John E. Hewett

A Randomized Prospective Trial to Assess the Role of Saline Hydration on the Development of Contrast Nephrotoxicity

Though simple and attractive, the role of hydration for the prophylaxis of contrast nephrotoxicity has not been definitively established. We prospectively evaluated the role of deliberate saline hydration in patients undergoing nonemergency cardiac catheterization. Patients (n = 53) were randomized on the day prior to scheduled catheterization to one of two groups – group 1 (n = 27) received normal saline for 24 h (at a rate of 1 ml/kg/h) beginning 12 h prior to scheduled catheterization, and group 2 (n = 26) were allowed unrestricted oral fluids. Serum creatinine measured 24 and 48 h postcardiac catheterization was compared to the pre-randomization baseline value. The mean baseline calculated creatinine clearance was 79.6 ± 31.9 ml/min and the mean baseline creatinine was 106 ± 28 µmol/l. An increase in serum creatinine by at least 44.2 µmol/l (0.5 mg/dl), within 48 h of contrast exposure, was considered to represent clinically significant acute renal insufficiency. Ten subjects (18.9%) developed acute renal insufficiency. The incidence of acute renal insufficiency was significantly lower in group 1 (1 out of 27) as compared to group 2 (9 out of 26; p = 0.005 for comparison between groups; relative risk 0.11, 95% confidence interval 0.015 to 0.79). Twenty-four hours after contrast exposure, the mean increase in creatinine was less in group 1 vs. group 2 (8 ± 11 vs. 20 ± 21 µmol/l, p = 0.02). The increase in creatinine was not significantly different in group 1 vs. group 2 48 h after contrast exposure (12 ± 21 vs. 29 ± 40 µmol/l, p = 0.17). Deliberate saline hydration decreases the incidence of contrast-related acute renal failure and the severity of contrast-induced renal dysfunction in patients undergoing non-emergency cardiac catheterization.

A meta-analysis of fibromyalgia treatment interventions.

Objective: To evaluate and compare the efficacy of pharmacological and nonpharmacological treatments of fibromyalgia syndrome (FMS). Methods: This meta-analysis of 49 fibromyalgia treatment outcome studies assessed the efficacy of pharmacological and nonpharmacological treatment across four types of outcome measures—physical status, self-report of FMS symptoms, psychological status, and daily functioning. Results: After controlling for study design, antidepressants resulted in improvements on physical status and self-report of FMS symptoms. All nonpharmacological treatments were associated with significant improvements in all four categories of outcome measures with the exception that physically-based treatment (primarily exercise) did not significantly improve daily functioning. When compared, nonpharmacological treatment appears to be more efficacious in improving self-report of FMS symptoms than pharmacological treatment alone. A similar trend was suggested for functional measures. Conclusion: The optimal intervention for FMS would include nonpharmacological treatments, specifically exercise and cognitive-behavioral therapy, in addition to appropriate medication management as needed for sleep and pain symptoms.

Self-efficacy predicting outcome among fibromyalgia subjects

OBJECTIVES This study examined whether pretreatment self-efficacy and pre- to post-treatment changes in self-efficacy predict post-treatment tender point index, disease severity, pain, and physical activity. METHODS One hundred nine subjects with fibromyalgia were assessed before and after a 6-week training intervention. Measures included tender point index, physician ratings of disease severity, the visual analog scale for pain, the Physical Activities subscale of the Arthritis Impact Measurement Scales, and the Arthritis Self-Efficacy Scale. RESULTS Pretreatment self-efficacy significantly predicted post-treatment physical activity, with higher self-efficacy associated with better physical activity outcome. Changes in self-efficacy significantly predicted post-treatment tender point index, disease severity, and pain; improvements in self-efficacy were associated with better outcomes on each measure. CONCLUSIONS Higher levels of self-efficacy are associated with better outcome, and may mediate the effectiveness of rehabilitation-based treatment programs for fibromyalgia.

