Osler's maneuver in an outpatient clinic setting

Osler's maneuver was performed on 912 consecutive outpatients aged 60 years of older in a 2-month period by 12 physicians. The incidence of an Osler-positive finding was 7.1% (65/912). The number of positive findings increased with age, ranging from 3.4% in the 60- to 70-year age group to 43.8% in the 86- to 90-year age group. A history of hypertension was present in 58.4% of patients with Osler-positive findings and in 59.6% of patients with Osler-negative findings. In a group of 48 previously screened patients who were independently examined, concordance was poor when the kappa test of reliability was used. Positive Osler findings were common in patients older than 70 years, in patients who smoked, and in patients with a high systolic blood pressure. These correlations may be related to a decrease in blood vessel compressibility, which may cause pseudo-hypertension. However, the findings on Osler's maneuver, are poorly reproducible, making the procedure an inadequate test.     

Epidemiology, clinical course and impact on hospitalization costs of acute diarrhea among hospitalized children in Athens, Greece.

The aim of this study was to describe the etiology, morbidity and hospitalization costs associated with acute diarrhea among hospitalized children in Greece. During 1999, 294 hospitalized children (median age 1 y) with acute diarrhea were prospectively studied. Bacterial and viral enteropathogens were detected in 100 (34%) and 37 (12.5%) patients, respectively; 17 (6%) patients had mixed infections. Isolated agents included Salmonella spp. (43 patients; 15%), rotavirus (32; 11%), Campylobacter spp. (26; 9%), enteropathogenic Escherichia coli (16; 5.5%), Shigella spp. (11; 4%), Aeromonas spp. (7; 2.5%), adenovirus (6; 2%), Yersinia enterocolitica (6; 2%), enterohemorrhagic Escherichia coli (2; 0.5%) and Giardia lamblia (1; 0.5%). Of the patients with bacterial infection, 70% were admitted between April and September 1999. A rotavirus-associated peak was noted in March. Patients with a bacterial infection were hospitalized for longer periods than those with viral infections. It is concluded that bacterial enteropathogens account for one-third of admissions due to acute diarrhea among children in Greece and are associated with significant hospitalization costs. Rotavirus is also a frequent cause of acute diarrhea necessitating hospitalization.     

Safety and efficacy of sedation with propofol for transoesophageal echocardiography in children in an outpatient setting

BACKGROUND: Transoesophageal echocardiography has become a powerful tool in the diagnosis and management of children with congenital cardiac malformations. Unlike adults, children will not tolerate transoesophageal echocardiography under light sedation. This study was undertaken, therefore, to evaluate the safety and efficacy of deep sedation with propofol for transoesophageal echocardiography in children examined in an outpatient setting. METHODS: This is a retrospective study of patients undergoing transoesophageal echocardiography with propofol given in bolus aliquots to achieve a level of sedation adequate to insert the transoesophageal echocardiographic probe and maintain sedation throughout the procedure. RESULTS: We included a total of 118 patients, 57% being male, with a mean age of 12.9 years. Adequate sedation was achieved using a mean propofol dose of 8.3 milligrams per kilogram, with the dose per kilogram decreasing concomitant with increasing weight of the patient. Patients less than two years of age were intubated for the procedure. There were no clinically significant changes in cardiac function or haemodynamics. Non-intubated patients received supplemental oxygen prior to, or just after, the onset of sedation, with transient hypoxaemia observed in one-fifth. Complications were rare, with minor problems occurring in 7.6%, and major ones in 4%. CONCLUSIONS: Transoesophageal echocardiography can be performed on an outpatient basis in children with a wide spectrum of congenital cardiac malformations, and propofol is an ideal sedative agent in this setting. Although not common, preparations must be made for significant haemodynamic and respiratory complications. In our study, we intubated all the children under 2 years of age.     

Reliability of a medication adherence measure in an outpatient setting

BACKGROUND: Reliable approaches for measuring antihypertensive medication compliance in the outpatient setting are not readily available. The objective of the current study was to determine the reliability of the Hill-Bone Compliance Scale among elderly hypertensive patients. METHODS: We conducted a cross-sectional survey of community-dwelling patients attending the hypertension section of the Internal Medicine Clinic in a large multispecialty group practice. Participants (n=239) completed a self-administered questionnaire consisting of demographic questions and the Hill-Bone Compliance to High Blood Pressure Therapy Scale, which includes a nine-item medication compliance subscale. RESULTS: The mean age of respondents was 69 years; 51% of patients were men, 73% were white, 86% had at least a high school education, and 61% were married. The Cronbach alpha was 0.68 for the medication compliance subscale. All nine items of the medication compliance subscale maintained higher correlations with their own subscale total than with the salt intake and appointment keeping subscale totals. After adjusting for other demographic variables, the odds ratio (95% confidence interval) of perfect medication compliance as reported on the medication compliance subscale was 1.71 (0.95-3.07) for participants 65 years of age and older versus those younger than 65 years of age, 2.53 (1.37-4.66) for whites versus nonwhites, 1.27 (0.73-2.20) for males versus females, 1.30 (0.73-2.29) for married versus unmarried participants, and 1.63 (0.74-3.62) for those with at least a high school education versus those with less education. CONCLUSION: The medication compliance subscale of the Hill-Bone Compliance Scale appears reliable and may be a useful tool for detecting noncompliant patients in outpatient settings.     

