Yasmin Maor

A comparison of three measures: the time trade-off technique, global health-related quality of life and the SF-36 in dialysis patients

We investigated the correlation between descriptive and valuational measures of health-related quality of life (HRQL) and assessed determinants affecting these measures. Our suspicion was that there is little similarity in the content of descriptive and valuational measures of HRQL. We thus conducted a cross-sectional observational study of 56 hemodialysis patients. All underwent structured interviews. Dependent variables were patients utilities [time trade-off (TTO)], global rating of HRQL and generic HRQL (SF-36). Independent variables were socioeconomic details, disease severity, comorbidity, symptoms, depression, social support, and laboratory data. The correlation between TTO and global HRQL was -0.33 (P = .0178) and between TTO and the SF-36 physical and mental summary scores -0.16 (P = .2383) and -0.20 (P = .1443), respectively. The regression models for the SF-36 physical and mental summary scores explained 75% and 64% of the variance, and for global HRQL 29% of the variance. The independent variables had no effect on the TTO. This confirmed our suspicion that a qualitative difference exists between TTO and descriptive quality of life tools. The TTO content could not be explained by the variables that entail the content of HRQL instruments.

Do we know what global ratings of health-related quality of life measure?

Information is lacking about the publics perception of the term health-related quality of life (HRQL). Specifically, what are the relations between the domains included in the operational definition of HRQL tools and global health ratings. The purpose of this analysis was to identify factors associated with global rating of HRQL. We conducted a survey of a representative sample of 2,030 Israeli adults, aged 45–75 years. Multiple linear regression analysis was used to identify associations between the dependent variable, the global rating, and socio-economic details, presence of disease states, and each of the domains of the SF-36. The results demonstrate that the model explains only 52% of the variance of the global rating score. The general health domain of the SF-36 explains the vast majority of the variance, 38.5% . Another important explanatory variable was physical functioning domain, which explains 7.0% of the variance and to a lesser extent vitality. The other domains of the SF-36, socio-economic details and presence of disease states contribute only small percentages to the total explained variance of the global ratings of HRQL. It seems that there is a considerable difference between the operational definition of the research community of HRQL and the public perception of this term.

How often should infertile men have intercourse to achieve conception

OBJECTIVE To clarify how often infertile men should have intercourse to achieve conception, the effect of sequential ejaculation on total motile sperm counts was investigated. DESIGN Case-control study. SETTING Infertility and IVF unit, tertiary care center. PARTICIPANTS Five hundred seventy-six men who produced two closely spaced sequential ejaculates. MAIN OUTCOME MEASURE The total motile sperm counts of the second ejaculates were compared with the total motile sperm counts of the first ejaculates. RESULTS In normospermic men (n = 359), the total motile sperm counts decreased significantly from 93 (18 to 601) (median [minimum to maximum] x 10(6)) in the first ejaculate to 42 (1.2 to 387) in the second ejaculate, produced 24 hours later. In contrast to the normospermic men, in the asthenospermic group (24 hours difference, n = 81) and in both oligospermic groups, (1 to 4 hours difference, n = 27; and 24 hours difference, n = 45), there were no significant changes in the total motile sperm counts (24 [5.9 to 229] versus 30 [0.8 to 150], 6 [0.8 to 18] versus 3.6 [0.1 to 63] and 13 [2.5 to 32] versus 10 [0.1 to 66], respectively). Moreover, in both oligoasthenospermic groups (1 to 4 hours difference, n = 23; and 24 hours difference, n = 41) the total motile sperm counts increased significantly (3.2 [0.6 to 7.9] versus 8 [0.4 to 48] and 4 [0.2 to 13] versus 4 [0.1 to 101], respectively). In all groups, pooling sequential ejaculates significantly increased the total motile sperm counts, over and above that of the first ejaculate, by 49% in the normospermic group, 95% in the asthenospermic group, 67% and 75% in the oligospermic groups (1 to 4 hours and 24 hours difference, respectively), and 233% and 139% in the oligoasthenospermic groups (1 to 4 hours and 24 hours difference, respectively). CONCLUSIONS Sequential ejaculation may overcome the impaired sperm transport causing low total motile sperm counts observed in some oligospermic and/or asthenospermic men. Most of these infertile men may significantly increase their fertility potential, assessed by the total motile sperm counts, either by pooling sequential ejaculates for IUI, GIFT, and IVF, or by having intercourse every day or even twice a day, at the time of ovulation.

The competing effects of disease states on quality of life of the elderly

During the period 1993–1994 we conducted a study in Israel on a national-based sample of 960 men to examine the relationships between urinary symptoms and various domains of quality of life (QoL). Regression analyses were performed for each of the eight SF-36 domains, separately for the entire population and for those without any co-morbidity. The dependent variable was the SF-36 domain scores. The independent variables included age, origin, education, employment and economic status, the degree of disturbance caused by urinary symptoms and the existence of co-morbidities. There was a significant difference between the entire population and the population without co-morbidities. In the entire population we found that severely bothersome urinary symptoms were related to scores on three QoL domains (social function, role–emotional and mental health) but there was no association with physical functioning and general health perceptions. In men without co-morbidity, urinary symptoms were substantially related to physical functioning and general health perceptions. These findings indicate that the relative weight of the impact of a symptom or disease on QoL domains is changed by the presence of other competing factors, such as co-morbidities or sociodemographic attributes.

