The effectiveness of a pram-walking exercise programme in reducing depressive symptomatology for postnatal women

The purpose of the research project was to examine the effects of exercise, social support and depression on postnatal women who reported experiencing postnatal depression. A 12-week randomized, controlled trial was conducted investigating the effects of an exercise intervention group (a pram-walking programme for mothers and their babies ) compared to a social support group (non-structured sessions, similar to a playgroup). Participants in both groups had given birth in the past 12 months. Pretest data of physical fitness and structured questionnaires were compared to post-test effects. The primary outcomes were to reduce the depressive symptomatology and improve fitness levels of participants in the pram-walking group. Secondary outcomes were to improve the social support levels of the participants in both groups and explore women's views about the programmes. It was hypothesized that the pram-walking group participants would improve their feelings of depression and fitness levels compared to the social support group, but that both groups would improve their perceived levels of social support. The results showed that mothers in the pram-walking intervention group improved their fitness levels and reduced their level of depressive symptomatology significantly more than the social support group. There were no significant changes to social support levels for both groups. Therefore, a direct association between improvement in fitness was related to improvement in depression for the pram-walking group. However, it is also suggested that other factors in combination with improvements in fitness influenced improvements in depression levels. It is recommended that pram-walking programmes for mothers with postnatal depression be implemented as pilot research into existing available services.     

Making interactive decision support for patients a reality

Interactive decision support applications might help patients to make difficult decisions about their health care. They lie in the context of traditional decision aids, which are known to have effects on a number of patient outcomes, including knowledge and decisional conflict. The problem of restricted uptake with decision aids may be addressed by interactive applications, particularly if associated with health information websites. We suggest that there may be an impact on the doctor-patient relationship and that this presents a number of opportunities. However, there are ethical challenges such as information bias and commercialisation.     

Morbidity of adjuvant hepatic arterial infusion pump chemotherapy in the management of colorectal cancer metastatic to the liver

BACKGROUND: Surgical resection remains the treatment of choice for patients with colorectal cancer metastatic to the liver. Hepatic arterial infusion pump (HAIP) chemotherapy in combination with surgical resection has been demonstrated in a recent study to improve disease-free and overall survival for patients with colorectal cancer metastatic to the liver. Other reports, however, have indicated significant toxicity related to HAIP chemotherapy in the form of biliary sclerosis. Thus, the value of adjuvant HAIP chemotherapy following hepatic resection or ablation remains controversial. The aim of this study was to examine the survival and toxicity in a single institutional experience with adjuvant HAIP chemotherapy. METHODS: Review of a prospective hepatobiliary database was performed. HAIP were placed in the standard technique following resection and/or radiofrequency ablation (RFA) of all liver metastases. Patients received floxuridine (FUDR) via the HAIP at standard doses. Complications were graded according to a standard 5-point grading scale. Statistical analysis was performed by chi(2) test. RESULTS: Thirty-four of 86 patients underwent placement of HAIP at the time of hepatic resection or ablation between January 1999 and November 2002. The HAIP group demonstrated a significantly greater (P <0.05) number (median 5 vs. 2) and size (median 5 cm vs. 3 cm) of hepatic lesions compared to the group without HAIP. The HAIP group experienced a greater frequency of complications (53% vs. 33%), with 6 (18%) patients in the HAIP group demonstrating biliary sclerosis. There were no deaths within 30 days of surgery. Median survival was similar in both groups (HAIP 20 months, no HAIP 24 months). CONCLUSIONS: Patients in the HAIP group had significantly worse overall predictors of outcome in metastatic colorectal cancer, yet the median overall survival in both groups was similar. However, adjuvant HAIP chemotherapy was associated with significantly greater morbidity. Given the availability of newer active systemic agents and regimens, the value of adjuvant HAIP chemotherapy remains controversial.     

Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery

Background

American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that patients with an ejection fraction (EF) of 30% or less should not undergo mitral valve replacement for mitral regurgitation (MR). We sought to establish, using a national cardiac surgery database, whether patients with left ventricular dysfunction may safely undergo mitral valve surgery for MR, and if so, which ones.

Methods

We queried the Society of Thoracic Surgeons (STS) National Database to identify patients who had isolated mitral valve replacement or repair for MR between 1998 and 2001. Mortality and morbidity outcomes were compared by EF category (≤ 30% vs > 30%), and observed mortality compared by EF group, stratified by predicted risk for mortality. A classification and regression tree (CART) model was then used to determine which patient characteristics contributed most to designate the high-risk patient.

Results

Of the 14,582 patients who had mitral valve surgery, 727 had an EF of 30% or less and 13,855 had an EF of more than 30%. Observed mortality rates were higher for patients with an EF of 30% or less (5.4% vs 3.1%). However, for low-risk to medium-risk patients, mortality rates remained fairly constant across levels of EF. Mortality is notably increased in the high-risk patients (predicted risk > 10%). A classification tree identifies three key characteristics for high risk: age more than 75 years, renal failure, and emergent or salvage procedure.

Conclusions

When the predicted mortality risk is less than 10%, EF has minimal impact on operative mortality for mitral regurgitation. In contrast to the ACC/AHA Guidelines, our data show that operative risk for mitral valve surgery is not prohibitive for most patients with ventricular dysfunction.     

The effect of extent of local resection on patterns of disease progression in malignant pleural mesothelioma

Background

We sought to determine whether or not there are differences in disease progression after radical or nonradical (debulking) surgical procedures for malignant pleural mesothelioma.

