CT colonography at low tube potential: using iterative reconstruction to decrease noise.

AIM: To determine the level of iterative reconstruction required to reduce increased image noise associated with low tube potential computed tomography (CT). MATERIALS AND METHODS: Fifty patients underwent CT colonography with a supine scan at 120 kVp and a prone scan at 100 kVp with other scan parameters unchanged. Both scans were reconstructed with filtered back projection (FBP) and increasing levels of adaptive statistical iterative reconstruction (ASiR) at 30%, 60%, and 90%. Mean noise, soft tissue and tagged fluid attenuation, contrast, and contrast-to-noise ratio (CNR) were collected from reconstructions at both 120 and 100 kVp and compared using a generalised linear mixed model. RESULTS: Decreasing tube potential from 120 to 100 kVp significantly increased image noise by 30-34% and tagged fluid attenuation by 120 HU at all ASiR levels (p<0.0001, all measures). Increasing ASiR from 0% (FBP) to 30%, 60%, and 90% resulted in significant decreases in noise and increases in CNR at both tube potentials (p<0.001, all comparisons). Compared to 120 kVp FBP, ASiR greater than 30% at 100 kVp yielded similar or lower image noise. CONCLUSIONS: Iterative reconstruction adequately compensates for increased image noise associated with low tube potential imaging while improving CNR. An ASiR level of approximately 50% at 100 kVp yields similar noise to 120 kVp without ASiR.

Improving preclinic preparation for patients with chronic conditions in quito, ecuador: a randomized controlled trial.

Objectives. As in many settings, patients in community health centers in Ecuador do not complete previsit forms or receive assistance to identify questions and concerns they would like to address in brief clinic visits with physicians. We examined the comparative effectiveness of providing (1) a previsit form to complete; (2) a previsit form along with assistance in completing the form; and (3) usual care. Methods. Parallel, three-arm randomized controlled trial in two health centers serving indigent to low-income communities in Quito, Ecuador, among 199 adult patients who took medications for at least one chronic condition. Outcome measures were self-reported satisfaction with the visit, confidence in asking questions, and extent to which patients' objectives were met. Results. Patients who received assistance in completing a previsit form were more than twice as likely as participants in usual care to report achieving everything they wanted during their visit (AOR 2.2, P = 0.039). There were no differences in any outcomes between the groups who received the previsit form with no assistance and usual care. Conclusions. For high-quality patient-centered primary care, it is important to develop and test innovative and scalable interventions for patients and physicians to make the best use of limited clinic time.

Physicians' participatory decision-making and quality of diabetes care processes and outcomes: results from the triad study.

OBJECTIVES: In participatory decision-making (PDM), physicians actively engage patients in treatment and other care decisions. Patients who report that their physicians engage in PDM have better disease self-management and health outcomes. We examined whether physicians' diabetes-specific treatment PDM preferences as well as their self-reported practices are associated with the quality of diabetes care their patients receive. METHODS: 2003 cross-sectional survey and medical record review of a random sample of diabetes patients (n=4198) in 10 US health plans across the country and their physicians (n=1217). We characterized physicians' diabetes care PDM preferences and practices as 'no patient involvement,' 'physician-dominant,' 'shared,' or 'patient-dominant' and conducted multivariate analyses examining their effects on the following: (1) three diabetes care processes (annual hemoglobin A1c test; lipid test; and dilated retinal exam); (2) patients'satisfaction with physician communication; and (3) whether patients' A1c, systolic blood pressure (SBP), and low-density lipoprotein cholesterol (LDL) were in control. RESULTS: Most physicians preferred 'shared' PDM (58%) rather than 'no patient involvement' (9%), 'physician-dominant' (28%) or 'patient dominant' PDM (5%). However, most reported practicing 'physician-dominant' PDM (43%) with most of their patients, rather than 'no patient involvement' (13%), 'shared' (37%) or 'patient-dominant' PDM (7%). After adjusting for patient and physician-level characteristics and clustering by health plan, patients of physicians who preferred 'shared' PDM were more likely to receive A1c tests [90% vs. 82%, AOR: 2.05, 95% CI: 1.03-3.07] and patients of physicians who preferred 'patient-dominant' treatment decision-making were more likely to receive lipid tests [60% vs. 50%, AOR: 1.58, 95% CI: 1.04-2.39] than those of providers who preferred 'no patient involvement' in treatment decision-making. There were no differences in patients' satisfaction with their doctor's communication or control of A1c, SBP or LDL depending on their physicians' PDM preferences. Physicians' self-reported PDM practices were not associated with any of the examined aspects of diabetes care in multivariate analyses. CONCLUSIONS: Patients whose physicians prefer more patient involvement in decision-making are more likely than patients whose physicians prefer more physician-directed styles to receive some recommended risk factor screening tests, an important first step toward improved diabetes outcomes. Involving patients in treatment decision-making alone, however, appears not to be sufficient to improve biomedical outcomes.