Self-efficacy and pain behavior among subjects with fibromyalgia

&NA; Given the lack of objective physical measures for assessing fibromyalgia syndrome (FS), the role of pain assessment is particularly important. The role of psychological factors is controversial among FS patients. This study was designed to better understand the relationship between pain behaviors and psychological variables. Specifically, this study(1) refined a pain behavior observation (PBO) methodology for use with FS patients,(2) determined whether stretching is a valid pain behavior,(3) assessed whether psychological variables including self‐efficacy and/or depression can predict pain behaviors after controlling for disease severity and age. The 73 FS subjects meeting the American College of Rheumatology classification system completed questionnaires measuring self‐efficacy, depression, and pain. Trained physicians conducted tender‐point examinations. Subjects were videotaped using a standardized procedure. Two trained raters independently coded all pain behaviors. Kappa coefficients and correlations among pain behaviors and self‐reported pain indicated that the PBO method was both reliable and valid. However, the newly defined pain behavior ‘stretching’ was found to be negatively associated with self‐reported pain. Hierarchical multiple regression (MR) analyses revealed that depression did not predict pain behavior over and above myalgic scores and age; however, in 3 separate MR analyses, self‐efficacy for function, pain, and other symptoms each predicted pain behavior over and above myalgic scores and age. This study indicated that the original pain behavior scoring methodology is appropriate for use with the FS population and should not be modified to include the pain behavior ‘stretching’. Self‐efficacy was related to pain behavior while depression was not among this FS sample.

Occurrence and Implications of Seizures in Subarachnoid Hemorrhage Due to Ruptured Intracranial Aneurysms

The records of 100 consecutive cases of subarachnoid hemorrhage due to ruptured aneurysm were reviewed to determine the incidence and the prognostic implications of seizures during the acute phase. Seizures occurred in 26% of the patients. Sixty-three per cent of the seizures occurred near the onset of the initial hemorrhage. The occurrence of these early seizures did not correlate with the location of the aneurysm or the prognosis. Most of the remaining seizures occurred immediately after rebleeding, with no greater morbidity or mortality compared to all patients who rebled. Pathogenic mechanisms of seizures associated with subarachnoid hemorrhage are proposed and discussed.

A prospective investigation of the impact of smoking bans on tobacco cessation and relapse

BACKGROUND AND OBJECTIVES To examine the long term impact of workplace smoking bans on employee smoking cessation and relapse. Over three years we studied a total of 1033 current or former smokers (intervention group) employed in smoke-free hospitals and 816 current or former smokers (comparison group) employed in non-smoke-free workplaces. The design of this natural experiment is a prospective cohort study. We randomly selected both hospitals and employees from 12 strata based on hospital size and state tobacco regulations, and sampled employees in the same communities. Main outcome measures were post-ban quit ratio and relapse rate. RESEARCH DESIGN Between groups comparisons were conducted using the Cochran-Mantel-Haenszel statistic for general association, stratified Cox proportional hazards models, and the CMH analysis of variance statistic based on ranks. McNemars test and the sign test were used to test for changes over time within each group. RESULTS Differences in the post-ban quit ratio were observed between intervention and comparison groups (p ⩽ 0.02). For employees whose bans were implemented at least seven years before survey, the post-ban quit ratio was estimated at 0.256, compared with 0.142 for employees in non-smoke-free workplaces (p = 0.02). After controlling for a variety of factors, time to quit smoking was shorter for the hospital employees (p < 0.001), with an overall relative risk of quitting of 2.3. Contrary to expectations, relapse rates were similar between the groups. CONCLUSION Employees in workplaces with smoking bans have higher rates of smoking cessation than employees where smoking is permitted, but relapse is similar between these two groups of employees. The results of this investigation have international applicability for policy makers, clinicians, employers, and employees. Countries should review smoking policies in workplaces in light of their own smoking patterns and efforts to deal with environmental tobacco smoke.

