in Guangxi Region. Population data were obtained from the national and county statistics bureaus. Motorcycle ownership, fatality and injury trends over time were calculated.Nationally, motorcycles accounted for 23.4% of all registered motor vehicles in 1987, increasing to 63.2% in 2001. Motorcyclist fatalities and injuries increased 5.5-fold and 9.3-fold, respectively, between 1987 and 2001. In 1987, 7.5% of all traffic fatalities and 8.8% of all traffic injuries were sustained by motorcyclists, with the corresponding proportions increasing to 18.9% and 22.8%, respectively, in 2001. The changing proportions of both traffic fatalities and injuries sustained by motorcyclists were positively correlated with the change in the proportion of motorcycles among all motor vehicles. In the 20 counties in Guangxi, motorcyclist fatality and injury rates also increased between 1997 and 2001. Moreover, these rates were considerably higher than the national rates.Motorcyclist injury in China is a serious public health problem. Motorcyclist fatalities and injuries are likely to continue to increase unless appropriate intervention programmes are implemented.

The aims of this study are (1) to establish a reliable and valid quality-of-life (QOL) questionnaire for Chinese patients with head and neck (HN) cancer who are treated with radiation therapy and (2) to evaluate the impact of the immediate side effects of treatment on the QOL of these patients. The 39-item "Quality of Life Radiation Therapy Instrument with Head and Neck Companion Module" (QOL-RTI/HN) was translated into Chinese. In the reliability evaluation phase (study module 1), the questionnaire was administered twice to 56 HN cancer patients, 7 days apart, during the second and third week of radiation therapy. In the validity evaluation phase (study module 2), 138 patients completed the QOL-RTI/HN before starting and at the end of radiation therapy. Sixty-nine of these 138 patients also completed the QOL-RTI/HN during the second week of their radiation therapy, at the same time as completing the Functional Assessment of Cancer Therapy-Head and Neck (FACT-HN) questionnaire. Cronbach alpha coefficients were 0.88 for the general-tool QOL-RTI and 0.90 for the HN subscale. Test-retest reliability was satisfactory with intraclass correlation coefficients of 0.89 for the general-tool QOL-RTI and 0.75 for the HN subscale. The instrument can discriminate between patients with stage I or II disease and those with stage III or IV disease (P.05). Concurrent validity was established by the good agreement with the FACT-HN (r = 0.86, P.001). A highly significant deterioration was in the QOL from the baseline to the end of treatment (mean difference for general tool = 1.95, P.001; mean difference for HN subscale = 4.85, P.001). The Chinese QOL-RTI/HN is a reliable and valid tool for determining the QOL in HN cancer patients receiving radiation therapy. The immediate side effects of treatment had a significantly negative impact on the patients' QOL. The impact was relatively large for the functional and treatment-site aspects.

Endurance exercise improves insulin sensitivity and increases fat oxidation, which are partly facilitated by the induction of metabolic transcription factors. Next to exercise, increased levels of FFA's also increase the gene expression of transcription factors, hence making it difficult to discern the effects from contractile signals produced during exercise, from those produced by increased circulatory FFA's. We aimed to investigate, in human skeletal muscle, whether acute exercise affects gene expression of metabolic transcriptional co-activators and transcription factors, including PGC-1alpha, PRC, PPARalpha, beta/delta, and gamma and RXR, SREBP-1c and FKHR, and to discern the effect of exercise per se from those of elevated levels of FFA. Two hours of endurance exercise was performed either in the fasted state, or following carbohydrate ingestion prior to and during exercise, thereby blunting the fasting-induced increase in FA availability and oxidation. Of the genes measured, PGC-1alpha and PRC mRNA increased immediately after, while PPARbeta/delta and FKHR mRNA increased 1-4 h after exercise, irrespective of the increases in FFA's. Our results suggest that the induction in vivo of metabolic transcription factors implicated in mitochondrial biogenesis are under the control of inherent signals, (PGC-1alpha, PRC), while those implicated in substrate selection are under the control of associated signals (PPARbeta/delta, FKHR) stimulated from the contracting skeletal muscle that are independent of circulating FFA levels.

The current study demonstrates that the large increase in normal tissue penalty often degrades target dose uniformity without a concomitant large improvement in normal tissue dose, especially in anatomically unfavorable patients. The excessively large normal tissue penalties do not improve treatment plans for patients having unfavorable geometry.

Purpose To identify preferences for and predictors of prognostic information among patients with incurable metastatic cancer. Patients and Methods One hundred twenty-six metastatic cancer patients seeing 30 oncologists at 12 outpatient clinics in New South Wales, Australia, participated in the study. Patients were diagnosed with incurable metastatic disease within 6 weeks to 6 months of recruitment. Patients completed a survey eliciting their preferences for prognostic information, including type, quantity, mode, and timing of presentation; anxiety and depression levels; and information and involvement preferences. Results More than 95% of patients wanted information about side effects, symptoms, and treatment options. The majority wanted to know longest survival time with treatment (85%), 5-year survival rates (80%), and average survival (81%). Words and numbers were preferred over pie charts or graphs. Fifty-nine percent (59%) wanted to discuss expected survival when first diagnosed with metastatic disease. Thirty-eight percent and 44% wanted to negotiate when expected survival and dying, respectively, were discussed. Patients with higher depression scores were more likely to want to know shortest time to live without treatment (P = .047) and average survival (P = .049). Lower depression levels were significantly associated with never wanting to discuss expected survival (P = .03). Patients with an expected survival of years were more likely to want to discuss life expectancy when first diagnosed with metastases (P = .02). Conclusion Most metastatic cancer patients want detailed prognostic information but prefer to negotiate the extent, format, and timing of the information they receive from their oncologists.

