A new dental unit for both patients in wheelchairs and general patients

Objective: To develop a dental unit to accommodate both patients in wheelchairs and general patients, and to evaluate the acceptability of the new chair for patients and dentists. Design: To integrate a unit for patients in wheelchairs and a unit for general patients into a single dental unit. Results: (1) The newly developed dental unit could be used for both patients in wheelchairs and general patients and could be installed in nearly the same space as occupied by a conventional dental unit. (2) The dentists could take the home position because of the height‐adjusting and tilting mechanisms. (3) The patients could be treated with a sense of assurance because of the wheelchair immobilizer and the safety devices. (4) The dentists could perform patient treatment safely. (5) As patients did not need to be transferred from their wheelchairs, assistance was unnecessary. (6) From the questionnaires, both patients and dentists rated the newly developed dental unit favourable. Conclusions: The new dental unit for patients in wheelchairs and general patients permitted dentists to perform and patients to receive dental treatment safely and in a comfortable position. Also, as a single unit could be used for treatment of both types of patients, it required no extra space. Therefore, it has the potential to be installed in the clinics of general dental practitioners to treat both groups of patients.     

A study of platelet function and morphology in a new family with May-Hegglin anomaly

A new family with May-Hegglin anomaly is presented. 9 patients were found to be affected, namely to present thrombocytopenia, giant platelets, and leukocytes inclusion bodies. A mild to moderate hemorrhagic diathesis was present in 8 patients (easy bruising, excessive bleeding after tooth extraction, menomethrorrhagia). One patient was asymptomatic. The bleeding tendency seemed to be relatively more pronounced in those patients who have larger platelets. Bleeding time was slightly prolonged in 4 of the affected patients. Platelet aggregation to Ristocetin and serotonin release was normal; on the contrary, platelet adhesiveness was slightly decreased in all patients. Plasma Btg was investigated in 7 patients, found to be normal in 5 and elevated in 2. Platelet Btg was found to be increased in all patients investigated. The ratio between Btg and platelet number was elevated in every instance. The circulating platelet mass (Btg platelet mass microgram/ml) was investigated in 7 patients, found normal in two and decreased in the remaining three. The disorder is transmitted as an autosomal dominant trait but there seems to be a variable phenotypic expression from one patient to the other.     

Characteristics of a population of women with breast implants compared with women seeking other types of plastic surgery

Several previous studies have shown that breast implant patients demonstrate a number of differences compared with the general population. However, studies have not compared patients with breast implants with women receiving other types of plastic surgery, of interest because this latter group has been proposed as a comparison group for assessing the long-term health effects experienced by breast implant patients. Questionnaire data obtained from 7447 breast implant patients and 2203 patients with other types plastic surgery were collected during the course of a retrospective cohort study, to determine whether implant patients demonstrate different characteristics compared with a more restricted group of patients. In contrast to previous investigations that compared implant patients with the general population, distinctive differences with respect to family income, number of pregnancies, alcohol consumption, cigarette smoking, or histories of previous gynecologic operations or operations for benign breast disease were not found. However, implant patients were significantly more likely than other plastic surgery patients to be white, have low levels of education, have early ages at first birth, be thin, and be screened frequently for breast disease. Furthermore, implant patients reported somewhat greater use of exogenous hormones and familial histories of rheumatoid arthritis. These results support the notion that other plastic surgery patients are a more appropriate comparison group than women in the general population for studies of the health effects of breast implants; however, there continue to be distinctive characteristics possessed by breast implant patients, which need to be taken into account in an assessment of what disease effects can be uniquely attributed to silicone breast implants.     

Carnitine palmitoyltransferase II deficiency: Diagnosis by molecular analysis of blood

Four missense mutations have been reported to be associated with the typical, adult form of carnitine palmitoyltransferase II (CPT II) deficiency: Three amino acid substitutions (R631C, P50H and D553N) appear to be rare, while the S113L mutation was found to be common in a group of European patients with CPT II deficiency.We analyzed genomic DNA from 20 American patients with recurrent episodes of myoglobinuria as well as DNA from 10 normal controls in order to determine the frequency of the reported missense mutations in our patient population.The three previously described rare mutations were not found in our group of patients. The S113L mutation was found in 19 of our patients: 5 patients were homozygous, 14 patients were heterozygous.Given the high frequency of this mutation in our series of patients we concluded that the clinical diagnosis of CPT II deficiency can be confirmed by a 'blood test' without resorting to a muscle biopsy.     

