William McIlroy

Laboratory diagnosis of iron-deficiency anemia: an overview.

BACKGROUND AND METHODSnTo determine the diagnostic values of laboratory tests used in the diagnosis of iron-deficiency anemia, the authors conducted a systematic overview of the relevant literature. Computerized searches of the MEDLINE database yielded 1,179 potentially relevant citations. Fifty-five studies included the results of laboratory tests and histologic examination of the bone marrow for at least 50% of an identifiable patient group. In these 55 studies, quality was assessed and descriptive information concerning the study populations, the tests conducted, and the results was extracted, all in duplicate.nnnRESULTSnSerum ferritin radioimmunoassay was by far the most powerful test, with an area under the receiver operating characteristic curve of 0.95. Test properties differed for populations of patients with inflammatory, liver, or neoplastic disease and patients without these conditions. Likelihood ratio lines, which allow precise interpretation of results across the entire range of ferritin concentration values, were constructed for the individual populations.nnnCONCLUSIONnSerum ferritin radioimmunoassay is an extremely powerful test for the diagnosis of iron-deficiency anemia and, appropriately interpreted, can be applied to the complete range of patients.

Laboratory diagnosis of iron-deficiency anemia

Background and methods:To determine the diagnostic values of laboratory tests used in the diagnosis of iron-deficiency anemia, the authors conducted a systematic over-view of the relevant literature. Computerized searches of the MEDLINE database yielded 1,179 potentially relevant citations. Fifty-five studies included the results of laboratory tests and histologic examination of the bone marrow for at least 50% of an identifiable patient group. In these 55 studies, quality was assessed and descriptive information concerning the study populations, the tests conducted, and the results was extracted, all in duplicate.Results:Serum ferritin radioimmunoassay was by far the most powerful test, with an area under the receiver operating characteristic curve of 0.95. Test properties differed for populations of patients with inflammatory, liver, or neoplastic disease and patients without these conditions. Likelihood ratio lines, which allow precise interpretation of results across the entire range of ferritin concentration values, were constructed for the individual populations.Conclusion:Serum ferritin radioimmunoassay is an extremely powerful test for the diagnosis of iron-deficiency anemia and, appropriately interpreted, can be applied to the complete range of patients.

Interviewer versus self-administered questionnaires in developing a disease-specific, health-related quality of life instrument for asthma.

We wished to determine the extent to which respondents provided the same answers to a health-related quality of life (HRQL) questionnaire in self- and interviewer-administered forms. One hundred and fifty patients with asthma who were symptomatic or required treatment at least once a week, and had airway hyperresponsiveness to methacholine aerosol (PC20 < 8.0 mg/ml) participated. Patients completed a 152-item HRQL questionnaire in both interviewer and self-administered forms, separated by a 2-week interval, the order determined by random allocation. The percentage of items endorsed by the self-administered approach was significantly higher than that of the interviewer-administered approach overall (46.9 vs 35.8%) (p < 0.0001). The difference was consistent across all six domains; the absolute difference in the proportion of items endorsed varied from 8.9 to 12.3%. The intraclass correlations for the proportion of subjects endorsing an item was 0.84. Self- and interviewer-administered questionnaires yield very similar results in discriminating between subjects, but the self-administered version shows systematically greater HRQL impairment.

Measuring quality of life in the frail elderly

This study was carried out to develop and test the Geriatric Quality of Life Questionnaire (GQLQ), a health-related qualify of life (HRQL) questionnaire designed for the frail elderly. One hundred patients were asked to identify areas of their daily lives affected by their health. The GQLQ, developed on the basis of the results, the Rand Physical and Emotional Function Questionnaires, and the Barthel Index, were administered serially to a group of 76 patients participating in a randomized trial of a Geriatric Day Hospital. Participants in all phases of the study were over 65 years of age, living in their own home but with sufficient functional status impairment to compromise their ability to live independently. The GQLQ includes 25 questions focusing on activities of daily living (ADL), symptoms, and emotional function. In the ADL and Symptom domains respondents define personal problem areas. The responsiveness coefficients of the GQLQ ADL and Symptom domains (0.26 and 0.30 respectively) were similar to those of the Rand Physical Function instrument and the Barthel Index (0.29 and 0.20). The responsiveness coefficient of the GQLQ Emotional Function domain (0.50) was similar to that of the Rand Emotional Function instrument (0.63). Correlations between the GQLQ ADL domain and the Barthel Index (0.41), and between GQLQ and the Rand Physical Function instrument (0.30), were similar to the correlation between the Barthel Index and Rand Physical Function (0.40). While the GQLQ captures important areas of health-related quality of life impairment for the frail elderly, we failed to show any advantages in either responsiveness or validity to existing, simpler measures. New, specific instruments should be tested in head-to-head comparisons with existing measures, particularly generic instruments, before dissemination.