Kikuchi's disease (KD) is a self-limiting lymphadenitis mostly affecting the cervical lymph nodes of young individuals. It has been classified into three histological subtypes and postulated to progress from the proliferative type (PT) to the necrotizing type (NT) and finally resolve into the xanthomatous type (XT). Since KD has been shown to be an apoptotic disease, the apoptotic activity was studied by the TUNEL method on 6, 12, and 6 cases of PT, NT, and XT, respectively, to see if the apoptotic activity could be shown to decrease in the order of the postulated sequence of evolution. Significant statistical difference among the three subtypes was found (P = 0.050). Further analysis revealed that PT versus NT was significant (P = 0.010), but NT versus XT (P = 0.385) or PT versus XT (P = 0.310) was not. Analysis of three stages of NT was also significant (P = 0.019). Immunohistochemical study showed that abundant CD8+ T cells and cytotoxic protein positive cells were present in PT and NT, but were relatively low in XT. Our results showed progression of PT to NT, but not from NT to XT. Xanthomatous type was not the resolving stage of KD, but seemed to be a distinctive histological variant of KD caused by either different etiology or an unusual host reaction.

The study evaluated the construct validity of the Chinese Hong Kong version of the disabilities of the arm, shoulder and hand questionnaire (DASH-HKPWH). Three hundred and thirty four patients with a broad range of upper extremity disorders were recruited into the study. Each completed DASH-HKPWH and SF-36 forms and their pain intensity (numeric pain rating scale) and grip strength were also measured. The mean DASH-HKPWH score was 40 (SD = 20). Principal component factor analysis identified a single factor, which accounted for 47% of the total variance. Pearson correlation was applied to assess convergent and divergent validity of the DASH-HKPWH by comparison with the above-mentioned subjective and objective measurements. Our findings were comparable to the DASH of other languages.

Assessing functional status of residents in nursing homes is one way to evaluate the quality of care provided. The purpose of this study was to investigate whether rehabilitation interventions could lead to improved functional independence. A prospective study was carried out to examine the change in activities of daily living (ADL) of 310 residents aged 65 or above over a period of 6 months. About 41.3% (n = 128) received rehabilitation therapy. Functional improvement was observed in 30.6% of the participants. The corresponding figures for stabilization and functional decline were 45.2% and 24.2%, respectively. Using a multinomial logistic regression, we found that factors significantly associated with change in functional status included baseline ADL score, family visit, number of beds in the institution, and transfer to acute hospitals. After adjusting for these confounding variables, change in functional status of those who received rehabilitation and those who did not was not significantly different.

Early identification of predictive factors relevant to functional outcomes for stroke patients is important to the establishment of an effective continuing care program. The objective of this study was to identify the predictive factors related to functional outcome at discharge after stroke rehabilitation therapy.105 first-time stroke patients admitted to the inpatient rehabilitation department of a university-based medical center were recruited for this prospective study. The functional outcomes of the patients were assessed at admission and at discharge using the Functional Independence Measure (FIM). Severity of stroke was determined using the Canadian Neurological Scale (CNS). Age, gender, side of hemiplegia (SIDE), type of stroke (TYPE), onset to admission interval (OAI), and length of rehabilitation stay (LORS) were also included as predictor variables.The mean (+/- SD) FIM score at discharge (76.6 +/- 26.4) correlated strongly (r = 0.78, p0.001) with the admission FIM score (56.3 +/- 24.1), moderately (r = 0.46, p0.001) with the admission CNS score (6.1 +/- 2.2), negatively (r = -0.38, p0.001) with age (63.2 +/- 12.3 years), negatively (r = -0.26, p = 0.009) with OAI (24.2 +/- 16.0 days), and negatively (r = -0.29, p = 0.002) with LORS (34.7 +/- 16.8 days). Stepwise regression analyses indicated that admission FIM score, age, and admission CNS score were the strongest predictors of functional outcome and accounted for 66% of the total variation in discharge FIM total score. The admission FIM score was the best predictor and accounted for 61% of the variation.The findings of this study imply that the admission FIM scores for inpatients receiving stroke rehabilitation can be used to predict functional outcomes at discharge from hospital.

Background: The prognosis for patients with localized primary cutaneous melanoma is known to depend principally on tumor thickness, and to a lesser extent on ulcerative state and Clark level. We have recently found in an analysis of 3661 patients that tumor mitotic rate (TMR) is also an important prognostic parameter, ranking second only to tumor thickness. However, few studies have assessed the accuracy and reproducibility with which these features of a melanoma are recorded by histopathologists. Aim: To assess interobserver reproducibility of major pathologic prognostic parameters in cutaneous melanoma. Methods: Single hematoxylin and eosin-stained slides of 69 dermally invasive primary cutaneous melanomas were circulated among six pathologists with differing experience in the assessment of melanocytic tumors. The observers independently determined the tumor thickness, Clark level of invasion, ulcerative state, and TMR for each lesion. Intraclass correlation coefficients and kappa scores for multiple ratings per subject were calculated. Results: The intraclass correlation coefficients were 0.96 for tumor thickness and 0.76 for TMR. The kappa scores were 0.83 for ulcerative state and 0.60 for Clark level. These results indicated excellent agreement among the pathologists for measurements of tumor thickness, ulcerative state, and TMR and fair to good agreement for Clark level. Conclusions: Appropriately trained and experienced histopathologists can assess prognostically important features of melanomas accurately and reproducibly. Given our recent finding of the significance of TMR in determining prognosis, it is important that this feature be assessed by a standardized method and documented for all primary cutaneous melanomas.

Background. Opinions on the clinical course and outcome of renal transplantation in patients with primary immunoglobulin A nephropathy (IgAN) have been controversial. Methods. We conducted a retrospective single-centre study on 542 kidney transplant recipients over the period 1984–2001. Long-term outcome and factors affecting recurrence in recipients with primary IgAN were analysed. Results. Seventy-five patients (13.8%) had biopsy-proven IgAN as the cause of renal failure, and their mean duration of follow-up after transplantation was 100 ± 5.8 months. Fourteen (18.7%) of the 75 patients had biopsy-proven recurrent IgAN, diagnosed at 67.7 ± 11 months after transplantation. The risk of recurrence was not associated with HLA DR4 or B35. Graft failure occurred in five (35.7%) of the 14 patients: three due to IgAN and two due to chronic rejection. Three (4.9%) of the 61 patients without recurrent IgAN had graft failure, all due to chronic rejection. Graft survival was similar between living-related and cadaveric/living-unrelated patients (12-year graft survival, 88 and 72%, respectively, P = 0.616). Renal allograft survival within the first 12 years was better in patients with primary IgAN compared with those with other primary diseases (80 vs 51%, P = 0.001). Thereafter, IgAN patients showed an inferior graft survival (74 vs 97% in non-IgAN patients, P = 0.001). Conclusions. Our data suggested that around one-fifth of patients with primary IgAN developed recurrence by 5 years after transplantation. Recurrent IgA nephropathy in allografts runs an indolent course with favourable outcome in the first 12 years. However, the contribution of recurrent disease to graft loss becomes more significant on long-term follow up.