Geographic variation in organ availability is responsible for disparities in liver transplantation between Hispanics and Caucasians.

The aims of this study were to determine whether disparities in waiting list outcomes exist for Hispanics and African Americans during the post-MELD era, and to investigate interactions between disparities and geography. Scientific Registry of Transplant Recipients data were used to compare Hispanics and African Americans to Caucasians listed between 2003 and 2008. Endpoints included (i) receipt of a liver transplant and (ii) death or removal from the waiting list for being too sick or medically unsuitable. Adjustment for possible confounders was performed using multivariate Cox regression, with adjustment for geographic variation using a fixed-effects multilevel model. In multivariate analysis, African Americans have similar hazard of transplantation and death/removal as Caucasians during the post-MELD era. However, Hispanics are less likely to receive a transplant than Caucasians despite adjustment for potential confounders (HR 0.80, 95% CI 0.77-0.83), while having a similar hazard of death/removal. This effect disappeared after adjusting for unequal regional distribution of Hispanics, who represent 8% of patients in donation service areas (DSAs) having median waiting times of < or = 155 days versus 19% in DSAs with median waiting times of >155 days. In conclusion, disparities in liver transplantation exist for Hispanics during the post-MELD era, caused by geographic variation in organ availability.

Knowledge of blood pressure targets among patients with diabetes.

INTRODUCTION: Tight blood pressure (BP) control is the single most important intervention to prevent cardiovascular mortality among patients with diabetes mellitus (DM). However, little is known about how many patients have specific target BP levels or the factors associated with patients' knowledge of these targets. OBJECTIVES: (1) To determine what proportion of patients with diabetes have BP targets; (2) To determine patient characteristics associated with having a BP target. METHODS: Cross-sectional, anonymous survey of 500 randomly selected outpatients with hypertension and DM receiving care in any Veterans Health Administration outpatient clinic in 2003. We examined multivariate associations between patient characteristics and having targets for BP. Covariates included age, race, gender, and education level; and factors specific to diabetes and BP treatment, including medication use, diabetes duration, and number of visits to diabetes healthcare providers in the previous year. RESULTS: Three hundred and seventy-eight (80%) patients responded. Although most (91%) had blood glucose targets, fewer than 60% reported having a BP target. In multivariate analyses, college education was associated with having a BP target (AOR 1.97 [95% CI: 1.16-3.34]). CONCLUSIONS: Less than two-thirds of diabetic, hypertensive patients had BP targets. Encouraging patients to set target BPs may promote hypertension self-management in this high-risk patient population. Less educated patients may especially benefit from interventions to increase awareness of BP targets.

Hepatitis B-related polyarteritis nodosa complicated by pulmonary hemorrhage.

A 34-year-old man presented with fever, weight loss, paresthesia, abdominal pain, and hypertension. He had hepatitis B antigenemia, with negative antineutrophil cytoplasmic antibody, antinuclear antibody, and antiglomerular basement membrane serology results. Renal arteriography showed multiple intrarenal microaneurysms. In spite of therapy with antiviral agents (lamivudine, famciclovir), prednisone, cyclophosphamide, and plasmapheresis, renal function deteriorated. He later developed rapidly progressive dyspnea and hemoptysis. Diffuse alveolar hemorrhage was confirmed by bronchoscopy. He died of respiratory failure. The cause of pulmonary hemorrhage in this case of polyarteritis nodosa is unclear, but may include underlying capillaritis, cocaine-induced pulmonary hemorrhage, or recurrent attacks of malignant hypertension.

SPATULA, a gene that controls development of carpel margin tissues in Arabidopsis, encodes a bHLH protein.

Studies involving mutants of the gene SPATULA indicate that it promotes the growth of carpel margins and of pollen tract tissues derived from them. We show that it encodes a new member of the basic-helix-loop-helix family of transcription factors. SPATULA is expressed in marginal and pollen tract tissues throughout their development confirming its role in regulating their growth. It is also expressed in many other tissues where it may act redundantly to control growth, including the peripheral zone of the shoot apical meristem, and specific tissues within leaves, petals, stamens and roots. Expression in the stomium, funiculus and valve dehiscence zone indicates an additional role in abscission. SPATULA expression does not require the function of the other carpel development genes CRABS CLAW and AGAMOUS, although its expression is repressed in first whorl organs by the A function gene APETALA2. Further, we have shown that disruptions to gynoecial pattern formation seen in ettin mutants can largely be attributed to ectopic SPATULA action. ETTIN's role seems to be to negatively regulate SPATULA expression in abaxial regions of the developing gynoecium. SPATULA is the first basic-helix-loop-helix gene in plants known to play a role in floral organogenesis.

