BACKGROUND & AIMS: BACKGROUND:A large insurer in Hawaii mails annual reminders to its members regarding recommended health screenings. This study examined the associations between the characteristics of physicians visited after the reminders were sent and the health screenings received for breast, cervical, and colorectal cancers, and for diabetes and cholesterol. METHODS:The study population included members identified as needing health screenings from 2000 to 2003 based on age and gender criteria. The study used a longitudinal design focusing on the 12 months after reminders were sent. Data were analyzed using logistic regression examining physician visits, other health services, and receipt of health screenings by 1-month intervals subsequent to the reminder mailings. RESULTS:In adjusted, multivariable models, members who saw physicians they had not seen in the past year had odds ratios for obtaining health screenings 6 to 8 times higher than members who only saw previously visited physicians. This enhanced response occurred among members receiving their first, second, and third (or subsequent) annual reminder letter. The more physicians that were visited and who were new to the members, the more likely the members were to obtain health screenings. CONCLUSIONS:Members seeing physicians they had not seen in the past year had significantly higher screening rates than the members only seeing physicians they had previously visited. The results suggest that healthcare screening may receive less attention at repeat visits with a physician than at visits with a physician who is new to a member.

背景与目标：

BACKGROUND & AIMS: -2

背景与目标： -2

BACKGROUND & AIMS: :Crossing of the pleurovisceral nerve cords in gastropods has supported the view that gastropods evolved by 180 degrees rotation between the ventral and dorsal body regions. Indeed, a rotation of this type occurs as a dramatic morphogenetic movement ("ontogenetic torsion") during the development of basal gastropods. According to a long-standing hypothesis, ontogenetic torsion in basal gastropods preserves an ancient developmental aberration that generated the contorted gastropod body plan. It follows from this reasoning that crossing of the pleurovisceral nerve cords during gastropod development should be mechanically coupled to ontogenetic torsion. The predicted mechanical coupling can now be examined because of the discovery of an early differentiating neuron in Haliotis kamtschatkana (Vetigastropoda) that expresses 5-hydroxytryptamine-like immunoreactivity. The neuron appeared to delineate the trajectory of the pleurovisceral nerve cords beginning before ontogenetic torsion. Before torsion, the neuronal soma is embedded in mantle epithelium at the ventral midline and two neurites extend anteriorly toward the apical sensory organ. Contrary to expectation, the two neurites of this cell did not cross-over during ontogenetic torsion because the soma of this mantle neuron shifted in the same direction as the rotating head and foot. Full crossing of the pleurovisceral nerve cords occurred gradually during later development as the mantle cavity deepened and expanded leftward. These results are consistent with a generalization emerging from comparative studies indicating a conserved developmental stage for gastropods in which the mantle cavity is localized to one side, despite a fully "post-torsional" orientation for other body components. Developmental morphology before this stage is much more variable among different gastropod clades.

背景与目标： 腹足动物胸膜内脏神经索的交叉支持了腹足动物通过腹侧和背侧身体区域之间180度旋转而进化的观点。实际上，在基础腹足类动物的发育过程中，这种类型的旋转是一种戏剧性的形态发生运动 (“个体发生扭转”)。根据长期存在的假设，基础腹足动物的个体发育扭转保留了古老的发育畸变，该畸变产生了扭曲的腹足动物身体计划。从这种推理可以得出，腹足动物发育过程中胸膜内脏神经索的交叉应与个体发生扭转机械耦合。现在可以检查预测的机械耦合，因为在Haliotis kamtschatkana (Vetigastropoda) 中发现了表达5-羟色胺样免疫反应性的早期分化神经元。神经元似乎描绘了个体发生扭转之前开始的胸膜内脏神经索的轨迹。在扭转之前，神经元躯体嵌入腹侧中线的套膜上皮中，两个神经突向前向顶端感觉器官延伸。与预期相反，该细胞的两个神经突在个体发生扭转期间没有交叉，因为该套神经元的躯体与旋转的头和脚沿相同的方向移动。在后来的发育过程中，随着地幔腔的加深和向左扩展，胸膜内脏神经索的完全交叉逐渐发生。这些结果与比较研究得出的概括一致，该比较研究表明腹足类动物处于保守的发育阶段，尽管其他身体成分完全处于 “扭转后” 方向，但地幔腔仍位于一侧。不同腹足纲进化枝在此阶段之前的发育形态变化更大。