Evaluation of right heart catheterization in critically ill patients ONTARIO INTENSIVE CARE STUDY GROUP

ObjectiveTo determine physicians assessment of the therapeutic effect and patient benefit of data obtained from right heart catheterization. DesignBefore/after study. SettingOne medical and one surgical academic ICU in two medical centers. PatientsA total of 107 critically ill patients with uncertain hemodynamic status. Data CollectionPhysicians looking after the patients were asked to evaluate the extent to which results of right heart catheterization resulted in changes in therapy and outcome. The same questions were asked of academic intensivists, two of whom reviewed each chart. ResultsAgreement regarding whether right heart catheterization had changed therapy was poor (chance corrected agreement [kappas] of −0.02 to 0.33). Treating physicians were more inclined than chart reviewers to conclude that management changes based on right heart catheterization improved outcome. Agreement on which patients benefited was poor (kappas of 0.03 to 0.32). ConclusionsPhysicians assessment of the effect of right heart catheterization on treatment decisions and patient outcomes is not reliable. Credible information regarding the benefits of right heart catheterization will require randomized trials.

Clinical Significance of Primitive Reflexes in Alzheimer's Disease

Study Objective: To establish the relationship between cognition, behavior, function, and clinical characteristics on the one hand, and the presence of primitive reflexes (PR) (pout, snout, palmomental and grasp) in patients with Alzheimers disease (AD).

A diagnostic and therapeutic N-of-1 randomized trial.

The objective of this paper is to study the effect of amitriptyline on a young woman with symptoms of lightheadedness, palpitations, somnolence and fatigue. We conducted a single case (N-of-1) randomized trial including three pairs of treatment periods. Each pair included one four-week period when the patient was receiving amitriptyline and one four-week period when the patient was receiving placebo. The clinical setting was a secondary care internal medicine practice. During active treatment periods, amitriptyline was given in a dose of 100 mg each evening. Efficacy symptoms included lightheadedness, headaches and somnolence/fatigue. Side-effects of dry mouth and constipation were also monitored. Each symptom was rated on a seven point scale in which higher numbers denoted fewer symptoms. For the combined efficacy score, the mean difference in scores and the associated standard error was in favour of amitriptyline. The most profound effect was on sleepiness. These differences represent clinically important treatment effects. Dry mouth and constipation were worse on the active drug, but differences did not reach statistical significance. Our experience suggests the usefulness of N-of-1 randomized trials in outpatient medical practice, including psychiatric practice.

Effect of a new nootropic agent, CGS 5649B, on cognition, function, and behavior in dementia

To determine the efficacy of CGS 5649B, the authors conducted a series of randomized, double-masked, single-subject studies using pairs of treatment periods, each pair including four weeks of active drug administration and four weeks of placebo administration. Thirty-two moderately demented patients completed three treatment pairs, receiving doses of 90, 200, or 600 mg of CGS 5649B during the active periods. Two patients met criteria for individual response in the behavioral measures. In the group analysis none of the differences achieved statistical significance. The authors conclude that CGS 5649B had a favorable impact on behavior for two of 32 patients.

Serum Cortisol: A Predictor of Mortality in Sepsis?

To evaluate the pattern and predictive value of serum cortisol levels in severe septic shock, we studied 20 consecutive critically ill patients with severe sepsis. Serum cortisol levels were measured at time of diagnosis, at 12 and 24 hours, and daily for 5 days. Underlying diagnoses included pneumonia (n = 9), urosepsis (n = 5), peritonitis (n = 4), and cellulitis (n = 2). Two patterns of cortisol secretion were identified. In Group A, serum cortisol levels were greater than 400 nmol/L and gradually decreased (n = 14). In Group B, levels were less than 400 nmol/L and remained below normal (n = 6). In Group A, 2 patients died (14.3%), whereas in Group B, 5 died (83.3%) (p < 0.05). The Simplified Acute Physiology Score (SAPS) was higher, intitial serum cortisol levels were lower, and serum lactate levels were higher in the nonsurvivors. In a logistical regression model, SAPS was the only independent predictor of death; when this variable was removed from the model, decreased initial serum cortisol was also predictive. Increased serum lactate was strongly associated with mortality. There appears to be an association between decreased initial serum cortisol and mortality in patients with severe septic shock.

Maternal Age and Alzheimer's Disease

The pathogenesis of Alzheimers disease (AD) is contributed to by genetic factors, but the mechanism is unknown. Because of the pathological similarities between AD and Downs syndrome, it has been