Interviews for the assessment of long-term incapacity for work: a study on adherence to protocols and principles

Background  

Assessments for long-term incapacity for work are performed by Social Insurance Physicians (SIPs) who rely on interviews with claimants as an important part of the process. These interviews are susceptible to bias. In the Netherlands three protocols have been developed to conduct these interviews. These protocols are expert- and practice-based. We studied to what extent these protocols are adhered to by practitioners.     

Diagnostic value of antibodies to modified citrullinized vimentin in early rheumatoid arthritis

A hundred and two patients (18 males, 84 females; mean age, 50.3 +/- 12.3 years) diagnosed as having early rheumatoid arthritis (RA) were examined. A control group consisted of 189 patients with various rheumatic diseases and 30 healthy donors. The serum concentrations of antibodies to modified citrullinized vimentin (MCVA) and to cyclic citrullinized peptide2 (CCTP2A) were measured by enzyme immunoassay (EIA); rheumatoid factor (RF) IgM was determined by nephelometric immunoassay. In early RA, the level of MCVA (median, 49.6 U/ml; interquartile range, 0.9-249.3) was significantly higher than in the control group 1.65 U/ml; 0.3-19.7). There was a direct significant correlation between the levels of MCVA and CCTP2A (p = 0.9), as well as RF IgM (p = 0.6). The diagnostic efficiency of MCVA (area under the curve, 0.705; 95% confidence interval, 0.607-0.803) was higher than that of CCTP, (0.590; 0.467-0.714), but lower than that of RF IgM (0.813; 0.736-0.889). MCVA was comparable with CCTP, and RF IgM in sensitivity; however, it ranked below them in specificity (71%). Choice of the optimum upper normal range (30 U/ml) permits up to an 88% increase in MCVA specificity and the concurrent consideration of results of testing MCVA, CCTP2A, and RF IgM is attended by up to a 78% increase in sensitivity. EIA of MCVA is a sensitive and specific serological test for the diagnosis of early RA.     

His Bundle Extrasystoles Revisited: The Great Electrocardiographic Masquerader

A 74‐year‐old man with past history of near syncope presented with frequent periods of second‐degree atrioventricular block (2° AVB). An electrophysiological study revealed prolonged atrial‐His and His‐ventricular (HV) intervals and frequent His bundle (H) extrasystoles. The latter manifested in the surface electrocardiogram as premature atrial, junctional, or ventricular beats, as well as 2° AVB that mimicked Wenckebach or Mobitz II block. Procainamide markedly suppressed H extrasystole. However, because of the presence of prolonged HV interval and history of presyncope, a permanent pacemaker was inserted. The case illustrates the varied manifestation of H extrasystole and presents guidelines for management. (PACE 2011; e56–e59)     

Maintenance of gastric pH above 6 with intravenous famotidine in patients with a bleeding duodenal ulcer

Background: The secondary prevention of bleeding from ulcers may be improved if antisecretory drugs are able to maintain a 24-h gastric pH close to neutral. Aim: To evaluate the effect of intravenous famotidine at a conventional dose of 40 mg/day on 24-h intragastric pH in patients with a bleeding duodenal ulcer, and to determine the dose required to maintain gastric pH > 6 by use of a Gastrojet (MIC, Switzerland) device (a pH meter-controlled programmable pump). Methods: Twelve patients (nine men, three women), aged 24–78 years, admitted for a bleeding duodenal ulcer, were studied after active bleeding had stopped for at least 6 h. Gastric pH was recorded for two consecutive 24-h periods, each starting at 16.00 hours. The patients were fasted during these periods and received an infusion of 2.5 L of isotonic glucose. They were given famotidine, as a continuous i.v. infusion of 40 mg during one period, and at a rate determined by the Gastrojet during the other period (in a random sequence), with the aim of maintaining the gastric pH above 6. Results: The 24-h median (interquartile range) pH and the mean (± S.E.M.) percentage of the 24-h period with a gastric pH > 6 were both significantly higher during the Gastrojet period than during the continuous infusion: 6.4 (6.3–6.5) vs. 5.7 (2.7–6.4) (P < 0.01) and 74±5% vs. 44 ± 7% (P < 0.002), respectively. The mean dose of famotidine delivered by the Gastrojet was 172 mg (range: 101–200 mg). The entire available amount of famotidine (200 mg) was delivered in four of the 12 patients. The percentage of time at pH > 6 (mean ± S.E.M.) was significantly higher at night (22.00 to 07.00 hours) than during the rest of the day (88 ± 2 vs. 70 ± 6%; P < 0.005) and the mean quantity of famotidine delivered per hour was significantly lower during the night (6.3 ± 0.8 mg/h vs. 8.4 ± 0.5 mg/h; P < 0.02). Conclusion: We conclude that 40 mg of famotidine delivered as a continuous i.v. infusion is not sufficient to maintain gastric pH > 6 for 24 h in duodenal ulcer patients. Our study with the Gastrojet device shows that it may be possible to achieve this goal by using a much larger dose, preferably delivered during the day.     

Mode of presentation and first line of management of non-recurrent urolithiasis in Kuwait

AIMS: To determine the incidence, mode of presentation, first line of management and composition of non-recurrent urolithiasis in Kuwait. METHODS: Consecutive patients admitted between January 1999 and December 2002 with non-recurrent urolithiasis were prospectively analyzed. RESULTS: The average annual incidence of hospital admission for non-recurrent urolithiasis in Kuwait was 43.44 per 100,000 population, representing men and women (ratio, 9:1) with a median age of 41.91 years. Of the hospital admissions for non-recurrent urolithiasis, 57.2% of cases were acute. Overall, the most predominant symptom was flank pain, while the least common symptom was acute urinary retention. Ureteroscopic stone manipulation was the most common initial treatment modality in the present series, as it was utilized in 43.3% and 37.09% for patients admitted on elective and emergency basis, respectively. Of the calculi available for chemical analysis, 91% contained calcium, 73% contained calcium oxalate, 17% contained mixed calcium and 1% contained calcium phosphate. The composition of the rest of the stones were urate in 7%, struvite in 1% and cystine in 1%. CONCLUSIONS: Urolithiasis is a common disease in the Kuwait region that mainly presents with flank pain. Ureteroscopic calculus removal is the most common modality of treatment. The majority of the calculi seen in Kuwait contained calcium.