BACKGROUND & AIMS: BACKGROUND:Side-stream spirometry offers a non-invasive method to monitor continuously respiratory mechanics in intubated patients. We studied the effects of different positions on dynamic lung compliance during anaesthesia. METHODS:The study consisted of 56 patients, operated in supine, prone, kneeling or lateral park-bench position. Dynamic lung compliance and inspiratory peak pressure were recorded after induction of anaesthesia, 15 min and 1 h after posturing the patient. RESULTS:The first measured compliances were comparable in all groups. The compliance in the lateral and the prone positions was significantly lower than in the supine position at 15 min (P < 0.01) and 1 h (P < 0.001) after the posture change. The peak inspiratory pressure was significantly lower in the kneeling position than in the other groups (P < 0.01 at the first measurement, P < 0.001 at the later measurements). No correlation was found between body mass index and compliance. CONCLUSION:We found that dynamic lung compliance decreased significantly upon change of posture from supine to lateral or prone position, whereas in the kneeling position no change in compliance was observed. We suggest that the kneeling position might be preferable to the prone position.

背景与目标：

BACKGROUND & AIMS: :Severe preeclampsia rarely occurs prior to 20 weeks of gestation except in pregnancies with triploidy. The patient reported herein is a 29-year-old primigravida who developed severe preeclampsia at 20 weeks of gestation. Evaluation of the pregnancy demonstrated a markedly abnormal quadruple screen. Amniocentesis demonstrated a fetus with triploidy, despite a normal appearance.

背景与目标： : 除三倍体妊娠外，妊娠20周前很少发生严重的先兆子痫。本文报道的患者是一名29岁的初产妇，在妊娠20周时出现严重的先兆子痫。对妊娠的评估显示出明显异常的四重筛查。羊膜穿刺术显示胎儿具有三倍体，尽管外观正常。

BACKGROUND & AIMS: PURPOSE:Consistent condom use is critical to efforts to prevent sexually transmitted infections among adolescents, but condom use may decline as relationships and contraceptive needs change. The purpose of this research is to assess changes in condom non-use longitudinally in the context of changes in relationship quality, coital frequency and hormonal contraceptive choice. METHODS:Participants were women (aged 14-17 years at enrollment) recruited from three urban adolescent medicine clinics. Data were collected at three-month intervals using a face-to-face structured interview. Participants were able to contribute up to 10 interviews, but on average contributed 4.2 interviews over the 27-month period. Independent variables assessed partner-specific relationship quality (five items; scale range 5-25; alpha = .92, e.g., this partner is a very important person to me); and, number of coital events with a specific partner. Additional items assessed experience with oral contraceptive pills (OCP) use and injected depo medroxy-progesterone acetate (DMPA). The outcome variable was number of coital events without condom use during the past three months. Analyses were conducted as a three-level hierarchical linear growth curve model using HLM 6. The Level 1 predictor was time, to test the hypothesis that condom non-use increases over time. Level 2 predictors assessed relationship quality and coital frequency across all partners to assess hypotheses that participants' condom non-use increases over time as a function of relationship quality and coital frequency. Level 3 predictors assessed the participant-level influence of OCP or DMPA experience on time-related changes in condom non-use. RESULTS:A total of 176 women reported 279 sex partners and contributed 478 visits. Both average coital frequency and average condom non-use linearly increased during the 27-month follow-up. At any given follow-up, about 35% reported recent OCP use, and 65% reported DMPA use. HLM analyses showed that condom non-use increased as a function of time (beta = .12; p = .03, Level 1 analysis). Increased condom non-use over time was primarily a function of increased coital frequency (beta = .01; p = .00), although higher levels of relationship quality were associated with increased condom non-use at enrollment (beta = .44; p = .00, Level 2 analysis). The temporal rise in condom non-use significantly increased among DMPA users (beta = .06; p = .00) but not OCP users (Level 3 analysis) (beta = -.04; p = .06). CONCLUSIONS:Developmentally, relationship characteristics and coital frequency appear to have increasing weight in decisions about condom use. Hormonal contraceptive methods are not equivalently associated with the overall temporal decline in condom use. Future research associated with dual contraceptive/condom use should address differential factors associated condom use in combination with different hormonal methods.