Prophylaxis and treatment of bacterial infections: do we need new strategies?

Bacterial infections in patients with hematologic malignancies still represent a severe and life-treating problem. Several observational studies during the last decade have revealed that neutropenic patients with fever are a heterogeneous population with various differences regarding response to initial therapy, development of serious complications and mortality. The role of neutropenia as main risk factor for infections in hematologic patients and the definition of different level of risk related to neutrophils count and duration of neutropenia have been extensively studied and different categories of patients based on the risk of infection, mostly the condition of neutropenia, have been clearly defined. The strategies on antimicrobial therapy and supportive care in hematologic patients need to be continuously assessed, in fact new conditions favouring the occurrence of infectious complications in patients with hematologic malignancies have progressively emerged. The use of oral prophylactic antibiotics in neutropenic cancer patients is still a matter of debate. Before 2005, several trials showed how the prevention of infection can be extremely important in this setting of patients but none was conclusive. In 2005 two meta-analysis and two large randomized clinical trials gave new evidence that antibacterial prophylaxis can reduce in neutropenic patients several important outcomes including mortality. The use of the empiric antibacterial therapy represents the cornerstone of the antimicrobial strategies in the febrile neutropenic patients leading, over the span of 20 years, to a dramatic decrease of deaths: Actually beta-lactam monotherapy is commonly used for the empiric treatment of febrile neutropenia. Recently, large randomized clinical trials and meta-analysis showed that the addition of an aminoglycoside and/or a glycopeptides results in a more favourable outcome only in selected severe infections. The use of antibiotics should be prudent and safe also in neutropenic hematologic patients to prevent emergence of microbial resistance, to save costs, to reduce toxicity. For this reasons, according to the evidence, antibacterial prophylaxis should be restricted to high risk hematologic patients and empiric parenteral antibiotic monotherapy should be recommended in case of febrile neutropenia limiting the use of amynoglicosides and glycopeptides. In the next future, a major effort should be made to state in hematologic patients new risk factors which could more accurately define subgroups for targeted anti-infective strategies.     

Personal observations of dobutamine effectiveness after surgery with extracorporeal circulation

This report describes the use of dobutamine in patients presenting a low output syndrome after cardiosurgical operations i EEC. Of 565 patients operated on valvular heart defects and coronary artery disease in 89 patients (15.7%) a low output syndrome was diagnosed and treated. Dobutamine proved to be effective in patients with moderate impairment of the left ventricular contractility. In those with severe left ventricular dysfunction, dobutamine was ineffective and other catecholamines ought to be used. The authors support the view that combined administration of dobutamine (or other catecholamines) and nitroglycerin in patients with low output syndrome proves to be superior to the effect of each single drug.     

初始沙盘在临床心理中的诊断鉴别作用

目的:探讨患者初始沙盘在临床心理中的诊断鉴别作用。方法:选择4名在临床中被误诊的患者。其中A例患者诊断一般心理问题;B、C、D例患者诊断为精神分裂症;使用沙盘对该4例患者重新进行临床分析与诊断。结果:根据患者初始沙盘中是否给玩具赋予特殊意义、使用玩具的多少、玩具之间是否有联系、使用栅栏情况、沙盘主题以及患者对沙盘的解释等对4名被误诊的患者进行重新诊断;A例患者重新诊断应为精神分裂症;B例患者应为强迫症(强迫思维);C例患者应为边缘型人格障碍;D例患者应为人际关系障碍。结论:在临床心理工作中,患者的初始沙盘可以起到高效、准确的诊断鉴别作用。     

Management of traumatic intracranial haematoma.

Deciding which head-injured patients should be transferred to a neurosurgical unit can be difficult. Traditional criteria emphasise the development of deteriorating responsiveness but lead to delayed diagnosis and to avoidable mortality and morbidity. To discover if a more liberal admission policy improved results a study was conducted analysing data collected prospectively from 683 patients who had a traumatic intracranial haematoma evacuated in the Glasgow neurosurgical unit between 1974 and 1980. In the first four years, before the change in policy, mortality was 38% but decreased to 29% afterwards. This reflected a reduction in the proportion of patients who talked after injury but who deteriorated into coma before operation--that is, 31% before the change in policy, 16% afterwards. If the potential benefits of CT scanning in the management of head injuries are to be realised patients must be scanned sooner than in the past. This will usually mean that more patients should go to a neurosurgical unit and that simple criteria for transfer should be established.     