Background Intervention of the biliary system is frequently done in patients with obstructive jaundice and is associated with significant morbidity and mortality. The pathogenesis is unknown. Materials and methods A rat model of bile duct ligation (BDL) for 2 weeks was established in which biliary intervention was feasible by injection of normal saline through an indwelling catheter in the bile ducts. Plasma levels of C-C chemokine MCP-1 and C-X-C chemokine MIP-2 were measured by using ELISA. Blood monocytes, Kupffer cells, and neutrophils in the liver were characterized with antibodies to ED1, ED2, and myeloperoxidase (MPO). Lipid peroxidation was measured by malondialdehyde contents and apoptosis by TUNEL stain of the liver. Results Biliary intervention resulted in an increase of plasma MCP-1 and MIP-2 proteins by 1 h, which declined to normal level by 3 h in both sham and BDL rats. The levels in BDL rats were significantly higher than in sham at most points. There was a transient increase of ED1- and ED2-positive cells and MPO-staining cells in sham rat liver by 1 h after intervention. ED2-positive cells increased significantly by 1 h, while ED1- and MPO-positive cells decreased, yet insignificantly after intervention in BDL rats. The cell counts in BDL were constantly higher than in sham. Malondialdehyde increased precipitously in BDL by 3 h and was significantly higher than in sham throughout the study period. Parenchymal liver injury, manifested by elevated ALT, as well as apoptosis and necrosis of liver cells, was significantly increased in BDL rats, but not in sham rats. Conclusion Biliary intervention augments chemokine expression, precipitates lipid peroxidation, and aggravates liver injury in cholestatic rats.

Objective: This study was performed to determine if ambulatory function is governed by motor impairment of limbs or balance ability in subjects with hemiplegia caused by stroke. Design: Seven patients who walked with physical assistance (FIM(TM) 4) after stroke and 13 who walked independently with assistive devices (FIM 6) were compared with 13 healthy subjects. Motor impairment of limbs was evaluated with the Fugl-Meyer Assessment. The Berg Balance Scale and limit of stability test of the Smart Balance Master were used to evaluate balance ability. Results: The FIM 6 group and the controls were best differentiated by motor impairment of the paretic limbs and limit of stability in the backward direction. Motor impairment of the upper limb and limit of stability in direction toward the paretic side separated the FIM 4 from the FIM 6 group. Upper limb motor impairment and the Berg Balance Scale consistently separated the three subject groups. Conclusions: Motor impairment in the paretic upper limb and balance dysfunction should be addressed in treatments working toward independent ambulation.

Department of Medical Biochemistry, University of Geneva, CMU, Switzerland, aaron.russell@crr-suva.chUncoupling protein 3 (UCP3) is a muscle mitochondrial protein believed to uncouple the respiratory chain, producing heat and reducing aerobic ATP production. Our aim was to quantify and compare the UCP3 protein levels in type I, IIa and IIx skeletal muscle fibers of endurance-trained (Tr) and healthy untrained (UTr) individuals. UCP3 protein content was quantified using Western blot and immunofluorescence. Skeletal muscle fiber type was determined by both an enzymatic ATPase stain and immunofluorescence. UCP3 protein expression measured in skeletal muscle biopsies was 46% lower ( P=0.01) in the Tr compared to the UTr group. UCP3 protein expression in the different muscle fibers was expressed as follows; IIx>IIa>I in the fibers for both groups ( P

Decreased fatty acid beta-oxidation in riboflavin-responsive, multiple acylcoenzyme A dehydrogenase-deficient patients is associated with an increase in uncoupling protein-3.Russell AP, Schrauwen P, Somm E, Gastaldi G, Hesselink MK, Schaart G, Kornips E, Lo SK, Bufano D, Giacobino JP, Muzzin P, Ceccon M, Angelini C, Vergani L.Department of Medical Biochemistry, University of Geneva Medical Center, 1206 Geneva, Switzerland. aaron.russell@crr-suva.chRiboflavin-responsive, multiple acylcoenzyme A dehydrogenase deficiency (RR-MAD), a lipid storage myopathy, is characterized by, among others, a decrease in fatty acid (FA) beta-oxidation capacity. Muscle uncoupling protein 3 (UCP3) is up-regulated under conditions that either increase the levels of circulating free FA and/or decrease FA beta-oxidation. Using a relatively large cohort of seven RR-MAD patients, we aimed to better characterize the metabolic disturbances of this disease and to explore the possibility that it might increase UCP3 expression. A battery of biochemical and molecular tests were performed, which demonstrated decreases in FA beta-oxidation and in the activities of respiratory chain complexes I and II. These metabolic alterations were associated with increases of 3.1- and 1.7-fold in UCP3 mRNA and protein expression, respectively. All parameters were restored to control values after riboflavin treatment. We postulate that the up-regulation of UCP3 in RR-MAD is due to the accumulation of muscle FA/acylCoA. RR-MAD is an optimal model to support the hypothesis that UCP3 is involved in the outward translocation of an excess of FA from the mitochondria and to show that, in humans, the effects of FA on UCP3 expression are direct and independent of fatty acid beta-oxidation.