背景与目标：

BACKGROUND & AIMS: The accuracy of cervicovaginal fetal fibronectin as a predictor of preterm birth was studied in patients with increased risk for preterm delivery (according to the Creasy-score). In a prospective blind observational study the smear from the posterior fornix vaginae of 56 pregnant patients without PROM was examined using a quantitative immunoassay for the detection of fetal fibronectin. The patients who tested positively for fetal fibronectin had significantly more preterm deliveries than those with a negative result (CHI square-test, p < 0.01, RR 5.1). Overall, sensitivity, specificity, positive and negative predictive values were 56%, 87%, 45% and 91%, respectively. In patients with preterm labor these values were 75%, 87%, 60%, and 93%, respectively. No patient with a negative result delivered preterm during the following two weeks. It is concluded that performing the fetal fibronectin test in patients with preterm labor is useful for the prediction of preterm birth. Routine testing in patients at increased risk (asymptomatic patients) is not recommended for lack of effectiveness.

背景与目标： 在早产风险增加的患者中研究了宫颈阴道胎儿纤维连接蛋白作为早产预测指标的准确性 (根据Creasy评分)。在一项前瞻性盲观察研究中，使用定量免疫测定法检查了56例无胎膜早破的孕妇的后穹窿阴道涂片，以检测胎儿纤连蛋白。胎儿纤连蛋白检测呈阳性的患者的早产明显多于阴性结果的患者 (卡方检验，p <0.01，RR 5.1)。总体而言，敏感性、特异性、阳性和阴性预测值分别为56% 、87% 、45% 和91%。在早产患者中，这些值分别为75%，87%，60% 和93%。在接下来的两周内，没有阴性结果的患者早产。结论对早产患者进行胎儿纤连蛋白试验对预测早产有一定的帮助。不建议对风险增加的患者 (无症状患者) 进行常规测试，因为缺乏有效性。

BACKGROUND & AIMS: Environmental pollution has become a major concern for the future of life on our planet; medical care, especially in hospitals, contributes significantly to this pollution. The increasing usage of highly-developed medical devices, drugs and disposable products are a drain on natural resources as well as financial ones. In this situation, it is a major task for hospital epidemiologists to maintain high standards of hygiene while reducing environmental pollution, reducing consumption of limited natural resources, and minimizing costs. The reduction of hospital waste, the control of polluting and toxic emissions, the avoidance of unnecessary disinfection procedures and disposables, the implementation of energy and water saving technologies are practicable measures in hospital ecology. To realize a sustainable development within hospitals, it is necessary that the need to maintain a balance between effective infection control and a good ecological environment is recognized and supported by health-care workers and the hospital management.

背景与目标： 环境污染已成为地球生命未来的主要问题; 医疗保健，尤其是医院的医疗保健，对这种污染有很大影响。高度发达的医疗设备，药品和一次性产品的使用日益增加，既消耗了自然资源，也消耗了金融资源。在这种情况下，医院流行病学家的主要任务是在减少环境污染的同时保持高标准的卫生，减少对有限自然资源的消耗并最大程度地降低成本。减少医院废物，控制污染和有毒排放物，避免不必要的消毒程序和一次性用品，实施节能节水技术是医院生态中的可行措施。为了实现医院内部的可持续发展，有必要在有效的感染控制和良好的生态环境之间保持平衡的需要得到医护人员和医院管理层的认可和支持。

BACKGROUND & AIMS: OBJECTIVE:To assess whether interindividual variation in renal plasma flow or in its response to angiotensin II infusion is associated with interindividual differences in blood pressure in a population-based sample of 287 non-Hispanic whites (143 women and 144 men), aged 20-49.9 years.