Perception of unsteadiness in patients with dizziness: association with handicap and imbalance

Dizziness is a common problem in patients seeking medical help and is often associated with imbalance and handicap. This study aimed to reveal whether the perception of unsteadiness could be an indication of greater imbalance and handicap in these patients. Patients with dizziness were categorized into two groups, steady patients (n = 15) and unsteady patients (n = 23), based on the presence or absence of self-perceived unsteadiness. The level of self-perceived handicap was evaluated by the Dizziness Handicap Inventory. Static balance ability was evaluated using a force platform and the center of pressure motion was calculated during various quiet standing conditions. Dynamic balance ability was evaluated by the functional forward reach test and Dynamic Gait Index. All the patients also went through isometric strength tests of the lower extremities. It was found that all patients reported themselves to be handicapped by dizziness. Patients who perceived themselves to be unsteady had greater handicap and poorer static standing, but did not differ from the steady patients in regard to muscle strength or functional balance tests. Thus, self- perceived unsteadiness was associated with greater handicap and poorer static balance in dizzy patients. In clinical management of these patients, special attention should be paid to balance and handicap.     

Genetic analysis of tall stature

Tall stature is less often experienced as an important problem than short stature. However, a correct diagnosis may be of eminent importance, especially when interventions are planned, or to know the natural history. Overgrowth can be caused by endocrine disorders and skeletal dysplasias, but also by several genetic syndromes. Despite a systematic diagnostic approach, there will be patients with tall stature who do not fit a known diagnosis. In this group of patients possibilities of genetic analysis do exist, but are not common practice. The FMR1 gene should be analyzed in patients with tall stature and mental retardation, and in these patients the NSD1 gene can be considered whenever some features of Sotos syndrome do exist. In tall patients without mental retardation and some features of Sotos or Beckwith-Wiedemann syndrome it may still be useful to look for mutations in the NSD1 gene, but also for changes in the 11p15 region. The various possibilities are discussed and placed in a flowchart.     

Primary angioplasty: preprocedural pharmacological therapy

Primary coronary angioplasty has been shown to be an effective reperfusion therapy for patients with acute myocardial infarction, not only for those who present to PTCA centres but also for patients who present to hospitals without angioplasty facilities. With the increasing use of primary angioplasty more patients will be transferred to a (tertiary) PTCA centre. An increase in treatment delay is associated with a worse clinical outcome. The importance of an open infarct-related vessel at acute angiography is becoming clear. Pharmacological pretreatment of patients during transportation to a PTCA centre with the aim to open the infarct-related vessel in advance might be beneficial. Glycoprotein IIb/IIIa receptor blockers seem to be the agents of choice for facilitated PTCA. The safety and (cost) effectiveness of this pretreatment of patients transported to undergo primary angioplasty remain to be evaluated.     

Ascertainment and treatment of delayed puberty

The majority of patients with pubertal delay, can be classified as having primary pubertal delay (constitutional delay of growth and puberty, CDGP), although any child with a chronic disease could present with delayed puberty. In contrast, children with hypogonadism, either hyper- or hypogonadotropic, exhibit a total absence of pubertal development. Hence, early evaluation of these patients should be performed. Delay of puberty leads to psychological problems, secondary to short stature and/or delay in the acquisition of secondary sex characteristics and the reduction of bone mass. Although the final height in patients with CDGP is usually normal, some of these patients do not reach the third percentile or remain in the lowest part of the growth chart according to familial height. The most common reason for treating CDGP patients, usually with sex steroids, is for psychological difficulties and for loss of bone mineralization. Treatment must be individualized. Therapeutic options and new drugs will be discussed. Appropriate treatment and adequate nutritional intake are indicated in patients with delayed puberty due to chronic illness. In patients with hypo- or hypergonadotropic hypogonadism, puberty must be induced or completed. Different treatments (GnRH analogues, gonadotropins and sex steroids), and the main objectives are discussed.     