Background :Families of patients with hepatocellular carcinoma (HCC) carry a high risk of developing HCC. We determine the number of fatalities in relatives of HCC patients during an 8-year period to understand the risk and cause of HCC in relatives of patients with HCC. Methods :From 1992 to 1997, 15 410 relatives of HCC patients in three generations were screened prospectively for HCC by ultrasonography, α-fetoprotein, liver biochemistry and viral markers. By using national citizen identification numbers, we searched the total fatalities in relatives of HCC patients between 1992 and 1999 from the national mortality data bank. The results were compared among different viral infection groups. Results :Of the relatives studied, 37.8% were hepatitis B s antigen (HBsAg) positive (+), 4.3% were anti-hepatitis C virus (HCV) (+) and 1.7% were both HBsAg (+) and anti-HCV (+). A total of 399 fatalities, including 139 because of HCC (34.8%), 37 because of liver diseases (9.3%), 88 because of other cancers (22.1%) and 135 because of other diseases (33.8%), were found. Relatives who were HBsAg (+) or anti-HCV (+)showed a lower cumulative survival than did relatives who were negative for both HBsAg and anti-HCV. Relatives with dual infection of hepatitis B and C virus showed the highest mortality due to HCC or terminal liver diseases. Conclusions :Chronic viral infection rather than a hereditary factor is the main cause of a familial tendency for HCC. Dual infection of hepatitis B and C virus increases the risk of HCC or decompensated liver diseases. Background:Families of patients with hepatocellular carcinoma (HCC) carry a high risk of developing HCC. We determine the number of fatalities in relatives of HCC patients during an 8-year period to understand the risk and cause of HCC in relatives of patients with HCC. Methods :From 1992 to 1997, 15 410 relatives of HCC patients in three generations were screened prospectively for HCC by ultrasonography, α-fetoprotein, liver biochemistry and viral markers. By using national citizen identification numbers, we searched the total fatalities in relatives of HCC patients between 1992 and 1999 from the national mortality data bank. The results were compared among different viral infection groups. Results :Of the relatives studied, 37.8% were hepatitis B s antigen (HBsAg) positive (+), 4.3% were anti-hepatitis C virus (HCV) (+) and 1.7% were both HBsAg (+) and anti-HCV (+). A total of 399 fatalities, including 139 because of HCC (34.8%), 37 because of liver diseases (9.3%), 88 because of other cancers (22.1%) and 135 because of other diseases (33.8%), were found. Relatives who were HBsAg (+) or anti-HCV (+)showed a lower cumulative survival than did relatives who were negative for both HBsAg and anti-HCV. Relatives with dual infection of hepatitis B and C virus showed the highest mortality due to HCC or terminal liver diseases. Conclusions :Chronic viral infection rather than a hereditary factor is the main cause of a familial tendency for HCC. Dual infection of hepatitis B and C virus increases the risk of HCC or decompensated liver diseases.

Persistent hepatitis B virus (HBV) replication is important for progression of chronic liver diseases. To understand whether there is a trend of HBV replication in siblings or not, 1850 relatives of patients with hepatocellular carcinoma (HCC) were examined prospectively for liver function test, viral markers and HBV DNA. The prevalence of HBsAg in the parents', siblings', children's and grandchildren's generations were 43.4%, 57.2%, 35.5% and 32.1%, respectively. The prevalence of hepatitis B e antigen (HBeAg) in sibling's generation (mean age 44.4 years) was 19%, which is higher than that of asymptomatic HBsAg carriers. For siblings in the children's generation, the prevalence of HBeAg in hepatitis B surface antigen (HBsAg) carriers declined from 40% in the eldest siblings to 19% in the youngest siblings. In 75 families clustered with three or more HBsAg carrier siblings, the mean age for seven families of which all siblings remained HBeAg + was younger, whereas the mean age for 35 families of which all siblings had cleared HBeAg was older. For the remaining 33 families, in only 10 families had the older siblings cleared the HBeAg earlier than the younger siblings. Twenty families showed that younger siblings cleared the HBeAg earlier than the older or middle siblings. We concluded that HBV replication in HCC relatives cannot be explained by familial tendency alone. A significant number of younger siblings appeared to have a shorter HBV replication phase than their older siblings. The possible role of this in maternal–fetal transmission is discussed.

Apolipoprotein E (apoE, protein; APOE, gene) is important in lipoprotein metabolism. Three isoforms, apoE2 (Cys112 Cys158), apoE3 (Cys112 Arg158), and apoE4 (Arg112 Arg158), are present in the general population. This report investigates the frequency distribution of apoE isoforms and the association of APOE genotypes with plasma lipid profile and coronary heart disease (CHD) in a population of Taiwan. ApoE isoforms were determined genetically by polymerase chain reaction and HhaI restriction enzyme digestion in control and coronary heart disease (CHD) patients. Plasma lipid and lipoprotein concentrations were also determined. The control group exhibited frequencies of 84.6% APOE3, 7.9% APOE4, 7.5% APOE2, 70.6% APOE3E3, 14.4% APOE3E4, 13.6% APOE2E3, and 1.4% APOE2E4. Comparable frequencies were observed in the CHD group. In both APOE2 carrier and APOE3E3 groups, the CHD patients expressed abnormal lipid profiles while the control group expressed normal lipid profiles. The APOE4 carriers, however, expressed abnormal lipid profiles in both normal control and CHD groups. Extremely high apoE levels in the hypertriglyceridemic group (TG > 400 mg/dL) seemed to be undesirable and were often observed in CHD patients.

When pressure ulcers occur health care services are faced with considerable challenges and costs. Additionally these ulcers cause significant physical and psycho-social impairment for patients and their families. The complexity of pressure ulcer management is widely acknowledged in the literature. However, the applicability of the major risk assessment scales in the context of spinal cord injury has not been explored. Retrospective case history audit of individuals with pressure ulcers provided data to compare the three commonly used Norton, Braden and Waterlow scales. Waterlow's scale was the most sensitive of the three scales compared.