METHODS:After seven days of eating a high-sodium diet (260 mmol/day), the renal plasma flow was determined by measuring the clearance of p-aminohippurate before and after infusion of 3 ng/kg per min angiotensin II. Multiple linear regression methods were used to assess whether measures of the renal plasma flow and of its response to angiotensin II infusion were predictive of systolic or diastolic blood pressures measured prior to administration of the high-sodium diet, on day 6 of the high-sodium diet, or during the renal clearance procedure on day 7 prior to angiotensin II infusion.

RESULTS:There was some evidence that measures of the renal plasma flow and of its response to angiotensin II infusion during the high-sodium diet were statistically significant predictors of measures of blood pressure in women; there was less evidence for this for blood pressures in men. Interindividual variation in measures of the renal plasma flow and of its response to angiotensin II infusion explained less than 10% of the interindividual variation in any measure of the blood pressure in both sexes.

CONCLUSION:These results suggest that interindividual variation in renal plasma flow ad in its response to angiotensin II infusion during a high-sodium diet will be of limited utility in elucidating the basis for interindividual differences in blood pressure.

背景与目标： 目的 : 在基于人群的287非西班牙裔白人 (143名女性和144名男性) 样本中，评估肾血浆流量或对血管紧张素II输注的反应的个体差异是否与血压的个体差异相关，年龄在20-49.9岁之间。
方法 : 在食用高钠饮食 (260 mmol/天) 7天后，通过在每分钟输注3 ng/kg血管紧张素II之前和之后测量对氨基马尿酸盐的清除率来确定肾血浆流量。使用多元线性回归方法来评估肾血浆流量及其对血管紧张素II输注的反应的测量是否可以预测高钠饮食第6天在给予高钠饮食之前测得的收缩压或舒张压。钠饮食，或在输注血管紧张素II之前第7天的肾脏清除过程中。
结果 : 有证据表明，高钠饮食期间肾脏血浆流量的测量及其对血管紧张素II输注的反应是女性血压测量的统计学显着预测指标; 男性血压的证据较少。肾血浆流量测量及其对血管紧张素II输注的反应的个体差异解释了男女血压测量中个体间差异的10%。
结论 : 这些结果表明，在高钠饮食中对血管紧张素II输注的反应中，肾血浆流量ad的个体差异在阐明血压个体差异的基础方面将是有限的。

BACKGROUND & AIMS: A patient with heterozygous protein S deficiency experienced cutaneous necrosis following subcutaneous heparin administration. Deficiencies of both protein C and protein S, known risk factors for the more frequently encountered coumarin necrosis, may predispose patients to this complication of heparin therapy as well. The putative association of protein S deficiency with cutaneous heparin necrosis could not be proven, however, since attempts to reproduce the heparin necrosis were unsuccessful.

背景与目标： 杂合蛋白S缺乏症患者在皮下注射肝素后出现皮肤坏死。蛋白C和蛋白S的缺乏是香豆素坏死较常见的已知危险因素，也可能使患者易患肝素治疗的这种并发症。然而，由于试图重现肝素坏死的尝试均未成功，因此无法证明蛋白质S缺乏症与皮肤肝素坏死的关系。

BACKGROUND & AIMS: :Inborn errors of vitamin B(12) (cobalamin) metabolism are characterized by decreased production of active cobalamin cofactors and subsequent deficiencies in the activities of methionine synthase and methylmalonyl-CoA mutase. With the recent discovery of the cblJ defect in two patients with phenotypes mimicking the cblF defect, there are nine genes known to be involved in cobalamin metabolism. The new defect is caused by mutations in the ABCD4 gene, encoding an ABC transporter. At the moment, there is no clear distinction between the cblJ and cblF defects either clinically or biochemically, and both defects result in blocks in the transport of cobalamin from the lysosome to the cytoplasm. A patient was diagnosed with hyperhomocysteinemia and methylmalonic aciduria at the age of 8 years. Incorporations of both [(14)C]propionate and [(14)C]methyltetrahydrofolate in cultured fibroblasts were within reference ranges and thus too high to allow for complementation analysis. We observed decreased synthesis of both adenosylcobalamin and methylcobalamin and accumulation of unmetabolized cyanocobalamin. Exome sequencing was performed to identify causative mutation(s) and Sanger re-sequencing was performed to validate segregation of mutation in the family. By this approach, a homozygous mutation, c.423C>G, in the ABCD4 gene was identified. Here, we report the successful application of exome sequencing for diagnosis of a rare inborn error of vitamin B(12) metabolism in a patient whose unusual presentation precluded diagnosis using standard biochemical and genetic approaches. The patient represents only the third known patient with the cblJ disorder.

