Retraction: Neurogenic Stunned Myocardium: A Literature Review

[This retracts the article DOI: 10.7759/cureus.3129.].

Symptomatic involvement of the stomach and duodenum as initial presentation of AL amyloidosis

Primary systemic or amyloid light chain (AL) amyloidosis is a multisystem disorder with myriad presentations. Although it can involve the upper gastrointestinal tract in 8% of cases, symptomatic involvement is exceedingly rare. We chronicle here a case of postprandial epigastric pain associated with AL amyloidosis involving the stomach and duodenum. Pathological examination of endoscopic biopsy using Congo red staining confirmed the diagnosis. In order to establish the underlying aetiology of AL amyloidosis, the patient underwent extensive workup. Eventually, she was diagnosed with multiple myeloma based on the standard set of investigations. This paper underscores the importance of clinical suspicion of amyloidosis in patients presenting with non-specific gastrointestinal symptoms and highlights the role of endoscopic biopsy to confirm the amyloid deposition. Since gastrointestinal amyloidosis is a disease with a poor prognosis, early diagnosis and treatment are particularly warranted.

Hemosuccus Pancreaticus: A Great Masquerader in Patients with Upper Gastrointestinal Bleeding

Hemosuccus pancreaticus is a rare but life-threatening cause of upper gastrointestinal bleeding through the main pancreatic duct. This clinical entity is a difficult diagnosis due to its rarity, intermittent nature of the hemorrhage, and peculiar clinical presentation. It is still considered a surgical problem but advances in medical therapy may enable clinically stable patients to undergo less-invasive angiographic embolization. We chronicle here a unique case of hemosuccus pancreaticus in a patient presenting with melena who could not be diagnosed on multiple standard forward-viewing esophagogastroduodenoscopies and computed tomography angiography. Eventually, side-viewing duodenoscope identified the intermittent bleeding through the ampulla of Vater. This paper illustrates that clinicians should be vigilant for this etiology, especially in patients with intermittent crescendo-decrescendo abdominal pain, acute gastrointestinal hemorrhage, and elevated serum lipase levels. A multidisciplinary team approach with the centralization of gastrointestinal bleed services and a well-established management protocol is of paramount importance to reduce the morbidity and mortality of this disorder. Additionally, this article serves to outline our current understanding of the epidemiology of and risk factors for hemosuccus pancreaticus, the pathophysiology of this disease, and currently available approaches to diagnosis and treatment.

The risky side of weight-loss dietary supplements: disrupting arrhythmias causing sudden cardiac arrest

The worldwide increasing prevalence of obesity has led to a corresponding increase in consumption of weight-loss dietary supplements. The limited de novo regulatory oversight and under-reported toxicity profile of these products reflect as a constellation of newer adverse events. We chronicle here the case of an otherwise healthy woman who developed ventricular fibrillation-related cardiac arrest secondary to the use of Hydroxycut and Metaboost preparations. Published medical literature has a handful of case reports associating these products with potentially life-threatening cardiac arrhythmias. The proposed hypothesis implicates ingredients of these diet aids to have proarrhythmogenic effects. Physicians should remain vigilant for possible cardiotoxicity associated with the use of dietary supplements. Individuals who are at risk of developing cardiac arrhythmias should avoid herbal weight-loss formulas, given the serious clinical implications. Additionally, this paper highlights the need for a proper framework to delineate the magnitude and scope of this association.

Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

An Overview of the Pathology and Emerging Treatment Approaches for Interstitial Cystitis/Bladder Pain Syndrome

Our article will discuss bladder pain syndrome (BPS), which is the presence of chronic suprapubic pain to bladder filling accompanied by other urinary symptoms, such as frequency, urgency, discomfort with filling, and relief with emptying of the bladder in the absence of infections or other pathology. It is mostly seen in females and occurs in 0.06%-30% of the population. Some of the proposed mechanisms causing BPS include damage to the bladder lining, a problem manifesting in the pelvic musculature, endocrine, neurological, allergic, autoimmune system, and inflammatory system; however, a definite cause has not been yet identified. Two types of this syndrome have been identified, ulcerative and non-ulcerative. In the ulcerative disease, areas of reddened mucosa associated with small vessels radiating towards a central scar (at times, covered by a small clot or fibrin) can be seen. In the non-ulcerative type, a normal bladder mucosa can be observed initially, and the subsequent development of glomerulations after hydrodistension is considered a definite sign of its diagnosis. The diagnosis of BPS is primarily clinical; however, cystoscopy and biopsy can also be performed, if needed. Finally, we will discuss in detail the treatment of BPS, which constitutes three different guidelines (The European Association of Urology (EAU) Guidelines 2017, the American Urology Association (AUA) Guidelines 2014, and The Royal College of Obstetricians and Gynecologists (RCOG) in conjunction with the British Society of Urogynaecologists (BSUG) Guidelines 2016). All are proposing different types of therapy, including conservative, medical, and surgical treatment.

