Factors influencing choice of medical vs. surgical treatment of pediatric appendicitis

PurposeTo examine what proportion of caregivers, if given a choice, would choose medical versus surgical treatment of appendicitis and what factors would be important in their decision.MethodsA survey was devised and given to the caregivers of children presenting to the pediatrician for a routine visit in community and academic pediatric clinics. The survey presented a summary of outcomes after medical (non-operative) and surgical treatment of uncomplicated appendicitis. Participants were then asked to choose medical versus surgical treatment if their child were to develop appendicitis. They were also asked to rate the importance of certain factors in their decision ? 1 being “not important” and 5 being “very important”.ResultsFour hundred surveys were distributed with an 86.2% (345/400) response rate. Six percent (21/342) of respondents reported a history of appendicitis and 49.4% (168/340) reported having known someone who had appendicitis. The majority of respondents, 85.3% (284/333), were mothers. A minority of respondents, 41.7% (95% CI: 36.7, 47.0), chose medical treatment over surgery for appendicitis. There was no statistical difference in the proportion of mothers (41.6%) versus fathers who chose medical treatment (41.3%). Caregivers who chose medical treatment were more likely to rate time in hospital (p = .008) and time out of school (p = 05) as important in decision making when compared with those who chose surgery. Those who chose surgical treatment were more likely to rate risk of recurrent appendicitis (p < .001) as important to decision making. In the multivariate analysis, those who rated time in hospital as very important had more than twice the odds of choosing medical therapy (OR 2.20, p = 0.02) when compared with those who rated it as less important. Not knowing someone who has had appendicitis was significantly associated with choosing medical therapy when compared with those who do know someone who has had appendicitis, OR 2.3, p = .002. Rating pain as very important was also significantly associated with choosing medical therapy, when compared to those rating pain 1–3, OR 3.38, p = .03.ConclusionsIn this survey of caregivers of children presenting for routine care, 41.7% would choose medical, or non-operative, therapy for their children with acute appendicitis. The risk of recurrence, time in hospital, and time out of school, pain, and knowing someone who has had appendicitis were all important factors that families may consider when making a decision. These data may be useful for surgeons counseling patients on which treatment to pursue.     

Primary Prevention of Sudden Cardiac Death in Heart Failure: Will the Solution Be Shocking?

Sudden cardiac death (SCD) may occur in as many as 40% of all patients who suffer from heart failure. This review describes the scope of the problem, risk factors for SCD, the effect of medications used in heart failure on SCD and the potential effect of the implantable cardioverter-defibrillator in primary prevention.     

Cells of origin of crossed and uncrossed corticospinal fibers in the cat

Summary The cortical distribution of the cells of origin of the dorsolateral and the ventral corticospinal tracts was studied in cat. This was done by making subtotal spinal transections, which in different experiments spared different portions of one ventral or one lateral funiculus at C5–C7. One week later horseradish peroxidase (HRP) injections were made one segment caudal to the lesion and the cortical distribution of the HRP labeled neurons was studied.Thus, it was found that the dorsolateral corticospinal tract at C5–C7 is composed of crossed and uncrossed fibers in a ratio of about 10 1, while the ventral corticospinal tract, which contains much fewer cortical fibers, is composed of crossed and uncrossed fibers in a ratio of approximately 1 1. Further, the primary motor cortex (area 4) was found to contribute fibers to both the crossed and the uncrossed dorsolateral corticospinal tract as well as to both the crossed and the uncrossed ventral corticospinal tract. The primary somatosensory cortex (area 3a, 3b, 1–2, 5a, 5b) as well as the secondary somatosensory cortex (area 2 pre-insularis), on the other hand, were found to contribute fibers mainly to the crossed dorsolateral tract. Area 4 was found to display a further organization, such that it contains a medial and a lateral part, both of which contribute mainly fibers to the crossed dorsolateral tract, while the remainder of area 4 contributes fibers to the crossed and uncrossed dorsolateral as well as to the crossed and uncrossed ventral tracts.This study was in part supported by grant 13.46.15 of the FUNGO/ZWO (Dutch Organization for Fundamental Research in Medicine) and grant C.R.L. 79.4.337.6.INT. of the INSERM (Institut National de la Santé et de la Recherche Médicale)     

