Does the use of a visualised decision board by undergraduate students during shared decision-making enhance patients' knowledge and satisfaction? - A randomised controlled trial.

OBJECTIVES: Aim of this RCT was to evaluate whether the added use of a decision board (DB) during shared decision-making improves patients' knowledge as for different treatment options and overall satisfaction with the consultation. METHODS: Forty-nine undergraduate students were trained in shared decision-making (SDM) and evaluated by an Objective Structured Clinical Examination (OSCE). According to their test results, all participants were randomly allocated to either the test- (DB) or the control-group (Non-DB). Both groups performed SDM with patients showing a defect in a posterior tooth (Class-II defect). Prior to the interview, patients of the DB group were given the decision aid for review. In the Non-DB group, patients were consulted without additional aids. After treatment decision, a questionnaire was completed by all patients to measure knowledge (costs, survival rate, characteristics and treatment time) and overall satisfaction with the consultation. Fifty DB patients and 31 Non-DB patients completed the questionnaire. RESULTS: DB patients (n = 50) demonstrated a statistically significant increase in knowledge compared to the Non-DB group (n = 31) (Mann-Whitney U-test; DB group = 10.04; Non-DB group = 4.16; P = 0.004). There was no significant difference between groups regarding satisfaction with the consultation (t-test; P > 0.05). CONCLUSIONS: During the shared decision-making process, the use of a decision board yielding information about Class-II treatment options leads to a significantly higher patient knowledge compared to knowledge gained through consultation alone. It is therefore desirable to provide DBs for dental diagnoses with several treatment options to increase transparency for the patient.

TNF-alpha associated with extracellular matrix fibronectin provides a stop signal for chemotactically migrating T cells.

The migration of T cells into extravascular sites of inflammation is regulated by information derived from the molecular structure of the invaded tissue and from chemokine and cytokine gradients in the context of the extracellular matrix (ECM). Although recent studies have highlighted the role of particular chemoattractants in leukocyte migration, to date little is known about how specific combinations of contextual signals control the migration of leukocytes and their localization at sites of inflammation. Here we studied the interplay between a pleiotropic cytokine, TNF-alpha, and two prototypic chemoattractants, RANTES and stromal cell-derived factor-1alpha (SDF-1alpha), on human CD45RO+ T cells migrating within an ECM-like context. For this purpose, we used a newly constructed three-dimensional gel system designed to follow, in real time, the migration of individual leukocytes along chemotactic gradients in vitro. We found that TNF-alpha, which binds the ECM protein fibronectin and lacks adhesion- and migration-promoting effects of its own, can act as a proadhesive cytokine on T cells exposed to RANTES and SDF-1alpha. Furthermore, fibronectin-complexed TNF-alpha provided anchorage signals to the T cells as they moved directionally along chemoattractive gradients. This effect of TNF-alpha required an intact TNF-alpha receptor II subtype on the migrating T cells. The anchoring effect of TNF-alpha appears to be specific; IL-2, an integrin-activating proadhesive cytokine, does not transmit stoppage signals to T cell migration induced by RANTES. Thus, TNF-alpha present in the ECM at sites of inflammation may function to anchor T cells recruited to these sites by chemotactic signals.

Diode-pumped femtosecond Yb:KGd(WO(4))(2) laser with 1.1-W average power.

We demonstrate what is to our knowledge the first mode-locked Yb:KGd(WO(4))(2) laser. Using a semiconductor saturable-absorber mirror for passive mode locking, we obtain pulses of 176-fs duration with an average power of 1.1 W and a peak power of 64 kW at a center wavelength of 1037 nm. We achieve pulses as short as 112 fs at a lower output power. The laser is based on a standard delta cavity and pumped by two high-brightness laser diodes, making the whole system very simple and compact. Tuning the laser by means of a knife-edge results in mode-locked pulses within a wavelength range from 1032 to 1054 nm. In cw operation, we achieve output powers as high as 1.3 W.

Adrenal insufficiency from metastatic colonic carcinoma masquerading as isolated aldosterone deficiency. Report of a case and review of the literature.

A case of adrenal insufficiency secondary to metastatic colonic carcinoma is reported. Because the patient was taking prednisone for an unrelated condition, his initial presentation mimicked isolated aldosterone deficiency with an elevated serum potassium of 8.7 mmol/l. Cortisol deficiency was documented by ACTH testing. The diagnosis of metastatic disease causing adrenal insufficiency was suspected after a computed body scan of the abdomen revealed marked bilateral adrenal enlargement. Adrenal insufficiency secondary to metastatic cancer is reviewed.

Halothane-induced nephrotoxicity.

Two cases are reported of combined renal and hepatic failure following exposure to halothane anesthesia. Both patients presented with postoperative fever and rapidly deteriorating liver and kidney function. Both required peritoneal dialysis. Both patients died, and in both cases this was the second exposure to halothane. The pathologic features of the 2 cases were similar in that the liver changes were typical of those seen with halothane hepatitis and the renal lesion was similar to that of methoxyflurane nephritis. This is, to our knowledge, the third report of renal failure occurring after halothane anesthesia. Possible mechanisms regarding its toxicity are discussed.

The myth of the low anion gap.

Sixty-seven thousand seven hundred forty consecutive sets of electrolyte levels measured at the Massachusetts General Hospital were reviewed, and their anion gaps were calculated. A low anion gap (less than 8 mEq/L) was found in 304 patients (0.8%). Repeatedly low anion gaps were found in only 19 patients. Eight patients were hypoalbuminemic, and eight were hyponatremic. For the entire population, there was a positive correlation between sodium concentration and anion gap. The average anion gap was 16.25 mEq/L. The most common cause of a low anion gap was presumptive laboratory error.

Low fractional excretion of sodium with contrast media-induced acute renal failure.

Risk factors, clinical courses, and urinary indices were examined in 12 consecutive patients with contrast media-induced acute renal failure. A high prevalence of preexisting renal disease, diabetes, vascular disease, and compromised cardiac output was observed. All patients had transient oliguria one to four days in duration, and all patients had return of renal function to their baseline values within five to ten days. Consistently low urinary sodium concentration and fractional excretion of sodium (FENa) were seen during the oliguric phase of the acute renal failure. Fractional excretion of sodium of less than 1% persisted for up to five days despite unequivocal renal function deterioration. The findings raise the possibility that acute renal failure secondary to contrast media may be mediated either by decreases in renal perfusion or by acute tubular obstruction.