Strongyloides stercoralis infection as a cause of acute granulomatous appendicitis in an HIV-positive patient in Athens,Greece

A case of acute granulomatous appendicitis due to Strongyloides stercoralis infection in an HIV-positive patient is described. To our knowledge this is the first case presented in the literature.     

Characterization of life quality in patients with respiratory tuberculosis treated in the outpatient setting

The overall Life Quality-100 questionnaire recommended by the World Health Organization was used to survey 29 patients with active respiratory tuberculosis and 19 healthy persons. Life quality (LQ) was assessed by 24 items pooled to form 6 categories. There were significant differences in the overall life quality and in the mental health scale. The activity, mobility, physical status of the patients were impaired. The survey revealed the aspects lowering LQ in patients with active respiratory tuberculosis. It is concluded that individual psychosocial correction of the status of a patient with tuberculosis is promising in making his/her life quality normal.     

Management approaches to adrenal incidentalomas (adrenalomas). A view from Athens, Greece.

We believe the management of adrenalomas should include the following: 1. A detailed history and physical examination to detect subtle evidence of hormonal hypersecretion or the possibility of metastatic carcinoma 2. Hormonal studies, such as The short dexamethasone suppression test (2 mg of dexamethasone) followed by a high-dose dexamethasone suppression test (8 mg), CRH assay, and analysis of the diurnal cortisol rhythm if serum cortisol is greater than 3 micrograms/dL 24-Hour (or spot) urinary catecholamine metabolites (metanephrine and normetanephrine) Plasma aldosterone level and renin activity in the hypertensive or normotensive patient with serum potassium less than 3.9 nmol/L 3. Additional imaging studies, such as MR imaging 131I-iodocholesterol (NP59) scanning to detect a subclinically functioning adenoma or carcinoma (MIBG scanning is rarely indicated) The role of FNA is limited. This modality may be helpful only in the patient with coexistent extradrenal carcinoma to confirm adrenal metastasis. Although genetic and molecular biology studies do not have wide clinical application, they should be encouraged and supported. Once all of these data are collected, the clinician should perform the following two steps: 1. All clearly nonfunctioning adrenalomas that are not suspicious for malignancy should be observed for several years, mainly with hormonal studies, until their secretory and benign nature is confirmed. 2. All patients with adrenalomas with evidence of subclinical function or potential for malignancy (using size, imaging, FNA, and molecular biology criteria) should undergo laparoscopic adrenalectomy for definitive diagnosis and therapy. The age, the overall medical condition, and the anxiety of the patient should be considered in the decision to operate on a patient with an adrenaloma.     

The Effect of Weather Variability on Pediatric Asthma Admissions in Athens,Greece

The aim of this study was to determine whether there is any association between weather variability and asthma admissions among children in Athens, Greece. Medical data were obtained from hospital registries of the three main Children's Hospitals in Athens during the 1978–2000 period; children were classified into two age groups: 0–4 and 5–14 years. The application of Generalized Linear Models with Poisson distribution revealed a significant relationship among asthma hospitalizations and the investigated parameters, especially for the children aged 0–4 years. Our findings showed that Hospital admissions for childhood asthma in Athens, Greece, is negatively correlated with discomfort index, air temperature and absolute humidity whereas there is a positive correlation with cooling power, relative humidity and wind speed.     

The Effect of Weather Variability on Pediatric Asthma Admissions in Athens, Greece

The aim of this study was to determine whether there is any association between weather variability and asthma admissions among children in Athens, Greece. Medical data were obtained from hospital registries of the three main Children's Hospitals in Athens during the 1978-2000 period; children were classified into two age groups: 0-4 and 5-14 years. The application of Generalized Linear Models with Poisson distribution revealed a significant relationship among asthma hospitalizations and the investigated parameters, especially for the children aged 0-4 years. Our findings showed that Hospital admissions for childhood asthma in Athens, Greece, is negatively correlated with discomfort index, air temperature and absolute humidity whereas there is a positive correlation with cooling power, relative humidity and wind speed.     

