The role of quality of care in health-related quality of life in patients with IBD.

In the literature there are indications of associations between health-related quality of life (HRQoL) in inflammatory bowel disease and disease activity, psychological status, coping, stressful life events, and social support. The aim of this study was to examine whether a relation exists between quality of health care and HRQoL, taking possible confounding variables into account. For this purpose, one single questionnaire was compiled from existing validated questionnaires. A population-based inception cohort of 1056 patients with inflammatory bowel disease in eight countries, diagnosed 6 to 8 years prior to the study, was approached to participate. In total, 824 patients responded (78%), and 517 could be included in statistical analyses. It was shown that in inflammatory bowel disease HRQoL was indeed influenced by quality of care (particularly with regard to the parameters of "providing information," "costs," and "courtesy"), as well as by disease activity, psychological status, type of hospital, social support, stressful life events, and way of administration of the questionnaire. Patients with active disease had lower psychological status and HRQoL scores at the time of the survey than patients without active disease. However, quality of care scores did not differ between these groups. The care aspect "costs" was scored worse by CD compared with UC patients, probably caused by a potentially more expensive treatment. In conclusion, it is shown in a large exploratory study, for the first time, that in inflammatory bowel disease, quality of care has a significant role in determining health-related quality of life.

Spleen length in childhood with US: normal values based on age, sex, and somatometric parameters.

PURPOSE: To investigate with ultrasonography (US) normal spleen length in healthy children. MATERIALS AND METHODS: The study comprised 512 healthy children (274 girls) with ages ranging from 1 day (full-term neonate) to 17 years who were examined between 1996 and 2001. The main sample comprised 454 children (249 girls) with body measurements (weight and height) between the 5th and 95th percentiles of the relevant growth curves. The remaining 58 children (25 girls) with body measurements outside the normal ranges formed a separate sample used for cross-validation. None had a problem that could affect spleen size. The relationships between the US-measured spleen length and age and body parameters were studied with nonlinear regression and multiple (backward stepwise) regression techniques. Normal ranges and related statistics were estimated and tabulated according to age group and sex. Spleen length growth curves and upper limits defined by the 90% upper confidence limit (UCL) are presented in graphs according to height, weight, and body surface area (BSA). RESULTS: Spleen length was highly correlated with age, height, weight, and BSA; there was no statistically significant difference between the sexes. The exact pattern of these relationships was nonlinear (polynomial type of third order for age, height, and weight and exponential type for BSA). Multiple regression analysis indicated that age, height, and either weight or BSA had significant positive associations with spleen length. The spleen lengths among the sample of 58 children whose height and weight were outside the normal ranges of growth parameters did not influence the proposed upper limits (almost all were within the 90% UCLs with respect to height and weight for the main sample). CONCLUSION: Normal spleen lengths and ranges in childhood were obtained with US in a large sample of individuals.

Smoking behavior of Greek warship personnel.

The results from a study undertaken to assess the smoking behavior of Greek warship personnel found that of the 274 participants, ages 19 to 38 years, 59.5% were current smokers who started the habit between the ages of 15 and 21 years. However, 33.1% of these current smokers started smoking after entering the Greek Navy. There were statistically significant associations between the habit of smoking and the occurrences of respiratory tract infections, alcohol consumption, lack of aerobic exercise during leisure time, and educational level of the personnel. Another significant association was between the age of introduction into the habit of smoking and the number of cigarettes smoked daily, with the level of education being a contributing factor. The method of entry into the Greek Navy and the rank held made a significant contribution to the time period of initiation into the habit of smoking. The impact of military life on the smoking behavior of the shipboard personnel is discussed and suitable intervention strategies have been recommended.

Validation of a reliable instrument (QUOTE-IBD) for assessing the quality of health care in Greek patients with inflammatory bowel disease.

Given the early onset, the chronic and recurrent nature of their disease and their normal life expectancy, patients with inflammatory bowel disease (IBD) may need considerable health care. The purpose of this study is to validate the Greek translation of the QUOTE-IBD questionnaire (GR-QUOTE-IBD). For that purpose we assessed its construct validity, and reliability. Fifty patients (33 ulcerative colitis, 17 Crohn's disease) completed the GR-QUOTE-IBD and visual-analogue scales (VAS) for the patients' evaluation of the quality of separate care dimensions, and of the total care. A subgroup of 33 patients (64%) completed the GR-QUOTE-IBD for a second time. Quality of life was assessed by the short version of the IBDQ. Clinical activity was assessed by Harvey-Bradshaw index and Colitis Activity Index. Correlations among all care dimensions and VAS were positive and highly significant (p<0.001). The total care and all eight dimensional care scores (quality impact and importance) had no significant differences between the baseline and the follow-up visit. Similarly, the correlation coefficients between the scores of the two occasions were all positive (close to one) and highly significant (p<0.001). The GR-QUOTE-IBD proved to be a valid and reliable instrument, applicable in international clinical studies.