Connaître les particularités du traitement par antivitamine K chez le patient âgé ou comment minimiser leur iatrogénie ?

Elderly patients are commonly frail, due to a lot of comorbid conditions and numerous medications. These patients are at high risk of bleeding when treated with vitamin K antagonist (VKA). Special considerations on the choice of VKA drug, dosing and monitoring have to be taken into account in the elderly in order to avoid over-anticoagulation and to minimize the haemorrhagic risk which consequences may be dramatic or fatal in this age group. In these patients, INR monitoring is crucial, especially at the start of treatment. The use of dosing algorithms specifically developed for elderly patients allows to decrease over-anticoagulation during the initiation period. INR has to be monitored more frequently in case of acute illness or in case of modification of the associated drugs. Patient education is of great importance, even in geriatric patients and has been shown to improve the quality of anticoagulation. New oral anticoagulants with a wider therapeutic index seem to be of great interest.     

Effect of Ascorbic Acid Supplementation on Certain Oxidative Stress Parameters in the Post Reperfusion Patients of Myocardial Infarction

Reperfusion injury causes oxidative stress thereby resulting in an imbalance between oxidant-antioxidant systems. In the present communication, the effect of ascorbic acid supplementation has been studied on certain oxidant and antioxidant parameters in the blood of the patients with myocardial infarction before and after thrombolysis. In patients after thrombolysis, the activity of antioxidant enzyme, superoxide dismutase, in the blood was found to be significantly reduced where as the activity of the oxidant enzyme, xanthine oxidase, was found to be significantly increased. Malondialdehyde levels, the index of free radical mediated damage, was also found to be significantly elevated in thrombolyzed patients compared to the patients before thrombolysis. Supplementation of vitamin C to the post reperfusion patients restored these parameters back to normal or near normal levels.     

Should patients positive for HIV infection receive pneumococcal vaccine?

Pneumococcal vaccination effectively reduces the incidence of invasive pneumococcal disease in normal subjects. Such invasive pneumococcal disease is 100 times more common in patients with HIV infection than in healthy people, so it seems logical to target this group of patients for vaccination. Few clinics routinely vaccinate patients positive for HIV, despite Department of Health guidelines. This is because of uncertainty about the vaccine''s efficacy in HIV disease. There are many reasons to suspect that the vaccine will fail to protect these patients, including the fact that antibodies alone may not be sufficient protection against all serogroups of Pneumococcus and the vaccine works in healthy people but not immunocompromised subjects. Vaccination of HIV positive patients may not be indicated, at least for the time being. The cost of vaccinating such patients in the absence of data showing efficacy may well be less than the cost of a necessarily large and lengthy trial. But the truth must be sought to end current indecision.     

Head injuries in three Scottish neurosurgical units. Scottish head injury management study.

The organisation of care for patients with head injuries in Scotland was investigated by studying retrospectively 785 patients admitted in 1974 and 1975 to neurosurgical units in Glasgow, Aberdeen, and Dundee. The reasons for the injuries and the patients'' clinical conditions were similar in each unit. The referral practices at the hospitals containing the units were compared and found to be different from that of the unit in Edinburgh. It is concluded that patients in the Glasgow, Aberdeen, and Dundee units, which operate a similar policy for head-injured patients, are in general similar. Transferring to a neurosurgical unit only selected patients rather than all patients with head injuries is safe practice only if policies are agreed with primary surgeons and patients can be transferred without delay.     

Meiotic studies of infertile men in case of non-obstructive azoospermia with normal karyotype and no microdeleted Y-chromosome precise the clinical couple management

To identify meiotic criteria for infertility management in non-obstructive azoospermic men, a prospective and multicentric study was organized in Andrological Departments of Paris (France), Roma (Italy) and Budapest (Hungary). In 117 non-obstructive azoospermic men with normal karyotype and no Y-chromosome microdeletion, histology and meiotic studies on bilateral bipolar testicular biopsies were done. Histologically, 40 patients (34%) presented spermatocyte or spermatid arrest, 39 (33%) hypospermatogenesis whereas no meiotic cell could be observed in the remaining patients (33%). Cytogenetically, meiotic figures could only be obtained from the two first histological groups. Meiotic abnormalities were observed in a total of 44 patients (37.6%) including nine patients (7.7%) with severe class I and class IIB anomalies and 19 patients (16.2%) with class IIC environmentally linked meiotic abnormalities. These results provided essential clues for an accurate clinical management. For patients with no meiotic figures and patients with class I and class IIB anomalies, an hormonal stimulation is illusory and a sperm gift should be directly proposed. An hormonal stimulation should be proposed to all the other patients, either directly or following the treatment of the testicular microenvironment for the patients presenting class IIC anomalies. The genetic risk and possibility of prenatal chromosomal analysis in case of pregnancy should be clearly exposed to all the couples in all the cases where type IIA, III or IV anomalies are present. This therapeutical strategy has been applied to all the patients in our series.     