American Heart Association High Blood Pressure Protocol 2017: A Literature Review

Hypertension is the most prevalent clinical symptom arising from various cardiovascular disorders. Likewise, it is considered a precursor or sequelae to the development of acute coronary artery disease and congestive heath failure (CHF). Hypertension has been considered a cardinal criterion to determine cardiovascular function. According to the World Health Organization (WHO) global observatory data, hypertension causes more than 7.5 million deaths a year, about 12.8% of the total human mortality. Similarly, the Center for Disease Control (CDC) states that 35% of the American adults have been estimated to have a persistently high blood pressure, which makes it about one in every three adults. Hypertension is a modifiable symptom that can be managed through pharmacological and non-pharmacological methods and standard protocols set forth by the American Heart Association (AHA). With new findings from various clinical trials related to the management of hypertension, new developments and recommendations have been made to update the previously established protocols for hypertension. This article aims to discuss and dissect the modern updates of hypertension management as comprehensively elaborated in the 2017 Hypertension Clinical Practice Guidelines.

Lafora Disease Masquerading as Hepatic Dysfunction

Lafora disease is fatal intractable progressive myoclonic epilepsy. It is frequently characterized by epileptic seizures, difficulty walking, muscle spasms, and dementia in late childhood or adolescence. We chronicle here an unusual case of an asymptomatic young male soccer player who presented with elevated liver enzymes. Neurological examination was unremarkable. The diagnostic workup for hepatitis, infectious etiologies, autoimmune disorders, hemochromatosis, Wilson's disease, alpha-1 antitrypsin deficiency, and other related diseases was inconclusive. He subsequently underwent an uneventful percutaneous liver biopsy. Based on the pathognomonic histopathological findings, Lafora disease was considered the likely etiology. The present study is a unique illustration of this rare disorder initially manifesting with abnormal liver enzymes. It underscores the importance of clinical suspicion of Lafora disease in cases with unexplained hepatic dysfunction. Prompt liver biopsy and genetic testing should be performed to antedate the onset of symptoms in these patients.

Management of Orthostatic Hypotension: A Literature Review

In the older population, especially the hospitalized patients who are prone to dehydration and hypovolemia, orthostatic hypotension (OH) presents as a debilitating disease. How different pharmacological and non-pharmacological interventions affect the incapacitating symptoms (falls and episodes of syncope), morbidity, and mortality related to OH has become a topic of debate. OH can predispose to ischemic heart disease (IHD). A non-pharmacological approach consisting of mobilization, early lifestyle changes, and therapeutic maneuvers is the first choice in the management of these patients. Individuals with persistent symptoms require pharmaceutical therapy to increase blood volume and peripheral vascular resistance. This article summarizes the management of OH that is vital to cope with the needs of the growing geriatric populations.

Neurogenic Stunned Myocardium: A Literature Review

Neurogenic stunned myocardium (NSM) is defined as the occurrence of cardiac abnormalities due to neurological events such as stroke, seizures, etc. These events lead to dysfunction of the autonomic nervous system (ANS) and ultimately cause injury to the myocardium. The clinical features seen in NSM include elevated troponin level, left ventricular dysfunction, and changes on the electrocardiogram (ECG). However, these features are also seen in Takotsubo cardiomyopathy as well as in an acute coronary syndrome (ACS). Hence, diagnosing the condition by clinical presentation alone is difficult. Thus, a patient of NSM who is at increased risk of developing coronary heart disease may require invasive procedures such as cardiac catheterization to rule out ACS. This review aims at raising awareness about NSM among physicians so that management of patients can be individualized.