Cardiovascular risk factors in people with different genotypes in the insertion/deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme (ACE)

The deletion (D) allele of an insertion/deletion (I/D) polymorphism at the locus for angiotensin I-converting enzyme (ACE) has been reported to be an independent risk factor for myocardial infarction (MI), particularly in people lacking traditional risk factors. Furthermore, a borderline association between Lp(a) lipoprotein level and the I/D polymorphism at the ACE locus was reported in one study. We have searched for possible "level gene" or "variability gene" effects of ACE genes on Lp(a) lipoprotein, total cholesterol (TC), high density lipoprotein (HDL) cholesterol (HDLC), low density lipoprotein (LDL) cholesterol (LDLC), triglycerides (TG), apolipoprotein B (apoB), apolipoprotein A-I (apoA-I), and body mass index (BMI). None of these variables differed significantly between genotypes in the I/D polymorphism in any of three population samples. A single population sample created by combining the three series, exhibited an insignificant trend towards individuals carrying the D-allele having a higher level of Lp(a) lipoprotein than those lacking it, and DD homozygotes had a significantly higher Lp(a) lipoprotein level than the combined group of ID/II individuals (p = 0.03). These results may indicate that the D-allele of the I/D polymorphism at the ACE locus could influence the level of Lp(a) lipoprotein.     

基于脑电复杂度的意识任务的特征提取与分类

本研究提出了利用事件相关脑电复杂度提取大脑运动意识特征，应用Mahalanobis距离判别式分析法，对人脑想象左右手运动任务进行分类，获得了满意的结果。对受试者想象左右手运动期间在大脑初级感觉运动皮层区记录的脑电信号采用复杂度分析方法量化了事件相关去同步（ERD）和事件相关同步（ERS）时程，结果表明EEG复杂度特征较好反映了ERD／ERS变化时程。最后对测试数据进行分类，最大分类正确率达到86．43％，通过最大分类正确率，最大信噪比，最大互信息等评价指标比较，验证了该方法的有效性，从而为大脑运动意识任务的特征提取及分类提供了新思路。     

Timing of bimanual movements in human and non-human primates in relation to neuronal activity in primary motor cortex and supplementary motor area

It has been established that repeated presentation of a transient target motion stimulus such as a constant-velocity ramp leads to the build up of steady state (SS), anticipatory smooth pursuit eye movements after two or three presentations. Each SS response is then composed of the anticipatory component of nonvisual origin, a visual component associated with the stimulus presentation and another nonvisual component that represents the decay of the response after extinction of the stimulus. Here we investigated the interactions that occur when each motion stimulus was itself a sequence containing more than one ramp component. Ramp components had a velocity of 15 degrees /s or 30 degrees /s to left or right and were separated by gaps of 200 ms duration. In an initial experiment, responses to 2-ramp stimuli were examined and compared with responses to the single-ramp stimuli from which they were constituted. We present evidence that the anticipatory, nonvisual components of the double-ramp response result from the linear summation of the nonvisual components of the responses to the constituent single-ramp components. In a 2nd experiment, we examined responses to a wide variety of 4-ramp sequences and again found evidence that, in the SS, the responses were formed from the linear summation of the constituent single-ramp components. Regression analysis performed on the velocity at onset of each ramp component indicated that this nonvisual part of the response was predictive of the upcoming ramp component. To confirm this, unexpected changes were introduced into single ramp components of the 4-ramp sequence after at least five prior presentations of the sequence had allowed a SS response to be established. Subjects continued to initiate a response to the modified component that was appropriate in velocity and direction for the corresponding part of the previous sequence and inappropriate for the newly modified stimulus. This preprogrammed response persisted unmodified for more than 170 ms after onset of the modified ramp component. In contrast, in the second presentation of the new sequence, the anticipatory component of the response was highly correlated with the SS response of the new sequence, but not with that of the prior sequence, showing that the preprogrammed response had been modified very rapidly. Similar behaviour was observed whichever of the 4-ramp components was modified, indicating that the velocity and direction of the anticipatory response to each component had been preprogrammed. The results suggest that velocity information related to at least four elements of a sequence can be temporarily stored and subsequently released with appropriate temporal order to form an anticipatory response throughout the whole sequence.     