In a prospective, randomized, double-blind study, 40 patients undergoing gynaecological oncology surgery received either 0.1% ropivacaine with fentanyl 1 microgram ml-1 or 0.2% ropivacaine with fentanyl 2 micrograms ml-1. A PCEA pump was set to deliver ropivacaine 8 mg with fentanyl 8 micrograms with each successful demand and a lockout period of 15 min without background infusion. Patients were observed for rest and activity pain VAS, side effect incidence, peak expiratory flow rate (PEFR), leg strength, sensory block to cold and pinprick, and PCEA usage into the second postoperative day. Passive and active pain scores for both groups were both satisfactory and comparable for the duration of the study. There were no differences between groups with regard to side effects. There was a 24% increase in total drug used in the high-concentration/low-volume group (P0.05). The study demonstrated that PCEA ropivacaine with fentanyl is an effective means of postoperative analgesia for this patient population. Reduced drug consumption with high-volume/low-concentration solution confirms similar findings by other investigators using alternate local anaesthetic agents, and suggests that the therapeutic ratio of ropivacaine is widened if a low-concentration/high-volume solution is used.

Objective: To test the efficacy, tolerance, and safety of low-dose oral estrogen in postmenopausal women with PD associated with motor fluctuations.Background: Motor fluctuations in PD may be predictable or unpredictable, and eventually affect most patients after long-term levodopa therapy. Although estrogen can modulate nigrostriatal dopamine levels, its effects on PD are unclear.Methods: Patients were randomized to receive conjugated estrogen (oral Premarin 0.625 mg daily; n = 20) or placebo (n = 20) in a double-blind, parallel-group, prospective study over 8 weeks. Existing antiparkinsonian drug regimes were kept unchanged. Changes in “on” and “off” periods using patient diaries, Unified Parkinson’s Disease Rating Scale (UPDRS) score, timed tapping score, and Hamilton Depression Scale score were determined by one rater. Subgroup analyses were also performed on patients with only predictable motor fluctuations.Results: Both treatment groups were similar in age, duration of disease and menopause, antiparkinsonian medication, and compliance with test medication and diary assessments. “On” and “off” times, and motor score (UPDRS subscale III) improved with estrogen, using the Mann–Whitney U test (p < 0.05 after Bonferroni adjustment). Mean “on” time improved by 7% (9 hours/week of awake time) in estrogen-treated patients versus a deterioration of 0.5% (1.4 hours) in placebo-treated patients (95% confidence interval, [CI] of mean difference, 5.73 to 14.9). Mean “off” time improved by 4% (4.4 hours/week of awake time) in estrogen-treated patients versus no change in placebo-treated patients (95% CI, 1.54 to 7.16). Mean subscale III score improved by 3.5 points in estrogen-treated patients versus 0.4 in placebo-treated patients (95% CI, 1.02 to 5.18). No other significant changes were observed (p > 0.05). Subgroup analyses in patients with only predictable motor fluctuations showed similar results, except improvement in mean subscale III score was marginally not significant (p = 0.07; 95% CI, 1.06 to 6.24). Five patients on estrogen had facial flushing, three had lower abdominal discomfort, and two had mild withdrawal vaginal bleeding. The adverse events were mild and resolved without sequelae.Conclusion: Low-dose estrogen is a safe and effective adjunct therapy to existing antiparkinsonian treatment in reducing motor disability in postmenopausal women with PD associated with motor fluctuations.

Phillips BA, Lo SK, Mastaglia FL. Muscle force measured using "break" testing with a hand-held myometer in normal subjects aged 20 to 69 years. Arch Phys Med Rehabil 2000;81:653-61. Objective: To measure the strength of 17 muscle groups in the upper and lower extremities in a large group of healthy subjects using "break" testing with a hand-held myometer, and to examine the intrasession and intersession reliability of the testing protocol. Subjects and Instrumentation: A convenience sample of 20 men and 20 women in each decade of age from 20 to 69 years ( n = 200) was tested using a Penny & Giles hand-held myometer. Results: Reliability coefficients were >.85 for both intrasession and intersession reliability, except for the ankle dorsiflexors. Men exerted a significantly greater force than women for all muscle groups. Age, weight, and side of testing were significant predictors of force in the majority of muscle groups. The fifth percentile values, as the lower limit of normal, are reported separately for gender and side of testing for each decade of age. Conclusion: Using the testing protocol specified in this study, data from patients with various neuromuscular diseases may be compared with the appropriate gender- and age-matched normal data to accurately identify the presence of weakness. © 2000 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation

Background. A sustainable pattern of participation in physical activity is important in the maintenance of health and prevention of disease, College students are in transition from an active youth to a more sedentary adult behavior pattern. Methods. We assessed self-reported physical activity and other characteristics in a sample of 2,729 male and female students (median age was 20 years) recruited from representative courses and year levels at four Australian College campuses. They were categorized as sufficiently or insufficiently active, using estimates of energy expenditure (kcal/week) derived from self-reported physical activity, Personal factors (self-efficacy, job status, enjoyment), social factors (social support from family/friends), and environmental factors (awareness of facilities, gym membership) were also assessed. Results. Forty-seven percent of females and 32% of males were insufficiently active. For females, the significant independent predictors of being insufficiently active were lower social support from family and friends, lower enjoyment of activity, and not working. For males, predictors were lower social support from family and friends, lower enjoyment of activity, and being older. Conclusions. Factors associated with physical activity participation (particularly social support from family and friends) can inform physical activity strategies directed at young adults in the college setting. (C) 1999 American Health Foundation and Academic Press.