Hepatitis B virus reactivation following imatinib therapy: A comparative review of 9 cases

Patients undergoing cytotoxic or immunosuppressive therapy for cancer have an established predilection for hepatitis B virus reactivation; however, the risk associated with newer molecularly targeted agents has not been well investigated. Imatinib, a small molecule tyrosine kinase inhibitor, induces rapid and sustained clinical benefit by inhibiting a number of signaling pathways, including BCR-ABL and c-KIT. We report the case of a patient who developed hepatitis B virus reactivation while receiving imatinib therapy for gastrointestinal stromal tumor. Furthermore, a structured literature search of the medical databases consisting of MEDLINE and PubMed was performed using the terms "hepatitis B", "reactivation", and "imatinib". The search identified nine case reports only. The data on patients' characteristics, epidemiology, clinical features, comorbid conditions, diagnosis, and management are summarized. Imatinib-associated hepatitis B virus reactivation was reported in seven patients with chronic myeloid leukemia, one with desmoid tumor, and one with gastrointestinal stromal tumor. This review serves to outline our current understanding of the epidemiology, risk factors, and pathophysiology of chronic hepatitis B virus reactivation secondary to imatinib therapy as well as the current approaches to diagnosis and management of this condition. We aim to increase awareness about this possible association and advocate for hepatitis B virus screening prior to imatinib therapy, especially in patients who are at increased risk for chronic hepatitis B virus infection.

Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management

Left ventricular pseudoaneurysm is a rare but life-threatening disorder that is frequently reported secondary to myocardial infarction or cardiac surgery. In this article, we chronicle the case of a patient with no prior risk factors who presented with a 2-week history of nonexertional atypical left chest pain. Apical 2-chamber transthoracic echocardiography revealed an unexpected outpouching of basal inferoseptal wall of the left ventricle, which had a narrow neck and relatively wide apex. The patient was diagnosed with left ventricular pseudoaneurysm and medical therapy was initiated. He refused to undergo the surgical intervention and subsequently, he was discharged from the hospital in stable condition. This article illustrates that physicians should be vigilant for atypical presentations of left ventricular pseudoaneurysm, and a high index of suspicion should be maintained for this stealth killer while performing appropriate diagnostic imaging. Additionally, we review the currently available approaches to diagnosis and management in these patients.

Brucellosis in renal transplant recipients: a comparative review of 5 cases

Although brucellosis in renal transplant recipients is rare, we studied the clinical characteristics of this infection in this patient population due to the significantly increased number of renal transplantations performed over the past few decades. We report one case from our experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of 5 cases of brucellosis in renal transplant recipients were found to date. The mean time from transplantation to diagnosis of brucellosis was 4.7 years (range, 4 months to 13 years). Blood culture and detection of anti-Brucella antibodies were frequently used diagnostic investigations. Treatment with appropriate antibiotic regimen led to a clinical cure and marked improvement in Brucella titre in all the patients. This review illustrates that clinicians should remain vigilant for this infectious aetiology following renal transplantation. Further studies are required to delineate the magnitude and scope of this association.

Pseudo-Wellens' syndrome secondary to concurrent cannabis and phencyclidine intoxication

Wellens' syndrome is an electrocardiographic pattern of T-wave changes associated with critical stenosis of the proximal left anterior descending artery, signifying imminent risk of an anterior-wall myocardial infarction. The Wellens' electrocardiographic pattern can also be noted in several cardiac and non-cardiac diseases. We chronicle here a unique case of a patient who presented with atypical left chest pain and dizziness for 6 hours. His pain started after he smoked phencyclidine-laced cannabis. Cardiac panel demonstrated normal troponin T levels. Electrocardiogram showed sinus rhythm with new deep biphasic T-wave inversions in anterolateral leads. Coronary angiography showed no pathological processes. Subsequently, ECG changes resolved coincidentally with the resolution of chest pain. He was eventually diagnosed with pseudo-Wellens' syndrome. This paper illustrates that physicians should be vigilant for Wellens' syndrome mimicked by acute phencyclidine and cannabis intoxication. Additionally, we present a review of various aetiologies of pseudo-Wellens' syndrome, especially in patients with substance abuse.

Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review

Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.

Comparison of Knowledge and Attitudes of Medical and Dental Students towards HIV/AIDS in Pakistan

The number of new human immunodeficiency virus (HIV) cases is increasing in Pakistan while it has seen a decline globally. A survey conducted recently has found that 132,000 people in Pakistan suffer from HIV. This study aims to check the levels of knowledge and attitudes about HIV/acquired immunodeficiency syndrome (AIDS) among medical and dental students.

This cross-sectional study was designed and conducted at Combined Military Hospital Lahore Medical College and the Institute of Dentistry (CMH LMC) in Lahore, Pakistan in 2016. Students enrolled in the courses of the MBBS and BDS were included in this study. The questionnaire consisted of three sections: demographics, knowledge and attitude.