Methods

Over a 49-month period, 132 patients with malignant pleural mesothelioma underwent surgery. Fifty-three underwent extrapleural pneumonectomy and 79 underwent nonradical procedures. Time to evidence of clinical disease progression was recorded, as was the site(s) of that disease.

Results

One-hundred nineteen patients were evaluable, of which 59% (22 radical; 48 nonradical) had disease progression. Overall 30-day mortality was 8.5% (7.5% radical; 9% nonradical). The median time to overall disease progression was considerably longer after extrapleural pneumonectomy than debulking surgery (319 days vs 197 days, p = 0.019), as was the time to local disease progression (631 days vs 218 days, p = 0.0018). There was no preponderance of earlier stage disease in the radical surgery group. There was a trend toward prolonged survival in those undergoing radical surgery, but no significant difference between the groups (497 days vs 324 days, p = 0.079). In those who had extrapleural pneumonectomy, time-to-disease progression significantly decreased with N2 disease compared with N0/1 involvement (197 days vs 358 days, p = 0.02).

Conclusions

Extrapleural pneumonectomy may be preferable to debulking surgery in malignant pleural mesothelioma to delay disease progression and give greater control of local disease. Involvement of N2 nodes is associated with accelerated disease progression and is therefore a contraindication to extrapleural pneumonectomy.     

Advantages of focused helical computed tomographic scanning with rectal contrast only vs triple contrast in the diagnosis of clinically uncertain acute appendicitis: a prospective randomized study

HYPOTHESIS: Focused helical computed tomographic (CT) scanning with rectal contrast only is a superior diagnostic modality compared with the traditional triple-contrast CT scan for the diagnosis of acute appendicitis. DESIGN: Prospective randomized analysis of both CT scan modalities. INTERVENTIONS: Only patients with uncertain diagnosis of acute appendicitis were entered in the study. The patients were then randomized to undergo the traditional triple-contrast CT scan or the new focused CT scan with rectal contrast only. Surgical management included operation or observation for 23 hours. RESULTS: Ninety-one patients participated in the study, including 52 in the triple-contrast group and 39 in the rectal-contrast group. The demographics of the triple-contrast vs the rectal-contrast groups were similar. The triple-contrast group had a sensitivity of 97%, specificity of 86%, positive predictive value of 90%, and negative predictive value of 93%. The rectal-contrast group had a sensitivity of 88%, specificity of 100%, positive predictive value of 100%, and negative predictive value of 100%. There were 4 false-positive findings and 1 false-negative finding in the triple-contrast group compared with none in the rectal-contrast group. In the triple-contrast group, there were 13 perforated appendixes compared with 1 in the rectal-contrast group. The cost of a triple-contrast scan was 620 US dollars compared with 305 US dollars for a focused rectal-contrast scan. The negative appendectomy rate for the study was 8.0% (4 of 48 patients in the triple-contrast group vs 3 of 39 in the rectal-contrast group). CONCLUSIONS: The demographics, sensitivity, specificity, and positive and negative predictive values were comparable in both groups. The focused rectal-contrast procedure was better tolerated by patients and demonstrated decreased morbidity, delay to diagnosis, perforation rate, and negative appendectomy rate with no missed diagnosis and decreased cost. Therefore, we believe that focused helical CT scanning with rectal contrast only is a superior diagnostic modality compared with the traditional triple-contrast CT scan for the diagnosis of acute appendicitis.     

Beneficial effect of helicopter emergency medical services on survival of severely injured patients

BACKGROUND: In Rotterdam, the Netherlands, a helicopter-transported medical team (HMT), staffed with a trauma physician, provides additional therapeutic options at the scene of injury. This study evaluated the influence of the HMT on the chance of survival of severely injured trauma victims. METHODS: This was a 2-year prospective observational study of consecutive adults who suffered multiple trauma (Injury Severity Score (ISS) 16 or more) and presented to the Erasmus Medical Centre emergency ward. The effect of the HMT was quantified by an odds ratio (OR), adjusted for confounding variables in logistic regression models. RESULTS: Complete data for a total of 346 patients were available for analysis. Two hundred and thirty-nine patients were treated by ambulance personnel alone and 107 received additional HMT assistance. Patients in the HMT group had significantly lower Glasgow Coma Scale scores (mean 8.9 versus 10.6; P = 0.001) and a higher ISS (mean 30.9 versus 25.3; P < 0.001). The unadjusted OR for death was 1.7 in favour of the group treated by ambulance staff only (OR for survival 0.61 (95 per cent confidence interval (c.i.) 0.37 to 1.0, P = 0.048)). After adjustment, however, patients in the HMT group had an approximately twofold better chance of survival (all injuries: OR 2.2 (95 per cent c.i. 0.92 to 5.9), P = 0.076; blunt injuries: OR 2.8 (95 per cent c.i. 1.07 to 7.52), P = 0.036). CONCLUSION: The presence of the HMT may increase chances of survival for patients suffering multiple trauma, especially for those with blunt trauma.     

The role of concomitant biceps tenodesis in shoulder arthroplasty for primary osteoarthritis: results of a multicentric study

This study evaluated the effects of concomitant biceps tenodesis in patients undergoing shoulder arthroplasty for primary osteoarthritis. Six hundred eighty-eight shoulders that had undergone replacement for primary glenohumeral arthritis were reviewed at a mean 43 months postoperatively. One hundred twenty-one patients had undergone a biceps tenodesis at arthroplasty, while the remaining patients did not. Tenodesis was significantly better than no tenodesis in most outcome parameters. No difference was found between the groups in complication rate. Biceps tenodesis is a useful adjunct to shoulder arthroplasty in the treatment of primary osteoarthritis.