The effect of acellular dermal matrix on drain secretions after immediate prosthetic breast reconstruction

Abstract In recent years the acellular dermal matrix (ADM) has gained popularity in prosthetic breast reconstruction. These procedures involve placement of a closed suction drain in the reconstructed breast. Although it is now widely accepted that ADM has an overall positive effect on the outcome of breast reconstruction, data regarding its effect on postoperative drain secretions is lacking. This study was designed to quantitatively evaluate the influence of ADM on postoperative drain secretions in the setting of immediate prosthetic breast reconstruction (IPBR). This is a prospective, comparative controlled study. Two groups of 16 patients each underwent skin sparing mastectomies (SSM) and IPBR with or without ADM. Closed suction drains were left in all the reconstructed breasts and daily secretion volumes were recorded and compared. Postoperative complications were also noted. Patients in the ADM group showed higher daily and overall secretion volumes compared with patients in the control group (p = 0.014) and the time for removal of the drains was higher by an average of 5 days (13 compared with 8 days, respectively; p = 0.004). There was no correlation between ADM and infection. This study provides the first objective evidence that ADM contributes to elevated and prolonged drain secretions when used for IPBR. This might affect possible prosthesis-related complications (e.g., rotation and malposition, capsular contraction, seroma formation, and infection). This study also noted erythema of the post-mastectomy skin flaps in selected patients, which may be attributable to a local inflammatory reaction to the ADM rather than infection.

Hyperprolactinemia in postmenopausal women

OBJECTIVE To study the clinical cause and course of hyperprolactinemia in postmenopausal women. DESIGN Retrospective case-note study. SETTING Tertiary care hospital. PATIENT(S) Six postmenopausal women with hyperprolactinemia. MAIN OUTCOME MEASURE(S) Clinical history and physical examination, serum levels of PRL, LH, FSH, computed tomography (CT) of the pituitary gland before and after treatment with bromocriptine. RESULT(S) At presentation, the mean age was 57.5 +/- 7.5 SD years. The mean level of PRL was 1,427 +/- 1,599 ng/mL (1,427 +/- 1,599 micrograms/L). All women suffered from secondary amenorrhea for a mean duration of 31.8 +/- 5.6 years. Five of six had galactorrhea at some time in the past. Pituitary imaging revealed a pituitary macroadenoma in four women, an enlarged sella suggestive of a pituitary macroadenoma in one woman, and a microadenoma in one. After treatment with bromocriptine, the PRL level decreased in all women to within normal limits. Five of six women developed hot flushes after the PRL level returned to normal. CONCLUSION(S) Most cases of hyperprolactinemia in postmenopausal women are due to macroadenoma rather than microadenoma, the common finding in younger women. The clinical course is suggestive of a prolonged disease that was not detected earlier, although clinical signs were present. These findings are suggestive of an enlargement of microadenomas to macroadenomas as time passes.

Changing Populations: The Elderly, Injection Drug Users, Health-Care-Associated and Immunocompromised Patients

A 38 year old man presented to hospital with a 10 day history of bloody sputum, left sided chest pain aggravated by inspiration and movement, dyspnea, fatigue and pyrexia. He had been using intravenous heroin and crack cocaine for the past 10 years and was diagnosed to be infected with both the human immunodeficiency virus and hepatitis C virus 5 years ago, but he declined therapy for both infections. He had just finished a 6-month course of directly observed antituberculous therapy. Hospital record from an admission 3 months previously disclosed that at that time he was colonized with methicillin resistant Staphylococcus aureus (MRSA) in his nostrils and throat. On examination, he was cachectic and jaundiced. The blood pressure in the right arm was 110/35 mmHg, his heart rate 110 beats per minute and the respiratory rate 36 per minute. His oxygen saturation on room air was 94%. Old and fresh track marks were present in both arms. Evaluation of fundi revealed multiple hemorrhages. His jugular venous pressure was markedly elevated at 15 cm. In addition to S3 and S4 gallop, there were a 3/6 holosystolic murmur over the second intercostal space radiating to the neck, a 3/6 systolic ejection murmur over the right sternal border and a 2/6 diastolic murmur over the left second intercostal space. Dullness to percussion was appreciated in the right lower lung field with decreased breath sounds and bronchial breathing. Also present were hepatosplenomegaly, ascitis and ankle edema. The neurological examination was normal. The chest radiograph showed consolidation and a cavity with an air fluid level in the right lower lung field. The electrocardiogram revealed second degree A-V block, left axis deviation and left ventricular hypertrophy. The hemoglobin was 66 g/L with normal indices, the white blood cell count 32 x 109 cells/L with the majority being polymorphonuclear cells and the platelet count 850 x 109 cells/L. The INR is 3.2 with elevated liver enzymes. The viral load was > 100,000 copies/ml and the urine contained 100 red blood cells, 100 white blood cells and red blood cell casts. A transthoracic echocardiogram showed two pedunculated vegetations about 2 cm in length on the anterior and posterior cusps of the aortic valve and an additional vegetation on the tricuspid valve, associated with severe aortic and tricuspid insufficiency. In light of the history of injection drug use and previous colonization with MRSA, decision was made to initiate empiric therapy with vancomycin and ciprofloxacin which was used instead of an aminoglycoside because of renal failure. Within 72 hours of their collection all 3 sets of blood cultures grew MRSA and Candida albicans was recovered from all blood cultures at 96 hours. Parenteral fluconazole was then added 3