A total of 414 students completed the questionnaire and out of them, 286 were medical students while the rest were dental students. The mean ± standard deviation score for the students was 10.02 ± 4.37 out of 17 for knowledge related to HIV and AIDS. For acceptable attitude towards AIDS and patients afflicted with the disease, an outcome of 1.93 ± 0.75 out of 4 was observed.

The results of this study indicate lack of knowledge about HIV, especially about the modes of transmission and prevention techniques. Therefore, regular interactive workshops and seminars, besides teaching sessions, focused lectures on HIV/AIDS, need to be conducted.

Inhibition and kinetic studies of cellulose- and hemicellulose-degrading enzymes of Ganoderma boninense by naturally occurring phenolic compounds

AIM

Ganoderma sp, the causal pathogen of the basal stem rot (BSR) disease of oil palm, secretes extracellular hydrolytic enzymes. These play an important role in the pathogenesis of BSR by nourishing the pathogen through the digestion of cellulose and hemicellulose of the host tissue. Active suppression of hydrolytic enzymes secreted by Ganoderma boninense by various naturally occurring phenolic compounds and estimation of their efficacy on pathogen suppression is focused in this study.

METHODS AND RESULTS

Ten naturally occurring phenolic compounds were assessed for their inhibitory effect on the hydrolytic enzymes of G. boninense. The enzyme kinetics (V_max and K_m ) and the stability of the hydrolytic enzymes were also characterized. The selected compounds had shown inhibitory effect at various concentrations. Two types of inhibitions namely uncompetitive and noncompetitive were observed in the presence of phenolic compounds. Among all the phenolic compounds tested, benzoic acid was the most effective compound suppressive to the growth and production of hydrolytic enzymes secreted by G. boninense. The phenolic compounds as inhibitory agents can be a better replacement for the metal ions which are known as conventional inhibitors till date. The three hydrolytic enzymes were stable in a wide range of pH and temperature.

CONCLUSION

These findings highlight the efficacy of the applications of phenolic compounds to control Ganoderma.

SIGNIFICANCE AND IMPACT OF THE STUDY

The study has proved a replacement for chemical controls of G. boninense with naturally occurring phenolic compounds.

Enigma of Extrapulmonary Tuberculosis: Where Do We Stand?

Tuberculosis remains a worldwide public health concern. Atypical extrapulmonary presentations may delay its diagnosis and treatment. The present study illustrates the importance of ruling out extrapulmonary tuberculosis in patients presenting with nonspecific symptoms of abdominal diseases. Furthermore, we discuss the variety of clinical presentations, diagnostic challenges, current therapeutic protocols, and prognostic factors associated with extrapulmonary tuberculosis. Early diagnosis and effective treatment may decrease morbidity and mortality in such patients.

Prevalence and Determinants of Frozen Shoulder in Patients with Diabetes: A Single Center Experience from Pakistan

Introduction

Frozen shoulder (FS) or adhesive capsulitis is a constellation of symptoms like pain, stiffness, and/or functional deficit at the glenohumeral joint. It is one of the musculoskeletal complications in patients with diabetes that can be particularly debilitating. The aim of this study is to estimate the prevalence of FS and to compare the determinants of this disease in a population with diabetes from Lahore, Pakistan.

Materials and Methods

We carried out this cross-sectional study on a systematically randomized sample of 80 patients with diabetes. It included 38 males and 42 females from 2,964 patients registered at the Diabetes Management Center, Services Hospital Lahore, Pakistan. The study was conducted in the months of April, May, and June 2017. A structured questionnaire was designed and the responses of patients were recorded at the clinic after informed verbal and written consent. The questionnaire outlined the key factors that can lead to a higher frequency of FS in patients with diabetes.

Results

Thirty-three of the total 80 respondents included in the study were diagnosed with FS. The estimated prevalence of FS in diabetics from this data was 41.3% in Lahore, which is an urban area of Pakistan with a population of more than seven million. Female sex, insulin dependence, uncontrolled blood glucose levels, and a positive family history were associated with a significantly higher prevalence of FS. In our study, most patients with FS were in Stage 1 of the disease and had unilateral involvement.

Conclusion

The present study shows that the prevalence of FS is higher in patients with diabetes residing in Lahore than in comparable foreign populations with diabetes. It can be attributed to socioeconomic status, lack of awareness, a higher threshold for diagnosis, and/or poor glycemic control. Mass awareness campaigns, especially for female patients with diabetes, are required to be initiated to create awareness about the disease and to facilitate early diagnosis and appropriate management. In-depth and multicenter studies are needed to further explore the association between FS and diabetes.