背景与目标： : 维生素b (12) (钴胺素) 代谢的先天性错误的特征是活性钴胺素辅因子的产生减少，随后蛋氨酸合酶和甲基丙二酰辅酶a变位酶的活性不足。随着最近在两名表型模仿cblF缺陷的患者中发现cblJ缺陷，已知有9个基因与钴胺素代谢有关。新的缺陷是由编码ABC转运蛋白的ABCD4基因突变引起的。目前，无论是在临床上还是在生化上，cblJ和cblF缺陷之间都没有明确的区别，这两个缺陷都会导致钴胺素从溶酶体到细胞质的转运受到阻碍。一名患者在8岁时被诊断出患有高同型半胱氨酸血症和甲基丙二酸尿症。培养的成纤维细胞中 [(14)C] 丙酸酯和 [(14)C] 甲基四氢叶酸的加入都在参考范围内，因此太高，无法进行互补分析。我们观察到腺苷钴胺和甲钴胺的合成减少以及未代谢的氰钴胺的积累。进行外显子组测序以鉴定致病突变 (s)，并进行了Sanger重新测序以验证家族中突变的分离。通过这种方法，在ABCD4基因中发现了一个纯合突变，c.423C>G。在这里，我们报告了外显子组测序在诊断罕见的先天性维生素b (12) 代谢错误中的成功应用，该患者的异常表现无法使用标准的生化和遗传学方法进行诊断。该患者仅代表第三位已知的cblJ疾病患者。

BACKGROUND & AIMS: BACKGROUND:The Cardiac failure, Hypertension, Age, Diabetes, Stroke [Doubled] (CHADS(2)) score is a useful scheme for risk stratification of thromboembolism patients, but there is little information about its usefulness for the evaluation of antiarrhythmic drug (AAD) therapy. METHODS AND RESULTS:This study included 459 paroxysmal atrial fibrillation (AF) patients (309 men, mean age 66 ± 12 years, mean follow-up 50 ± 35 months) and prophylactic efficacy was analyzed on the basis of CHADS(2) score. (1) Survival rates free from AF recurrence at 1, 6, 12 and 24 months were, respectively, 89%, 74%, 63% and 47% in score-0 group (n=152); 92%, 68%, 59% and 48% in score-1 group (n=158); 86%, 64%, 56% and 46% in score-2 group (n=84); 81%, 65%, 51% and 35% in score-3 group (n=43); and 68%, 50%, 36% and 18% in ≥ score-4 group (n=22) (P<0.05; score-0, score-1 or score-2 vs. ≥ score-4 group). (2) Survival rates free from progression to chronic AF at 12, 36, 60 and 90 months were, respectively, 95%, 93%, 91% and 89% in score-0 group; 97%, 91%, 89% and 88% in score-1 group; 96%, 93%, 88% and 83% in score-2 group; 91%, 74%, 67% and 60% in score-3 group; and 91%, 82%, 68% and 55% in ≥ score-4 group (P<0.01; score-0, score-1 or score-2 vs. ≥ score-4 group). (3) In multivariate logistic regression analysis adjusted for potentially confounding variables, CHADS(2) score was associated with AF recurrence (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.16-1.81, P<0.001), and progression to chronic AF during AAD therapy (OR 1.64, 95% CI 1.04-2.69, P<0.001). CONCLUSIONS:When using a rhythm control strategy, the CHADS(2) score is a useful scheme for predicting the outcome of AAD treatment of patients with paroxysmal AF.  