Predictive validity of a medication adherence measure in an outpatient setting

This study examines the psychometric properties and tests the concurrent and predictive validity of a structured, self-reported medication adherence measure in patients with hypertension. The authors also assessed various psychosocial determinants of adherence, such as knowledge, social support, satisfaction with care, and complexity of the medical regimen. A total of 1367 patients participated in the study; mean age was 52.5 years, 40.8% were male, 76.5% were black, 50.8% graduated from high school, 26% were married, and 54.1% had income <$5,000. The 8-item medication adherence scale was reliable (alpha=.83) and significantly associated with blood pressure control (P<.05). Using a cutpoint of <6, the sensitivity of the measure to identify patients with poor blood pressure control was estimated to be 93%, and the specificity was 53%. The medication adherence measure proved to be reliable, with good concurrent and predictive validity in primarily low-income, minority patients with hypertension and might function as a screening tool in outpatient settings with other patient groups.     

Evaluation of a tympanic membrane thermometer in an outpatient clinical setting

Temperature measurement is one of the most commonly performed medical procedures. A study was conducted to evaluate the correlation between temperature measurements obtained by glass-mercury and infrared tympanic membrane thermometers. One hundred two patients completed the study, and the mean difference between the two methods of temperature measurement was -0.311 +/- 0.691 C (95% confidence interval, +1.071 to -1.693 C). The relationship between the two devices as calculated by linear regression analysis is tympanic membrane temperature = 0.74 x oral/rectal temperature + 10.2 (r = .763). In view of the poor correlation found in our study, we cannot recommend automatic substitution of the glass-mercury thermometer with an infrared tympanic membrane device.     

Cryptosporidial diarrhoea in children

Summary By auramine and modified Ziehl-Neelsen staining, cryptosporidial oocysts were found in the stools of 31 (1.36%) out of 2,367 patients with diarrhoea. All specimens were also tested for Salmonella, Shigella, Campylobacter, Yersinia, and Rotavirus. Among these patients, 432 were children and 24 (5.5%) of them were positive for cryptosporidia. All children infected with cryptosporidia were immunocompetent. Watery diarrhoea, vomiting and abdominal pain were the most frequent symptoms. The survey showed that in patients with gastroenteritis, cryptosporidial oocysts were found more commonly in the stools of children than in those of adults, and the prevalence of infection was the highest in August and September (16 cases). The epidemiological aspects and clinical significance are discussed.

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Kryptosporidien-Diarrhoe bei Kindern

Zusammenfassung Mit Hilfe einer Auramin- und einer modifizierten Ziehl-Neelsen-Färbung wurden Kryptosporidien-Oozysten in den Stühlen von 31 (1,36%) der 2367 untersuchten Patienten mit Durchfall gefunden. Alle Proben wurden daneben auf Salmonellen, Shigellen, Campylobacter, Yersinien und Rotaviren untersucht. Unter den Patienten befanden sich 432 Kinder, von denen 24 (5,5%) einen positiven Kryptosporidien-Nachweis aufwiesen. Alle mit Kryptosporidien infizierten Kinder waren immunkompetent. Die häufigsten mit einer Kryptosporidien-Infektion einhergehenden Symptome waren wäßrige Diarrhoe, Erbrechen und Abdominalschmerzen. Bei Gastroenteritis wurden Kryptosporidien-Oozysten häufiger im Stuhl von Kindern als im Stuhl von Erwachsenen gefunden. Die Inzidenz der Infektion war in den Monaten August und September (16 Fälle) am höchsten. Sowohl epidemiologische Gesichtspunkte als auch die klinische Bedeutung dieser Befunde werden diskutiert.

     

Chronic diarrhoea in children

Chronic diarrhoea in children shows an age related spectrum. In infants and young children a major role is related to persistent intestinal infections, intolerance to specific nutrients such as cow's milk protein, and toddler's diarrhoea. In older children and adolescents, inflammatory bowel diseases are strongly increasing and nonspecific diarrhoea is also frequent. Coeliac disease is a major cause of diarrhoea throughout childhood. In neonates, congenital diarrhoea is a rare but severe syndrome that includes several highly complex diseases. In children, diagnosis should be based on noninvasive techniques. Endoscopy should be decided based on clinical criteria, but also driven by noninvasive tests to assess the digestive absorptive functions and intestinal inflammation. A stepwise approach may reduce the need of endoscopy, also in the light of its relatively limited diagnostic yield compared to adult patients. Treatment of chronic diarrhoea in children is also substantially different from what is generally done in adults and includes a major role for nutritional interventions. Therefore chronic diarrhoea in children is a complex age-specific disorder that requires an age-specific management that is in many aspects distinct from that in adults.