From the Gut to the Heart: Campylobacter jejuni Enteritis Leading to Myopericarditis

Campylobacter jejuni enteritis is the most common enteric infection in the developed world. Although rare, pericarditis and myopericarditis have been increasingly documented as complications following campylobacteriosis. The present paper implicates that myopericarditis and non-ischemic cardiomyopathy following Campylobacter jejuni infection might be more prevalent than initially thought and perhaps underreported so far. Therefore, it is imperative to perform the appropriate initial diagnostic testing, including stool cultures, in order to make an accurate diagnosis early in the course of the disease. Identifying the etiology of myopericarditis as bacterial will ensure appropriate treatment with antibiotics in addition to the cardiac medications needed for supportive care.

Use of psychoactive drugs among patients visiting outpatient clinics in Karachi, Pakistan

INTRODUCTION

This study was conducted to determine the proportion of usage of psychoactive drugs, and to identify factors associated with its use among patients visiting outpatient clinics of a tertiary care hospital in Karachi, Pakistan.

METHODS

A cross-sectional study was conducted involving 461 adult (age 18 years and above) patients, who were surveyed by using interviewer-administered questionnaires. All interviews were conducted by a medical students. Out of the total number of participants, 242 (52.5 percent) were males and 219 (47.5 percent) were females.

RESULTS

In all, 118 (25.6 percent) of the respondents were using some sort of psychoactive drugs, however, only 20 (4.3 percent) study subjects were diagnosed with any psychiatric illness. Factors found to be significantly associated with usage of psychoactive drugs included belonging to the female gender (p-value equals 0.019), older (more than 50 years) age (p-value is less than 0.001), being married (p-value equals 0.004), having formal schooling of up to 12 years (p-value equals 0.001) and physical inactivity (p-value equals 0.004). In addition, those whose family members were using psychoactive drug(s) or who suffered from non-communicable diseases were more likely to use psychoactive drugs in comparison to others (p-value is less than 0.001).

CONCLUSION

The use of psychoactive drugs is quite common in our patients regardless of having any psychiatric disease. Efforts are required to control and prevent the abuse of these drugs. Education and awareness programmes for doctors and patients may help to prevent the inappropriate use of psychoactive drugs. Regulatory intervention to control use of these drugs is also recommended.

Association of iron deficiency anaemia in children of 1-2 years of age with low birth weight, recurrent diarrhoea or recurrent respiratory tract infection--a myth or fact?

AIMS AND OBJECTIVE

To investigate for the presence or absence of any association between low birth weight, recurrent diarrhoea or recurrent acute respiratory infections with iron deficiency anaemia in Pakistani children aged 1-2 years.

METHODOLOGY

From July 1993 to July 1995 a case control study was conducted at the Community Health Centre (CHC). Fifty cases and 100 controls were included. Informed consent was taken from mothers for the blood tests of their children and a questionnaire was administered to them. Data obtained from the completed questionnaires was analyzed by chi-square and t-tests.

RESULTS

There was no statistically significant difference in low birth weight (p = 0.712), recurrent diarrhoea or respiratory infections between anaemic and non-anaemic children at 1-2 years age (OR of 1.71 and 1.48 respectively).

CONCLUSION

This study does not uphold the belief that low birth weight, recurrent diarrhoea or respiratory infections have a causal association with iron deficiency anaemia in 1-2 years children.

Is there a value of mantoux test and erythrocyte sedimentation rate in pre-employment screening of health care workers for tuberculosis in a high prevalence country?

SETTING

Pre-employment screening of health care workers (HCWs) is practiced widely. Research needs to be carried out to evaluate the screening procedure in developing countries.

OBJECTIVE

To evaluate the efficacy of Mantoux test and erythrocyte sedimentation rate (ESR) for the diagnosis of active tuberculosis (TB), in pre-employment screening of HCWs, in a high prevalence country.

DESIGN

Pre-employment screening of all new employees was reviewed from June to September 2000. The screening consisted of history, physical examination, blood and urine tests, Mantoux test and a chest radiograph. Patients with clinical, laboratory or radiological features suggestive of active TB were referred to a specialist.