We identified and quantified prognostic factors for emphysematous pyelonephritis.The clinical information, laboratory data and radiological findings from 38 patients with emphysematous pyelonephritis were retrospectively analyzed.There were no significant differences between the nonsurvivor and survivor groups with respect to age, gender, diabetes mellitus history, presence of bacteremia, identity of infecting organisms, blood glucose level, leukocyte count, urinary white blood count, presence or absence of urinary tract obstruction or urolithiasis, and modes of treatment. There were significant differences between the nonsurvivor and survivor groups, however, with respect to platelet count (84,300 +/- 119,500 versus 220,400 +/- 161,800/mm.3, p = 0.001), serum creatinine level (3.61 +/- 1.25 versus 2.19 +/- 1.32 mg./dl., p = 0.003) and urinary red blood counts (56.47 +/- 41.86 versus 27.65 +/- 36.14, p = 0.028). Patients with radiological type I emphysematous pyelonephritis were significantly more likely to die than those with type II (69 versus 18%, p = 0.002).Serum creatinine level is the most reliable predictor of outcome in patients with emphysematous pyelonephritis. By calculating likelihood ratios, patients with creatinine levels greater than 1.4 mg./dl. and platelet counts 60,000/mm.3 or less were at high risk. The posttest probability of death increased from 69 and 18% to 92 and 53% for type I and II emphysematous pyelonephritis, respectively. Patients with creatinine levels 1.4 mg./dl. or less and platelet counts greater than 60,000/mm.3 were at much lower risk. Posttest mortality risk in these patients dropped from 69 and 18% to 27 and 4% for type I and II emphysematous pyelonephritis, respectively.

In patients who have malignant pleural effusion, it is difficult to diagnose trapped lung before thoracoscopy, thoracostomy, and drainage of the effusion. Predicting the outcome of pleurodesis in patients who have malignant pleural effusion without trapped lung is also difficult.To investigate the factors that may be useful in diagnosing trapped lung and predicting the outcome of pleurodesis.Prospective cohort study.University medical center.65 patients with symptomatic malignant pleural effusion.A chest tube was inserted for drainage of the effusion, and pleurodesis was done using bleomycin as the sclerosant.The pH and glucose levels of the effusion and the elastance of the pleural space (defined as the decline in pleural fluid pressure in cm H2O after removal of 500 mL of effusion) were measured. The outcome of pleurodesis was evaluated 1 month after the chest tube was removed.Patients with an elastance of 19 cm H2O or more had a higher incidence of trapped lung (11 of 14 patients) than did those with an elastance less than 19 cm H2O (3 of 51 patients) (P0.001). None of the 14 patients with an elastance of 19 cm H2O or more and none of the 14 patients with a trapped lung had successful pleurodesis. Forty-two of 43 patients with an elastance less than 19 cm H2O who did not have a trapped lung had successful pleurodesis. Elastance seemed to be the best predictor for trapped lung and outcome of pleurodesis, although outcome was also correlated with pH and glucose levels of the effusion. Low-dose bleomycin (30 mg) is as effective as the usual dose of bleomycin (60 mg) for pleurodesis.In patients with symptomatic malignant pleural effusion, measurement of the elastance of the pleural space is a simple and effective method for the diagnosis of trapped lung and prediction of the outcome of chemical pleurodesis with bleomycin.

A survey of hepatitis B surface antigen (HBSAG) and antibodies against hepatitis C virus (anti-HCV) in 173 patients undergoing hemodialysis in Taiwan revealed that 15 (9%) patients were positive for both HBSAG and anti-HCV, 106 (61%) were positive for anti-HCV alone, and 14 (8%) were positive for HBSAG alone. Most HBSAg positivity was acquired before the onset of hemodialysis. Anti-HCV positivity, however, was mainly acquired via the hemodialysis procedure. Patients with dual markers were younger (43.7 +/- 3.3 years old, p = 0.0274), had the longest period on hemodialysis (6.6 +/- 1.3 years, p0.001), and more severe liver dysfunction. When compared with those who were negative for both markers, patients with both HBSAG and anti-HCV had an increased incidence of chronicity (5/15 vs. 2/38; p0.05), ultrasonographic cirrhosis (5/15 vs. 1/38; p0.05), and clinical decompensation (2/15 vs. 0/38; p0.05). Their risk for developing ultrasonographic cirrhosis and clinical decompensation was also greater than that of patients with anti-HCV alone (5/15 vs. 8/106 and 2/15 vs. 2/106; p0.05 for both). The presence of HBSAG alone, however, did not increase the incidence of liver dysfunction. The presence of anti-HCV alone was only associated with a greater elevation of serum alanine aminotransferase (44.2 +/- 5.5 vs. 19.1 +/- 2.5 U/l; p0.05) and an increased incidence of chronicity (30/106 vs. 2/38; p0.05). Our results indicate that a high prevalence of HCV superinfection impose a significant risk on a large population of HBSAG-positive hemodialysis patients in Taiwan. As the coexistence of anti-HCV and HBSAG is associated with more severe liver dysfunction, it is urgent to devise effective methods to prevent HCV circulation in a hemodialysis environment-especially in a hepatitis B virus endemic area such as Taiwan.

Disability accompanying occupational low back pain (LBP) can include a wide range of incapacitating symptoms which, for the practitioner, can be time-consuming and difficult to identify systematically. A questionnaire designed for case-finding and assessment could assist in both the early recognition of disability and in planning management. A suitable questionnaire for clinical use could not be found in the literature. The Curtin Back Screening Questionnaire (CBSQ) was developed, therefore, as a discriminative screening instrument to serve this purpose. The methods and results of the development and validation of the CBSQ are presented herein. Development of the questionnaire followed the principles of Kirschner and Guyatt (1985) employing data from 74 subjects with at least moderately severe work-related LBP. The research design for the validation was multiple-group repeated-measures with a study population of 150 subjects. The screening function of the questionnaire was developed through selecting 8 questions from the whole questionnaire using regression analysis. The questionnaire includes 79 items based on the subjects' perceived health status. The response structure of the CBSQ has been adapted from that of the General Health Questionnaire (GHQ) and some items in the CBSQ have been developed from items in the Sickness Impact Profile (SIP) and GHQ. The questionnaire discriminates effectively between subjects with different degrees of disability, it correlates quite well with the SIP, test-retest reliability for the whole questionnaire is 0.98, the receiver-operating characteristics are more favourable than those for the SIP, and the CBSQ screening score provides an index of severity which correlates with work incapacity.(ABSTRACT TRUNCATED AT 250 WORDS)

Apolipoprotein B (apoB) signal peptide (sp) polymorphism was characterized by polymerase chain reaction in blood samples of 58 coronary artery disease (CAD) patients and 319 control individuals of Chinese Han ethnic origin in Taiwan. In the CAD group, 77% of the observed alleles were sp27 (sp with 27 amino acids), and the remaining 23% sp24 (sp with 24 amino acids). The frequency distributions of the apoB sp allele in the control group were 0.81 for sp27 and 0.19 for sp24. The genotype distributions were 0.64 sp27/27, 0.26 sp27/24 and 0.10 sp24/24 in the CAD group; 0.64 sp27/27, 0.33 sp27/24 and 0.03 sp24/24 in the control group. The frequency of sp24/24 was significantly higher (p = 0.012) in the CAD group than in the control group. Several studies have shown that the frequency of sp24/24 is higher in hyperlipidemic than in normolipidemic groups. This marker is probably in linkage disequilibrium with some other atherogenic genes. Our study shows that the differences in both apoB signal peptide alleles and sp27/27 and sp27/24 genotype distributions are statistically significant between the Taiwanese and Caucasians.