Preference mapping: relating acceptance of ''creaminess'' to a descriptive sensory map of a semi-solid

Abstract Creaminess is used by consumers to describe the texture of many food products. The overall objective of this study was to investigate the underlying sensations to the acceptance of textural creaminess. Eight puddings varying in thickness, mouthcoating, rate of melt and smoothness were developed by altering the amount and type of starch, amount of milk-fat and amount of sodium salts. Puddings were evaluated by descriptive analysis for appearance, texture and flavor characteristics. Concurrently, consumers evaluated the puddings for “liking of creamy texture”. Sensory descriptive data were subjected to principal component analysis, resulting in a multidimensional product space that was related to the consumer acceptance data using the AUTOFIT selection strategy. More than 90% of consumer responses were selected and validated by AUTOFIT. A dimension related to thickness seemed important to consumer acceptance of creamy texture. In general, hedonic scores for creamy texture were higher for samples that were smoother and had more dairy flavor, although, hedonic scores for creamy texture varied considerably on dimensions related to dairy flavor and smoothness.

Quick Test for Comparing Two Populations with Bivariate Data

A simple nonparametric test is given for testing the equality of two populations when the observations (X, Y) are bivariate and the alternative of interest is that the conditional c.d.f. of Y given X for one population dominates that for the other for every value of X. The procedure consists of fitting a curve through the combined set of data points and considering and conditional distribution of the number of points above the curve from one population, given certain information (depending on the design of the experiment), on the combined set of data. When used to compare two bivariate distributions, the test reduces to Fishers exact test for 2 X 2 tables.

Proteomic analysis of nipple aspirate fluid using SELDI‐TOF‐MS

Proteomic analysis of body fluids, including breast nipple aspirate fluid (NAF), holds promise to aid in early cancer detection. We conducted a prospective trial that collected NAF from women scheduled for diagnostic breast surgery to determine 1) the consistency of proteomic results, 2) protein masses associated with breast cancer, 3) subsets of women with a unique proteomic profile and 4) a breast cancer predictive model. NAF was collected preoperatively in 114 women and analyzed by SELDI‐TOF mass spectrometry over a 3–50 kDa range using H4, NP and SAX ProteinChips. For all 3 chips, the same protein peaks were detected over 90% of the time in duplicate samples. The overall coefficient of variation was ≤ 0.17% for each chip for the internal standard and ≤ 0.29% for the unknown proteins. Seven candidate protein ion masses frequently expressed in NAF were identified. Three (5,200‐H4, p=.04, 11,880‐H4, p=.07 and 13,880 Da‐SAX, p=.03) were differentially expressed in women with/without breast cancer. Protein expression differed between women with/without pathologic nipple discharge (PND), but the 5,200, 11,880 and 13,880 proteins remained associated with breast cancer even if PND samples were excluded. Subset analysis identified differences in expression between benign disease and DCIS and between DCIS and invasive cancer for the 5,200 and 33,400 Da proteins. The best cancer detection model included age, parity and the 11,880 Da protein, and excluded women with PND. 1) NAF proteomic analysis using SELDI‐TOF is reproducible with the same sample set across different platforms, 2) differential proteomic expression exists between women/without breast cancer and 3) combining proteomic and clinical information that are available before surgery optimizes the prediction of which women have breast cancer.

Pain-Patient MMPI Subgroups: The Psychological Dimensions of Pain

Two-hundred-forty male pain patients were given the MMPI and an extensive pain history questionnaire. A hierarchical clustering procedure was used, and three distinct profiles emerged. One profile was essentially “normal,” while a second profile revealed the “hypochondriasis” configuration, and a third was highly elevated on scales which reflect a “psychopathological” type of profile. A discriminant analysis yielded functions correctly classifying over 90% of the subjects in each group. Although the three groups did not significantly differ on age, education, income, IQ, assertiveness, type of pain, or years of pain duration, they did differ on the pain history questions relating to pain severity and pain impact on their lives. The psychopathological group reported significantly more distress than the hypochondriasis group, and the hypochondriasis group reported significantly more distress than the normal group. The implications for pain treatment are discussed.