Whom should I name as my IRA beneficiary?

Many times, people will end up passing on some or all of their individual retirement accounts to someone else. Naming a beneficiary can depend on your financial and family situation and should be considered carefully.

Health and human rights of adolescent girls in Afghanistan.

Physicians for Human Rights (PHR) conducted a study in early 1998 to assess the health and human rights conditions of Afghan women and girls living under the Taliban regime in Kabul. This paper highlights the concerns and experiences of adolescent girls in Kabul, includes a brief overview of the political situation in Afghanistan and Taliban policies toward women and girls, and presents findings from interviews with adolescent girls and women with adolescent daughters. It concludes with a discussion of current international standards for the protection of women's and girls' rights and the crucial role of health professionals in helping defend these rights.

A computer alert system to prevent injury from adverse drug events: development and evaluation in a community teaching hospital.

CONTEXT: Adverse drug events (ADEs) are the most common type of iatrogenic injury occurring in hospitalized patients. Errors leading to ADEs are often due to restricted availability of information at the time of physician order writing. OBJECTIVES: To develop, implement, and evaluate a computer alert system designed to correct errors that might lead to ADEs and to detect ADEs before maximum injury occurs. DESIGN: Prospective case series. SETTING: A 650-bed community teaching hospital in Phoenix, Ariz. PATIENTS: Consecutive sample of 9306 nonobstetrical adult patients admitted during the last 6 months of 1997. INTERVENTIONS: Thirty-seven drug-specific ADEs were targeted. Our hospital information system was programmed to generate alerts in clinical situations with increased risk for ADE-related injury. A clinical system was developed to ensure physician notification of alerts. MAIN OUTCOME MEASURES: A true-positive alert was defined as one in which the physician wrote orders consistent with the alert recommendation after alert notification. RESULTS: During the 6-month study period, the alert system fired 1116 times and 596 were true-positive alerts (positive predictive value of 53%). The alerts identified opportunities to prevent patient injury secondary to ADEs at a rate of 64 per 1000 admissions. A total of 265 (44%) of the 596 true-positive alerts were unrecognized by the physician prior to alert notification. CONCLUSIONS: Clinicians can use hospital information systems to detect opportunities to prevent patient injury secondary to a broad range of ADEs.

The Onchocerciasis Elimination Program for the Americas: a history of partnership.

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$ 2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999.

The onchocerciasis elimination program for the Americas: a history of partnership / Programa de Eliminación de la Oncocercosis para las Américas: historia de solidaridad

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999

La decisión tomada en 1987 por la Merck & Co., fabricante de productos farmacéuticos, de proveer Mectizan® (ivermectina) gratuitamente a los programas de control de la oncocercosis ha obligado a la comunidad sanitaria internacional a buscar formas de distribuir el medicamento a las poblaciones rurales que se ven más afectadas por la enfermedad. En las Américas, la OPS respondió al reto con un llamado a eliminar de la Región toda morbilidad por oncocercosis para el año 2007 mediante la distribución de ivermectina al público. Desde 1991, una alianza multinacional de diversas entidades (la OPS, países con oncocercosis endémica, agencias de desarrollo no gubernamentales, los Centros para el Control y la Prevención de Enfermedades en Atlanta, Georgia, instituciones académicas y agencias de financiamiento) ha generado el apoyo político, económico y técnico necesario para tratar de alcanzar esa meta. Esta alianza está representada por el Programa de Eliminación de la Oncocercosis en las Américas (OEPA), subvencionado por la Fundación Ceguera de los Ríos y actualmente por el Centro Carter. El OEPA se creó como iniciativa de alcance regional destinada a eliminar una enfermedad que no merece atención prioritaria. Desde su aparición en 1993, el OEPA ha aportado más de US$ 2 millones en ayuda económica, administrativa y técnica para fomentar y subvencionar programas en Brasil, Colombia, Ecuador, Guatemala, México y Venezuela, logrando así aprovechar al máximo la donación de la Merck & Co. Ahora que hemos llegado a la mitad de una subvención de 5 años y US$ 4 millones aportada por el Banco Interamericano de Desarrollo, se sabe que el OEPA tiene la capacidad para apoyar la iniciativa regional hasta fines de 1999

The Onchocerciasis elimination program for the Americas: a history of partnership

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination all morbidity from onchocerciasis from the region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center, OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$ 2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico, and Venezuela, so as to take full advantage of the Merck donation, Now halfways into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999 (AU)

The onchocerciasis elimination program for the Americas: a history of partnership