The current study examined self-efficacy and social support as predictors of maintenance after an attempt to stop smoking. As in previous studies, self-efficacy at the end of treatment was a significant predictor of reported smoking during the follow-up period. At 3 months after treatment the prediction from self-efficacy was weaker than a prediction from the level of post-treatment smoking. However at 10 months self-efficacy was the strongest predictive variable assessed in the study. In contrast, social support for the quit attempt was not a significant predictor of maintenance at any stage. The results provided qualified support for the contention that self-efficacy can often be a more powerful predictor than previous performance attainments, especially under conditions of greater situational change.

The passing and landing patterns among netball players were investigated by examining all the 595 passes in an international match between Australia and New Zealand. Intra-class correlations were used to test inter-observer reliability. The independence of two variables was tested using a Pearson chi 2 test and a contingency coefficient was used to assess the degree of association between variables. An inter-rater reliability in the identification of movement patterns was 0.99. Most of the landings observed in this match were on the forefoot and not the hindfoot as generally reported in controlled experiments. Only 14% of the players leapt to receive a pass compared with 76% reported earlier under controlled environments. The distribution of passing techniques unexpectedly showed that approximately 50% of all the players did not reach for the ball as it was thrown directly to them. However, over 70% of the players threw straight passes which were mainly received in the chest quadrant and other types of passes such as loop, bounce and rebound were used less frequently. Nearly 50% of all players used a right-handed pass to dispose of the ball, while the next most popular pass was to use both hands (40.2%). Landing and passing patterns differed between players in different positions. Footfall patterns on landing after a catch were associated with the trajectory of the ball.

OBJECTIVE: To examine the characteristics of childhood pedestrian injuries in the Perth metropolitan area from 1980 to 1989. DESIGN: Retrospective descriptive study. SETTING: Perth metropolitan area, Western Australia. PARTICIPANTS: Child pedestrians aged 0 to 14 years who were injured during the period 1 January 1980 to 31 December 1989. MAIN OUTCOME MEASURES: An extensive database which reported fatal and non-fatal motor vehicle collisions was used to obtain details on the child pedestrian, the vehicle involved in the collision, and the environmental factors related to these injuries. RESULTS: A total of 1282 child pedestrian injuries were reported in the 10 year period. Children aged between 5 and 9 years, and were overrepresented among those injured. This study also demonstrated a similar proportion of injuries involving the 10-14 year age group. Injuries frequently occurred mid block, on local urban roads, between the hours of 3 p.m. and 7 p.m., and a greater than expected proportion of drivers involved in these collisions were in the under-21 age category. To describe the pattern of childhood pedestrian injuries we calculated both age-specific injury rates, and injury rates based on the number of registered motor vehicles. The latter revealed a greater than 20-fold variation between local government areas. CONCLUSIONS: Further analytical research, incorporating a measure of the child pedestrian's exposure to roads and traffic is required to identify those features in the individual and the environment which have a significant influence on the likelihood of a collision. Such research is required to institute effective preventive measures. Language: en

A Guttman stages of drug use model was confirmed for Australian youth in this systematic household survey of 13-17-year-olds in Perth (n = 1093). The same model held for both sexes and all ages although the model was more efficient for the older youth. General drug use prevalence, expansion of drug repertoire and frequency of use all increased with age. Multiple drug use was prevalent. Marijuana use was not a necessary stage for the progression to other illicit drug use as 29% of current users of other illicit drugs reported never using marijuana. The hazard rate for use of marijuana or other illicit drugs, if one was a current tobacco smoker, was high. Alcohol and tobacco were implicated as important 'gateway' drugs though hazard rates showed tobacco to be the more important of the two. Implications of the study are that delaying or eliminating the onset of tobacco use are important goals of prevention programmes and that multiple drug use should be recognized and addressed in health education programmes for youth.

Pedestrian-motor vehicle collisions that involved children aged 0 to 14 years in Perth, Western Australia were examined for the period 1980-1989 in order to identify factors which contribute to the severity of injury. Nearly half (49%)of the l, 82children injured during this period required hospitalization, with a further 46% of the children requiring some form of medical treatment. Multivariate analysis indicated that children aged 0 to four years had a higher risk of sustaining a severe injury compared with children aged five to nine and ten to 14 years, with relative risks of 1.6 and 1.7 respectively. A greater proportion of more severe injuries occurred after 3 pm. Injuries tended to be more severe when the collision occurred on a highway or main road, and when the child was actually on the road at the point of impact Further research on more comprehensive datasets, which consider the child's behavior at the time of injury as well as driver attributes, will provide greater insight into factors contributing to the severity of injury.

The summer alcohol consumption of women living in metropolitan Perth was measured using both a retrospective and prospective diary. Overall, 1356 women fully completed both the retrospective and prospective alcohol consumption diaries. The prospective diary yielded a significantly higher level (9%) of consumption (p less than 0.00001) compared with the retrospective diary. Although there was no significant difference in the percentage of women drinking at harmful levels (greater than 280 g absolute alcohol per week) between the two diary methods, there did appear to be an important percentage difference (1.9% versus 2.8%) suggesting that the prospective diary did detect a larger percentage of women at risk. This would be both practically and statistically significant in large populations. The heavier the drinker the greater the variability in reported consumption between the two diary weeks. However, it is interesting to note that the direction of the variation depended on which diary was used as the base for classifying women as different types of drinkers. Women who drank at hazardous (140-280 g per week) or harmful (greater than 280 g) levels during the retrospective diary week reported a lower level of consumption during the prospective diary week. Conversely women who drank at hazardous or harmful levels during the prospective diary week reported a lower level of consumption during the retrospective diary week. Possible explanations for these findings are explored and methodological considerations for future studies are discussed.