RESULTS

Out of 207 employees, a Mantoux reaction of > or = 10 mm and ESR of > or = 25 mm/first hour was noted in 90 (43.5%) and 21 (10.1%), respectively. One person had symptoms suggestive of TB and was already on anti-tuberculosis therapy at the time of screening. All other employees were asymptomatic. Based on radiographic findings, four (2%) cases were referred and one was given anti-tuberculosis therapy. An additional 48 (23.1%) employees were referred on the basis of positive Mantoux or elevated ESR; none were found to have active TB.

CONCLUSION

In high prevalence countries use of Mantoux test and ESR in pre-employment screening of HCWs is not recommended for detection of active TB.

The relationship of socio-demographic factors with iron deficiency anaemia in children of 1-2 years of age

OBJECTIVE

To investigate associations between different socio-demographic factors with iron deficiency anaemia in Pakistani children of 1-2 years of age.

METHODOLOGY

A case control study, with 50 cases and 100 controls, was conducted at the Community Health Centre, an outpatient clinic of the Aga Khan University, Karachi, Pakistan, between July 1993-July 1995. Informed consent was taken from mothers for their children's blood tests and a questionnaire was administered to them. The data was analyzed using chi-square, t-tests and logistic regression.

RESULTS

The numbers of pregnancies, live births and living children were more among cases than controls but the differences were not statistically significant. Although father's education did not show a significant association (OR 1.35, 95% CI 0.22-8.33), maternal education was significantly associated with the children's anaemic status (OR 3.55, 95% CI 1.40-9.02). The difference in monthly incomes between families of cases and controls was the most significant variable among all those studied (p-value 0.006).

CONCLUSION

This study showed that while lack of maternal education and low monthly family incomes are both significantly associated with the development of childhood anaemia, low monthly income is most significant.

ACC/AHA guidelines as predictors of postoperative cardiac outcomes

PURPOSE

Recently, the American College of Cardiology - American Heart Association (ACC-AHA) published guidelines and an associated algorithm for preoperative cardiovascular evaluation of patients undergoing non-cardiac surgery. Our purpose was to (i) test guideline's ability to predict adverse cardiac events within seven days after surgery, (ii) determine whether medical clinical predictors or surgical risks was a better predictor of cardiac events.

METHODS

Retrospective review of 119 cardiology and anesthesia consultations over 15 mo, ending March 31, 1998. Patients were classified into their respective medical clinical predictor and surgical risk groups, as outlined in ACC-AHA guidelines. Associations between the medical predictor and surgical risk scores and adverse cardiac outcomes were quantified via multiple logistic regression analysis. Two outcomes were employed. Outcome I, included: myocardial infarction/ischemia; angina; congestive heart failure, arrhythmia or death. Outcome 2 expanded the definition to include "cancellation of surgery due to cardiac risk" as a negative cardiac outcome.

RESULTS

Diabetes, Canadian Cardiovascular Class (CCS) III or IV angina, and MI within six months before surgery were strongly associated with the two cardiac outcomes. For outcome 1 and 2, medical predictors and surgical risks, considered simultaneously, performed with a sensitivity of 93% and specificity of 46-51%. When considered separately, major clinical medical predictors had a sensitivity of 87-89%, while surgical risks showed a specificity of 89% in predicting the two outcomes.

CONCLUSION

Medical predictors in ACC-AHA classification scheme were highly sensitive whereas surgical risks were more specific in predicting adverse post-operative cardiac events. Prospective study is needed to confirm these observations.

Evaluation of Traditional Classroom Teaching Methods Versus Course Delivery Via the World Wide Web

Higher education is moving with deliberate speed to an electronic classroom. Much has been published on faculty experiences with World Wide Web (WWW) course delivery. However, little research exists on the evaluation of these methods. The purpose of this study was to evaluate students' perceptions of two approaches to teaching: classroom and WWW modules. Classroom methods were rated significantly higher in relation to content, interaction, participation, faculty preparation, and communication. Technical skills were rated higher for WWW modules. Critical thinking and time allotted for assignments were not significantly different between classroom and WWW instruction. Open-ended comments were rich and supported both positive and negative aspects of classroom and WWW-based modules. Implications call for creativity in course development, course redesign and orientation, active communication with students, support for technical problems, faculty development, and university-wide planning through partnerships.

Promotion of advance care planning in the nonhospitalized elderly

Factors that influence the execution or lack of execution of advance directives in 162 nonhospitalized older adults were examined. Significant results were found, and implications for geriatric nurses are presented.