Somatotopic organization of corticospinal and corticotrigeminal neurons in the rat

The method of retrograde axonal transport of horseradish peroxidase was employed to examine the topographic organization of corticospinal and corticotrigeminal neurons in the rat. In both the first somatic sensory (SI) area and the motor (MI) area of the cortex these labeled corticofugal neurons, all of which are found in layer V, are grouped in a well organized, somatotopic pattern. Corticospinal projections which extend to lumbar levels of the spinal cord originate only from neuronal somata located in the hindlimb representation of SI and MI. Those neurons projecting to the cervical enlargement have somata mainly in the forelimb representation of SI and MI and the ventrolateral part of the trunk representation within SI. Cortical projections to the rostral cervical spinal segments appear to originate mainly from the neck and posterior head representations of SI and MI, though this conclusion is clearest for SI. Finally, neurons located exclusively within the head, muzzle, and vibrissal representation of SI project to the spinal trigeminal complex. Corticofugal neurons near the frontal pole and in an area of cortex ventrolateral to SI also project to the spinal cord. The areas involved are probably homologous to the supplementary motor (MII) and second somatic sensory (SII) areas respectively. The corticospinal and corticotrigeminal projections from these areas also appear to be organized in a somatotopic manner.It is concluded that in the rat, as in other species, the corticospinal and corticotrigeminal neurons in the sensorimotor cortex are arranged somatotopically. The somatotopic pattern found correlates remarkably well with that determined by single unit, evoked potential and cortical stimulation techniques.     

Mapping the effects of motor cortex stimulation on somatosensory relay neurons in the rat thalamus: Direct responses and afferent modulation

Single unit recordings were used to map the spatial distribution of motor (MI) cortical influences on thalamic somatosensory relay nuclei in the rat. A total of 215 microelectrode penetrations were made to record single neurons in tracks through the medial and lateral ventroposterior (VPM and VPL), ventrolateral (VL), reticular (nRt), and posterior (Po) thalamic nuclei. Single units were classified according to their: 1) location within the nuclei, 2) receptive fields, and 3) response to standardized microstimulation in deep layers of the forepaw-forelimb areas of MI cortex. For mapping purposes, only short latency (1-7 msec) excitatory neuronal responses to the MI cortex stimulation were considered. Percentages of recorded thalamic neurons responsive to the MI stimulation varied considerably across nuclei: VL: 42.6%, nRt: 23.0%, VPL: 15.7%, VPM: 9.3%, and Po: 3.9%. Within the VPL, most responsive neurons were found in "border" regions, i.e., areas adjacent to the VL, and (to a lesser extent) the nRt and Po thalamic nuclei. The same parameters of MI cortical stimulation were used in studies of corticofugal modulation of afferent transmission through the VPL thalamus. A condition-test (C-T) paradigm was implemented in which the cortical stimulation (C) was delivered at a range of time intervals before test (T) mechanical vibratory stimulation was applied to digit No. 4 of the contralateral forepaw. The time course of MI cortical effects was analyzed by measuring the averaged evoked unit responses of the thalamic neurons to the T stimuli, and plotting them as a function of C-T intervals from 5-50 msec. Of the 30 VPL neurons tested during MI stimulation, the average response to T stimulation was decreased a mean 43%, with the suppression peaking at about 30 msec after the C stimulus. This suppression was more pronounced in the VPL border areas (-52% in areas adjacent to VL and nRt) than in the VPL center (-25%).