Improved validation of the Inflammatory Bowel Disease Questionnaire and development of a short form in Greek patients.

OBJECTIVES: The Inflammatory Bowel Disease Questionnaire (IBDQ) is a disease-specific questionnaire for assessing health-related quality of life. The main objective of this study is to assess three main areas of the validation of the Greek IBDQ: internal validity, designating items to dimensions, and selecting items for a short form. An additional aim is to present alternative validation methods for improved and robust results. METHODS: A total of 134 patients with IBD, including 74 with ulcerative colitis (UC) and 60 with Crohn's disease (CD), completed the Greek IBDQ. Internal validity was assessed by using standard methods and multiple correlation analysis. Factor analysis of the 32 items of the questionnaire was carried out to identify the underlying dimensions, using principal factor analysis and maximal likelihood. For selecting items for a short form, three methods of linear regression analysis were used. RESULTS: All items had adequate convergent validity (except item 11 in the CD group) and acceptable discriminant validity (except item 11 for both groups). Factor analysis yielded five factors (emotional function, social function, systemic symptoms, bowel symptoms, and abdominal symptoms). The combination of three regression techniques and their internal validity yielded two similar but distinct short forms, one for UC and one for CD. Both forms had high correlation with the total IBDQ score (R(2) = 0.949 and 0.977, respectively). CONCLUSIONS: The Greek IBDQ had good internal validity. The original designation in four dimensions and the original short form could be improved with only slight modifications.

A comparison of Child-Pugh, APACHE II and APACHE III scoring systems in predicting hospital mortality of patients with liver cirrhosis.

BACKGROUND: The aim of this study was to assess the prognostic accuracy of Child-Pugh and APACHE II and III scoring systems in predicting short-term, hospital mortality of patients with liver cirrhosis. METHODS: 200 admissions of 147 cirrhotic patients (44% viral-associated liver cirrhosis, 33% alcoholic, 18.5% cryptogenic, 4.5% both viral and alcoholic) were studied prospectively. Clinical and laboratory data conforming to the Child-Pugh, APACHE II and III scores were recorded on day 1 for all patients. Discrimination was evaluated using receiver operating characteristic (ROC) curves and area under a ROC curve (AUC). Calibration was estimated using the Hosmer-Lemeshow goodness-of-fit test. RESULTS: Overall mortality was 11.5%. The mean Child-Pugh, APACHE II and III scores for survivors were found to be significantly lower than those of nonsurvivors. Discrimination was excellent for Child-Pugh (ROC AUC: 0.859) and APACHE III (ROC AUC: 0.816) scores, and acceptable for APACHE II score (ROC AUC: 0.759). Although the Hosmer-Lemeshow statistic revealed adequate goodness-of-fit for Child-Pugh score (P = 0.192), this was not the case for APACHE II and III scores (P = 0.004 and 0.003 respectively) CONCLUSION: Our results indicate that, of the three models, Child-Pugh score had the least statistically significant discrepancy between predicted and observed mortality across the strata of increasing predicting mortality. This supports the hypothesis that APACHE scores do not work accurately outside ICU settings.

Verification of the median-to-ulnar and ulnar-to-median nerve motor fiber anastomosis in the forearm: an electrophysiological study.

OBJECTIVE: To estimate the real occurrence of the motor median-to-ulnar nerve anastomosis in the proximal forearm (Martin-Gruber anastomosis, MGA), as its frequency varies between 6 and 44% in the literature and to investigate the incidence of the ulnar-to-median nerve anastomosis in the distal forearm. METHODS: Compound muscle action potentials (CMAP) recorded over thenar, hypothenar, and first dorsal interosseus muscle on median or ulnar nerve stimulation at wrist and elbow and collision blocks of the median and ulnar nerve were compared in a group of 50 healthy volunteers. Particular precautions were undertaken in order to avoid false positive results due to stimulus spread to the neighboring nerve. Cases of uncertain MGA were classified as either MGA or non-MGA on the basis of posterior probabilities estimated by discriminant analysis. RESULTS: The estimated frequency of MGA was 54% using the potential comparison method and 46% using the collision technique. An ulnar-to-median nerve anastomosis was not found in any subject. CONCLUSIONS: While the MGA is very common, the ulnar-to-median nerve anastomosis is a rarity. Standard nerve conduction studies of the median nerve with CMAP recordings solely over thenar will detect less than 14% of MGA cases.