Predictors of quality of life in women: hormone therapy self-efficacy and health-promoting behaviors

Osteoporosis and coronary heart diseases (CHD) are two major health problems that affect postmenopausal women. The literature emphasizes that prevention of osteoporosis and/or CHD through the practices of health-promoting behaviors and hormone therapy usage can improve quality of life (QOL) for women. The purpose of this study was to examine the impact of health-promoting behaviors and hormone therapy self-efficacy on QOL. The sample contained 210 women between the ages of 45 and 84 years of age, who completed three instruments developed specifically for this study. The majority of the participants perceived moderate satisfaction with their life as a whole, performed many health-promoting behaviors, and perceived slight confidence in their ability to continue hormone therapy. Among current users of hormones, hormone therapy self-efficacy beliefs explained 31% of the variance in QOL. Among non-users of hormones, health-promoting behaviors explained 7% of the variance in QOL. In the entire sample, health-promoting behaviors explained 10% of the variance in QOL. There were significant differences between current users of hormones and non-users of hormones in QOL and in health-promoting behaviors. The study has implications for intervention and for future research.

The hormone replacement therapy self-efficacy scale

This study describes the initial development and psychometric evaluations of an instrument to measure self-efficacy in hormone replacement therapy (HRT) use. The development of the scale was based upon Bandura's self-efficacy construct. The sample was 116 women who were 50 years old and above and who were current or past users of HRT. Factor analysis was used to develop construct validity and Cronbach's alpha was used to compute reliabilities. Factor analysis isolated two factors, efficacy beliefs in HRT (EBs-HRT) and outcome expectations in HRT (OEs-HRT). The developed tool contains 14 items, eight items compose the EBs-HRT subscale and six items make-up the OEs-HRT subscale. The two subscales and total instrument were found to have good internal reliabilities. Implications for HRT intervention using the developed tool are discussed.

Nocturnal enuresis in children

This common condition can be managed by the general practitioners. The key answer to nocturnal enuresis is nocturnal self-awakening and recently more emphasis is given on this which is an area of greatest promise. Behavioural modification in conjunction with an enuretic alarm also teaches this skill and has the highest cure rate and the lowest relapse rate. Enuretic alarms can be used any time from age 5 onwards. But drugs are only indicated when there is need for short term dryness e.g. when the child has to be away from home.

Providing culturally sensitive care to Egyptians with cancer

PURPOSE

This article describes key aspects of Egyptian culture and provides intervention strategies that oncology practitioners may use to provide quality care to Egyptian immigrants and Egyptian-American oncology patients.

OVERVIEW

The growing diversity of the United States population challenges oncology professionals to provide culturally appropriate care. Egyptian immigrants and Americans of Egyptian descent comprise a unique population whose cultural and religious beliefs impact on decision making and behaviors related to cancer diagnosis and treatment. This population is overwhelmingly Muslim, although a sizeable minority are members of Eastern Christian sects. Dietary restrictions, social conduct, and religious observance are among the areas that require understanding by health providers.

CLINICAL IMPLICATIONS

Learning about patients' perspectives on health and illness, in light of their cultural values and beliefs, will allow health professionals to enhance the quality of assessments and interventions and provide culturally appropriate care.

Cancer prevention and early detection among Egyptians

Although cancer is frequently not perceived as a significant health problem in developing countries, cancer death in developing countries is higher than in developed countries. Therefore, cancer prevention and early detection in developing countries is becoming a universal challenge to health care providers. The purpose of this exploratory study was to identify knowledge, attitudes, and behaviors related to cancer prevention and early detection among Egyptians. Data were collected from 99 people, and the design was descriptive and correlational, using a self-administered survey. Results showed that the Egyptians surveyed had some knowledge about warning signs of cancer as well as prevention and early detection strategies. In addition, results indicated a significant difference between males and females in warning signs of cancer as well as prevention and early detection methods. Participants were less likely to believe their lifestyle behaviors affect their chances of developing cancer. Current practices undertaken included dietary behaviors, abstinence from smoking, check-up for minor suspicious symptoms, and annual complete physical examinations. Barriers to undertaking practices included factors related to lack of preventive resources, lack of information about preventive strategies, family financial concerns, and specific attitudes toward cancer. The study findings indicate the need for providing people with information to help them make decisions regarding undertaking cancer prevention and early detection practices.

Health promotion and osteoporosis prevention among postmenopausal women

BACKGROUND

Although there is a plethora of literature about osteoporosis, little is known about the attitudinal variables that may predict osteoporosis-preventive behaviors (OPBs) among postmenopausal women. This study examined the relationship between variables from the Health Promotion Model (HPM) and OPBs of calcium intake, exercise participation, and taking of estrogen/hormone replacement therapy (ERT/HRT).