背景与目标：

BACKGROUND & AIMS: PURPOSE:To evaluate outcomes among early-stage breast cancer patients after conservative surgery and full-dose intraoperative radiotherapy electrons (ELIOT) by applying the Groupe Européen de Curiethérapie-European Society for Therapeutic Radiology and Oncology (GEC-ESTRO) recommendations for partial breast irradiation (APBI). MATERIALS AND METHODS:One-thousand eight-hundred and twenty-two patients were stratified into the three GEC-ESTRO categories of "good candidates", "possible candidates" and "contraindication" in order to assess outcomes. RESULTS:All the 1822 cases except 7 could be classified according to GEC-ESTRO groups: 573 patients met the criteria to be included in the "good candidates" group, 468 patients in the "possible candidates" group and 767 patients in the "contraindication" group. Median and mean follow-up length was 3.5 years (range 0-10.5 years) and 3.8 years (SD 2.2), respectively. The 5-year rate of in-breast tumor reappearances for "good candidates", "possible candidates" and "contraindication" groups were 1.9%, 7.4% and 7.7%, respectively (p 0.001). While the regional node relapse showed no difference, the rate of distant metastases was significantly different in the "contraindication" group compared to the other two categories, having a significant impact on survival. CONCLUSIONS:Among the ELIOT population, the GEC-ESTRO recommendations enabled the selection of the good candidates with a low rate of local recurrence, but failed to differentiate the "possible candidates" and the "contraindication" groups.

背景与目标：

BACKGROUND & AIMS: :Extensive laboratory testing is often performed in the emergency department evaluation of the new-onset seizure patient. To determine the utility of such testing, a prospective study of patients with a new-onset seizure presenting to the ED of an inner-city, university-affiliated teaching hospital was done. One hundred thirty-six patients were entered into the study between October 1984 and January 1988. All patients had uniform data collection performed. Pertinent historical information and physical examination findings were recorded on a standardized form before laboratory abnormality was a sole or contributory cause of the seizure disorder. These included four patients with hypoglycemia, four with hyperglycemia, two with hypocalcemia, and one with hypomagnesemia. Only two cases (hypoglycemia) were not suspected on the basis of findings on the history or physical examination. In ED patients, the incidence of a new-onset seizure due to a correctable metabolic disturbance is low. We conclude that, with the exception of the serum glucose, the extensive ED laboratory workup often done for the evaluation of a new-onset seizure is unnecessary. Further test ordering should be directed by the medical history and physical examination.

背景与目标： : 在急诊科对新发癫痫患者的评估中，经常进行广泛的实验室测试。为了确定这种测试的实用性，对向市中心大学附属教学医院的ED呈递的新发癫痫发作患者进行了前瞻性研究。在1984年10月和1988年1月之间，有136名患者进入了研究。所有患者均进行了统一的数据收集。在实验室异常是癫痫发作的唯一或促成原因之前，将相关的历史信息和体格检查结果记录在标准化表格上。其中包括4名低血糖患者，4名高血糖患者，2名低钙血症患者和1名低镁血症患者。根据病史或体格检查发现，仅怀疑有2例 (低血糖)。在ED患者中，由于可纠正的代谢紊乱而引起的新发癫痫发作的发生率较低。我们得出的结论是，除血清葡萄糖外，通常不需要进行广泛的ED实验室检查以评估新发癫痫发作。进一步的检查顺序应由病史和体格检查指示。

BACKGROUND & AIMS: OBJECTIVES:To evaluate first-year doctor of pharmacy (PharmD) students' communication apprehension, outcome expectations, and self-efficacy for communication over the duration of a 15-week patient-counseling course. DESIGN:First-year PharmD students (n=94) were asked to complete a 47-item, self-administered questionnaire on 3 occasions over the duration of the Nonprescription Drugs/Patient-Counseling course during the fall 2009 and 2010 semesters. ASSESSMENT:Eighty-seven of 94 students completed the survey instrument across data collection periods. There were significant reductions in total communication apprehension scores and in the communication apprehension subscores for meetings and public speaking, and significant increases in self-efficacy over time. No differences were found for outcome expectations of communication scores or the subscores for interpersonal conversations and group discussion. CONCLUSIONS:Communication apprehension may be decreased and self-efficacy for communication increased in first-year PharmD students through a 15-week Nonprescription Drugs/Patient-Counseling course using small-group practice sessions, case studies, and role-play exercises in conjunction with classroom lectures.

背景与目标：