Comparison of Ranson, APACHE II and APACHE III scoring systems in acute pancreatitis.

INTRODUCTION: Acute pancreatitis runs an unpredictable course. The early prediction of the severity of an acute attack has important implications for management and timely intervention. AIM: To assess the prognostic accuracy of Ranson and APACHE II and III scoring systems in predicting the severity of acute pancreatitis. METHODS: One hundred fifty-three patients with acute pancreatitis (67.3% gallstone-related, 9.2% alcoholic, 17% idiopathic, and 6.5% of miscellaneous causes) were studied prospectively. Data conforming to the scoring systems were recorded 24 (the APACHE scores) and 48 hours (the Ranson score) after admission. Analysis was performed by using receiver operating characteristic curves (ROC), area under a curve (AUC), and by comparing likelihood ratios of positive test (LRPT). RESULTS: One hundred nineteen cases of pancreatitis were classified as mild, and 34 were classified as severe. The mortality rate was 3.2%. All three scores correlated with length of stay and disease severity. AUC for Ranson was found to be significantly larger than AUC for APACHE II and APACHE III score (0.817, cut-off > or =3; 0.618, cut-off, > or =10; and 0,676, cut-off > or =42 respectively). The Ranson score achieved the highest sensitivity and the lowest false-negative rate, but the positive and negative predictive values and LRPT were of similar extent for all three scores. CONCLUSION: The APACHE III offers little, if any, advantage over the APACHE II score. Ranson criteria proved to be as powerful a prognostic model as the more complicated APACHE II and III scoring systems, but with the disadvantage of a 24-hour delay.

Mental distress and sociodemographic variables: a study of Greek warship personnel.

BACKGROUND: Mental disorders have been found to be the main cause of maladjustment and early discharge of the personnel in the Hellenic Navy and the armed forces in general. This study investigates the mental health status of a warship's military personnel by use of a widely used self-administered scale. METHODS: The 28-item Greek version of the General Health Questionnaire was administered to 281 men aboard a Greek warship to determine their mental health status and to examine possible associations with sociodemographic variables (rank, educational level, marital status). RESULTS: A high prevalence of General Health questionnaire cases (48.8%) was found which indicated conscripts as the group with the greater tendency for problems of adjustment and performance among the personnel of the warship. A negative association was found between educational level and psychological distress, whereas married subjects were found to have better levels of psychological well-being as defined by lower General Health questionnaire scores, compared with unmarried subjects. CONCLUSIONS: Although a further methodological and more sophisticated inquiry is necessary, the findings of the present study could be useful for the design of mental health interventions in the naval and the military setting.

The identification of risk factors for cardiac arrest and formulation of activation criteria to alert a medical emergency team.

AIM: (1) To identify risk factors for in-hospital cardiac arrest; (2) to formulate activation criteria to alert a clinical response culminating in attendance by a Medical Emergency Team (MET); (3) to evaluate the sensitivity and specificity of the scoring system. METHODS: Quasi-experimental design to determine prevalence of risk factors for cardiac arrest in the hospitalised population. Weighting of risk factors and formulation of activation criteria to alert a graded clinical response. ROC analysis of weighted cumulative scores to determine their sensitivity and specificity. SETTING: An acute 700 bed district general hospital with 32,348 adult admissions in 1999 and a catchment population of around 365,000. SUBJECTS: 118 consecutive adult patients suffering primary cardiac arrest in-hospital and 132 non-arrest patients, randomly selected according to stratified randomisation by gender and age. RESULTS: Risk factors for cardiac arrest include: abnormal respiratory rate (P = 0.013), abnormal breathing indicator (abnormal rate or documented shortness of breath) (P < 0.001), abnormal pulse (P < 0.001), reduced systolic blood pressure (P < 0.001), abnormal temperature (P < 0.001), reduced pulse oximetry (P < 0.001), chest pain (P < 0.001) and nurse or doctor concern (P < 0.001). Multivariate analysis of cardiac arrest cases identified three positive associations for cardiac arrest: abnormal breathing indicator (OR 3.49; 95% CI: 1.69-7.21), abnormal pulse (OR 4.07; 95% CI: 2.0-8.31) and abnormal systolic blood pressure (OR 19.92; 95% CI: 9.48-41.84). Risk factors were weighted and tabulated. The aggregate score determines the grade of clinical response. ROC analysis determined that a score of 4 has 89% sensitivity and 77% specificity for cardiac arrest; a score of 8 has 52% sensitivity and 99% specificity. All patients scoring greater than 10 suffered cardiac arrest. CONCLUSION: Risk factors for cardiac arrest have been identified, quantified and formulated into a table of activation criteria to help predict and avert cardiac arrest by alerting a clinical response. A graded clinical response has resulted in a tool that has both sensitivity and specificity for cardiac arrest.