Objectives To determine the benefits and risks of a non-steroidal anti-inflammatory drug (NSAID) as prophylaxis for ectopic bone formation in patients undergoing total hip replacement (or revision) surgery. Design Double blind randomised placebo controlled clinical trial, stratified by treatment site and surgery (primary or revision). Setting 20 orthopaedic surgery centres in Australia and New Zealand. Participants 902 patients undergoing elective primary or revision total hip replacement surgery. Intervention 14 days' treatment with ibuprofen (1200 mg daily) or matching placebo started within 24 hours of surgery. Main outcome measures Changes in self reported hip pain and physical function 6 to 12 months after surgery (Western Ontario and McMaster University Arthritis index). Results There were no significant differences between the groups for improvements in hip pain (mean difference -0.1, 95% confidence interval -0.4 to 0.2, P = 0.6) or physical function (-0.1, -0.4 to 0.2, P = 0.5), despite a decreased risk of ectopic bone formation (relative risk 0.69, 0.56 to 0.83) associated with ibuprofen. There was a significantly increased risk of major bleeding complications in the ibuprofen group during the admission period (2.09, 1.00 to 4.39). Conclusions These data do not support the use of routine prophylaxis with NSAIDs in patients undergoing total hip replacement surgery. Trial registration NCT00145730.

ContextThe antioxidant acetylcysteine prevents acute contrast nephrotoxicity in patients with impaired renal function who undergo computed tomography scanning. However, its role in coronary angiography is unclear.ObjectiveTo determine whether oral acetylcysteine prevents acute deterioration in renal function in patients with moderate renal insufficiency who undergo elective coronary angiography.Design and SettingProspective, randomized, double-blind, placebo-controlled trial conducted from May 2000 to December 2001 at the Grantham Hospital at the University of Hong Kong.ParticipantsTwo hundred Chinese patients aged mean (SD) 68 (6.5) years with stable moderate renal insufficiency (creatinine clearance

Neurovascular contact (NVC) with the root exit zone (REZ) of the ipsilateral facial nerve is associated with hemifacial spasm (HFS), but unresolved issues remain.To 1) determine the frequency of symptomatic and nonsymptomatic NVC, 2) determine the features of NVC associated with HFS, and 3) correlate severity of HFS to these features.Two independent, blinded, prospective assessments of high-resolution MR and MR angiography (MRA) images were performed on Chinese cases (HFS: n = 44; age-matched control subjects: n = 20).Over 88% of 44 symptomatic sides in patients with HFS had NVC of the ipsilateral facial nerve. At least 80% of symptomatic sides involved NVC at the anterior aspect of the REZ [REZ(ant.)]. Although NVC was observed in approximately half of nonsymptomatic sides, at least 70% of them were not at REZ(ant.). NVC at the cisternal and intracanalicular portions of the facial nerve were not associated with HFS. Half of our patients with HFS had bilateral NVC, but none had bilateral symptoms. Most of our MR/MRA images showed that the size and position of the arterial branches of the vertebrobasilar system were markedly asymmetric. Of patients with bilateral NVC, over 83% had asymmetric NVC sites. The anterior inferior cerebellar artery was the most common vessel involved in NVC, but was not significantly associated with HFS. Most of the NVC involved one vessel at one contact point with no indentation. The development of HFS was significantly associated with nerve indentation in NVC. The development and severity of HFS were not associated with multiple contact points in NVC. No significant interobserver variability existed between the blinded assessments.MRI/MR angiography are accurate, fast, and safe in characterizing neurovascular contact (NVC) at the brainstem. The site of NVC and ipsilateral facial nerve indentation in NVC are significant determinants for the development of hemifacial spasm (HFS). The lack of bilateral NVC at the anterior aspect of the root exit zone of the facial nerve could explain in part the lack of bilateral symptoms. The development and severity of HFS are not associated with a specific blood vessel or multiple contact points in NVC.

Most studies of the predictors of systemic embolism in patients with mitral stenosis have been retrospective.To prospectively study factors associated with systemic embolism in mitral stenosis.Prospective cohort study.University-affiliated medical institution with 3000 beds.534 consecutive patients with a mitral valve area of 2.0 cm2 or less; 132 patients were in sinus rhythm, and 402 were in atrial fibrillation.Nine clinical and 10 echocardiographic variables were assessed for prediction of systemic embolism over a mean (+/- SD) follow-up of 36.9 +/- 22.5 months. Diagnosis of systemic embolism was based on symptoms and signs (sudden onset of peripheral arterial ischemic or neurologic manifestations without prodromes) and on findings on computed tomography, angiography, and surgery.For patients in sinus rhythm, age (relative risk [RR], 1.12 [95% CI, 1.04 to 1.21]), the presence of a left atrial thrombus (RR, 37.1 [CI, 2.82 to 487.8]), mitral valve area (RR, 16.9 [CI, 1.53 to 187.0]), and the presence of significant aortic regurgitation (RR, 22.4 [CI, 2.72 to 184.8]) were positively associated with embolism. For patients in atrial fibrillation, previous embolism (RR, 3.11 [CI, 1.66 to 5.85]) was positively associated with embolism; percutaneous balloon mitral commissurotomy (RR, 0.37 [CI, 0.18 to 0.79]) was a negative predictor.It may be prudent to give anticoagulants not only to patients in atrial fibrillation and patients with previous systemic embolism but also to those showing a left atrial thrombus or significant aortic regurgitation on echocardiography. Early percutaneous balloon mitral commissurotomy may also help prevent systemic embolism in patients with mitral stenosis.