区域效应－一个前列腺癌早期诊断的新思路

目前临床上有许多怀疑前列腺癌但穿刺阴性的病例,为了避免漏诊,多数患者必须接受重复穿刺。尽管部分患者经重复穿刺确诊为前列腺癌,而更多患者经过长期随访以及反复穿刺最终确诊为良性病变。近期研究证实,癌灶附近的组织学表现正常的组织中也可发生与癌灶相似的分子改变。因此,我们认为在前列腺癌的发生过程中存在区域效应。在这一理论指导下,选择适当的可反映前列腺癌区域效应的标记物,在穿刺阴性的标本中检出与癌灶相似的分子改变,就可以帮助临床医生在常规病理诊断之前,提前预测前列腺癌的发生。如果能够找到这样的标记物,并在大规模的诊断试验中证实其可行性,那么就可以极大地改善前列腺癌诊断的现状。     

Coronary pressure and FFR predict long-term outcome after PTCA

Although coronary stents have been the most important improvement in percutaneous coronary interventions in the last 10 years, it is well known to interventionalists that many patients after percutaneous transluminal coronary angioplasty (PTCA) have a favourable outcome without stenting. Coronary angiography, however, is not sensitive enough to identify those particular patients and it has been suggested that a combination of angiographic and functional criteria would be more suitable to distinguish patients with a low restenosis chance after plain balloon angioplasty. In the present study, the authors investigated the value of coronary pressure measurement for conditional stenting in 85 patients. It was demonstrated that in patients in whom a high fractional flow reserve (FFR) was present (> 0.90), the incidence of coronary events at two-year follow-up was almost three times lower than in those patients with an FFR below 0.90. Such high FFRs could be obtained in approximately 45% of all patients. In an additional group of patients, it was demonstrated by intravascular ultrasound (IVUS) studies that the mechanism of a high FFR after plain balloon angioplasty is most likely the result of a larger lumen compared with patients with a suboptimal FFR. This means that, in patients in whom both the angiographic and the functional result after PTCA is optimal, a restenosis rate is achieved similar to that achieved by stenting. Obviously, in such patients, additional stenting and a number of problems in the long-term possibly related to stenting can be avoided. Therefore, coronary angiography and coronary pressure measurement have a complementary value in the evaluation of PTCA results and such information can be easily obtained by using a pressure wire instead of a regular guidewire.     

Invasive fungal infection in immunocompromised patients

At present, the concept of immunocompromised patient cannot be applied exclusively to the classic groups of cancer, HIV-infected or transplanted patients. The cytotoxic treatment of patients with much more common conditions such as asthma, inflammatory bowel disease or rheumatoid arthritis has produced an exponential increase in the universe of patients with different degrees of immunological commitment. The generalization of transplantation procedures, even in advanced ages of life, the prolonged survival of patients with cancer and the decrease of the viral load in HIV-infected patients have resulted in long-term immunosupresions. The prevalence of invasive fungal infections (IFIs) is increasing in immunocompromised patients but each group of immunocompromised patients present peculiarities that must be recognized to be addressed appropriately. Despite the recent advances in the diagnosis and treatment of IFIs, they still present unacceptable morbility and mortality rates. Although IFIs are commonly caused by Candida spp. or Aspergillus spp., a variety of fungi are emerging as agents of IFIs. These emerging fungi require an individualized basic and clinical study. The aim of this work is to review the IFIs caused by common and emerging fungi in the three more numerous groups of immunocompromised patients: HIV-infected patients, solid organ transplant recipients and cancer patients, especially those with hematological malignancies or hematopoietic stem-cell transplantation.