Role of appendicitis and appendectomy in the pathogenesis of ulcerative colitis: a critical review.

Besides a genetic predisposition, a causal role of various environmental factors has been considered in the etiology of ulcerative colitis (UC). The association between appendectomy and UC has recently been the subject of intense scrutiny in the hope that it may lead to the identification of important pathogenetic mechanisms. Published data from animal models of colitis demonstrated reduction in experimental colitis after appendectomy, especially if performed at an early age. Several epidemiological case control and cohort studies have shown a strong and consistent relationship. The metaanalysis of 17 case-controlled studies showed an overall odds ratio 0.312 (95% confidence intervals = 0.261-0.373) in favor of appendectomy (p < 0.0001). One of the two recent large cohort studies is in agreement with these results, but the other failed to confirm them. All these studies have suggested that alterations in mucosal immune responses leading to appendicitis or resulting from appendectomy may negatively affect the pathogenetic mechanisms of UC. Further investigation of the role of appendectomy in UC is expected to open new fields for basic scientific research and may lead to the improvement of our understanding for the disease pathogenesis.

Assessing health-related quality of life in patients with inflammatory bowel disease, in Crete, Greece.

BACKGROUND: Health Related Quality of Life (HRQoL) is an important outcome measure in Inflammatory Bowel Disease (IBD). The aim of our study was to assess HRQoL in a population of 135 Greek patients with IBD. METHODS: A cohort of 135 patients with IBD, 81 with ulcerative colitis (UC) and 54 with Crohn's disease (CD) were enrolled in our study. Demographic and disease-related data were recorded. HRQoL was assessed by a disease-specific and a generic questionnaire, IBDQ and SF-36, respectively. Disease activity was assessed by Harvey-Bradshaw Index and the Colitis Activity Index for CD and UC patients, respectively. RESULTS: Among all variables recorded in our study, only disease activity had a significant effect on HRQoL. Patients with active disease scored significantly lower on both IBDQ and SF-36 when compared to those in remission. Only two among the four IBDQ dimensions, bowel and systemic, had significant ability in distinguishing best patients in remission from those with active disease. CONCLUSIONS: IBD has a negative impact on HRQoL. Patients with active disease are more impaired than patients in remission. In our population of patients bowel and systemic dimensions had a predominant value in patients' perception of quality of life. Patients in our study using the same instrument scored higher than previously reported.

Increasing incidence of cholangiocarcinoma in Crete 1992-2000.

BACKGROUND: There have been recent reports of an increased incidence of cholangiocarcinoma. PATIENTS AND METHODS: Patients with cholangiocarcinoma, resident on the island of Crete, diagnosed between 1992 and 2000, were studied. Case ascertainment was enhanced by collaboration of the pathology departments and all gastroenterologists of Crete in providing relevant data. A specially designed patient protocol was used. Crude incidence rates are presented. RESULTS: During the 9-year period 7 patients were diagnosed with cholangiocarcinoma of the intrahepatic ducts, 17 with Klatskin and 16 patients with extrahepatic ducts carcinoma. A steady incidence increase of cholangiocarcinoma, irrespective of location, was shown. The estimated incidence rate per three-year period progressively increased from 0.998 to 2.329 and 3.327 per 100,000 for the periods 92-94, 95-97 and 98-2000, respectively. Median survival time was 8.5 months. No significant difference was seen between survival according to the location of cholangiocarcinoma. CONCLUSION: A steady incidence increase of cholangiocarcinoma cases in Crete during the time-period 1992-2000 was shown.