The decision in 1987 by the pharmaceutical firm Merck & Co. to provide Mectizan (ivermectin) free of charge to river blindness control programs has challenged the international public health community to find effective ways to distribute the drug to rural populations most affected by onchocerciasis. In the Americas, PAHO responded to that challenge by calling for the elimination of all morbidity from onchocerciasis from the Region by the year 2007 through mass distribution of ivermectin. Since 1991, a multinational, multiagency partnership (consisting of PAHO, the endemic countries, nongovernmental development organizations, the Centers for Disease Control and Prevention in Atlanta, Georgia, as well as academic institutions and funding agencies) has developed the political, financial, and technical support needed to move toward the realization of that goal. This partnership is embodied in the Onchocerciasis Elimination Program for the Americas (OEPA), which is supported by the River Blindness Foundation (RBF) and now by the Carter Center. OEPA was conceived as a means of maintaining a regional initiative to eliminate what is otherwise a low priority disease. Since its inception in 1993, the OEPA has provided more than US$2 million in financial, managerial, and technical assistance to stimulate and/or support programs in Brazil, Colombia, Ecuador, Guatemala, Mexico and Venezuela, so as to take full advantage of the Merck donation. Now halfway into a five-year, US$ 4 million grant provided through the Inter-American Development Bank, the OEPA's capacity to support the regional initiative is assured through 1999

Fetotoxicity and teratogenesis of SWL treatment in the rabbit.

The potential effects of extracorporeal application of shockwaves on an embryo or fetus were explored in an animal model. In experimental Series A, the fetuses of 30 gravid rabbits were exposed to piezoelectrically induced and sonographically guided shockwaves on Day 25 or 20 of gestation under technical conditions corresponding to extracorporeal lithotripsy in humans. Fetotoxicity was examined by abdominal section 24 hours or 9 days later, and immediate/intermediate damage was assessed (resorptions, viability, gross injuries, and microscopic lesions of the target and neighboring fetuses). In series B, the kidneys of an additional 28 gravid rabbits (including a control group) were exposed to the same shockwave treatment on Day 11 of gestation in order to investigate indirect embryotoxic effects, including teratogenic potency. One day before the expected birth, the maternal kidneys, uteri, and adjacent organs were examined for lesions, and the 156 offspring were assessed for embryolethal, embryonoxious, or teratogenic sequelae. Shockwave targeting of the cranium, thorax, abdomen, or placenta was usually lethal to the fetuses. When the uterine wall or the space between two fetuses was targeted, the fetuses suffered from superficial hematoma, as was found in the surrounding soft tissues within a radius of 1.5 cm. Fetuses outside this region were vital and free of lesions. Shockwave treatment of the maternal kidney resulted in renal petechial hemorrhage or subcapsular hematoma. However, statistically significant embryotoxic or teratogenetic effects could be demonstrated neither from maternal data (resorptions) nor from fetal findings (body measurements, vitality test, inner organs, skeletal deformities). When using a piezoelectric lithotripter with a small focus of high energy, lesions of a fetus are to be expected only when it is located in or close to the focus. It seems that embryotoxic or teratogenic sequelae do not occur when shockwaves are focused outside the uterus. Nonetheless, this preliminary research does not justify clinical use of extracorporeal shockwave lithotripsy in pregnant humans.

Guidelines for internal peer review in the cardiac catheterization laboratory. Laboratory Performance Standards Committee, Society for Cardiac Angiography and Interventions.

The Laboratory Performance Standards Committee of the Society for Cardiac Angiography and Interventions has proposed guidelines for establishing an internal peer review program in the cardiac catheterization laboratory. The first step is to establish a committee and a data base. This data base should include quality indicators that reflect: physician qualifications, outcomes of procedures, and processes of care. The outcomes must be risk-adjusted to account for the variable severity of illness. Data should be collected by catheterization laboratory personnel and entered into a laboratory-specific computerized data base. These data must be analyzed and organized into profiles that reflect the quality of care. Based on this information, the Committee would institute the following interventions to improve physician performance: education, clinical practice standardization, feedback and benchmarking, professional interaction, incentives, decision-support systems, and administrative interventions. The legal aspects of peer review are reviewed briefly.

Physician complicity in misrepresentation and omission of evidence of torture in postdetention medical examinations in Turkey.

Between June 1994 and October 1995, representatives of Physicians for Human Rights studied the problem of physician complicity in torture (ie, misrepresentation and omission of medical evidence in postdetention examinations of detainees) in Turkey. The research consisted of a survey of forensic documentation of torture, interviews with individual physicians who examine detainees, analyses of official medical reports of detainees, and interviews with survivors of torture. Results from the survey, interviews, and medical report analyses provide evidence that torture of political and criminal detainees continues to occur in Turkey and that Turkish physicians are coerced to ignore, misrepresent, and omit evidence of torture in their examinations of detainees to certify that there are no physical signs of torture.