METHODS

One hundred women completed measures of benefits and barriers to calcium intake, exercise participation, ERT/HRT usage; self-efficacy; control of health; importance of health; and health status. Participants also reported their actual calcium intake, exercise participation, and use of ERT/HRT:

RESULTS

Participants consumed an average of 1,243 mg of calcium from milk, yogurt, calcium-rich foods, and supplements; 81% participated in weight-bearing and resistant training exercise but on an irregular basis; and 31% were users of ERT/HRT at the time of data collection. There were significant relationships between some of the HPM variables and calcium intake and exercise participation. There was a significant difference between past and current users of ERT regarding benefits and barriers to taking hormones. Hormone users reported higher calcium intake and greater exercise participation than nonusers.

CONCLUSION

There is early evidence that variables of the HPM are associated with OPBs. After continued testing, intervention programs for osteoporosis prevention may use variables of the HPM as a theoretical base for behavior changes.

A comparison of American and Egyptian cancer patients' attitudes and unmet needs

The purpose of this descriptive study was to compare and contrast similarities and differences in statements made by American and Egyptian cancer patients who expressed their attitudes toward cancer and reported their unmet needs. A total of 61 American and 66 Egyptian patients, who were receiving chemotherapy or radiotherapy, or a combination of the two treatments at the time of data collection, participated in the study. The American sample was drawn from patients at a large midwestern hospital, whereas the Egyptian sample was drawn from patients at the largest university hospital in Cairo, Egypt. Data were collected through a structured interview method in both patient populations. Analyses of responses showed five categories of attitudes for the American patients: (a) fighting spirit and adaptation, (b) fear/anxiety/disbelief, (c) hope, (d) passivity in plan of care, and (e) faith. For Egyptian patients, seven categories emerged: (a) stoicism and fatalism, (b) dependency, (c) compliance with the medical regimen, (d) anxiety/fear/insecurity, (e) powerlessness, (f) hope and optimism, and (g) family support. American cancer patients reported their unmet needs as (a) information, (b) needs related to treatment side effects, and (c) psychological support. Egyptian cancer patients reported their unmet needs as (a) relief from dependency, (b) relief from physical symptoms, and (c) information. These findings have implications for international oncology nursing, and imply the need for further research to determine if attitudes and unmet needs affect coping effectiveness and quality of life among cancer patients.

Preparing student nurses for patient education

Patient education is an integral part of the nurse's responsibility. Furthermore, public awareness of health issues has greatly increased public demand for information from health professionals. The author presents some teaching strategies that can be used by nurse educators to prepare students for their future role as teachers.

Postmenopausal women. Factors in osteoporosis preventive behaviors

Osteoporosis is a serious health hazard mainly affecting postmenopausal and elderly women. Osteoporotic fractures are one of the leading causes of morbidity and death in the elderly population. Prevention of further loss of bone mass in postmenopausal women can be achieved if women take estrogen replacement therapy, consume adequate levels of calcium, exercise regularly, and practice healthy lifestyle behaviors. Elderly women need to follow the same strategies as postmenopausal women with more emphasis on prevention of falls.

Identification of stressors, level of stress, coping strategies, and coping effectiveness among Egyptian mastectomy patients

The purpose of this study was to identify stressors, level of stress, coping strategies, and coping effectiveness in Egyptian female mastectomy patients. A total of 64 women who had had mastectomies participated in the study. Coping effectiveness was measured by McNett's Coping Effectiveness Questionnaire (MCEQ). Factor analysis and reliability measures were established on MCEQ using the study sample. Data were collected using a structured interview method. Participants were also asked about age, education, and time since mastectomy. These data were examined in an effort to predict coping effectiveness. The participants reported five stressors: hope for cure, treatment effectiveness, fear of the unknown, progression of the disease, and pain. The treatment effectiveness stressor had the highest mean level of stress. There was a significant difference in the level of stress among the five stressors. Coping strategies reported were categorized into four groups: faith, compliance with the medical regimen, seeking information and social support, and self-distraction. Coping effectiveness was significantly and positively correlated with age and time since mastectomy, which accounted for 35% of the variance in coping effectiveness. Findings suggest that continuing assessments of Egyptian mastectomy patients' needs, further research studies, and an intervention program to ameliorate cancer-related anxiety and to help cancer patients cope effectively may be helpful.

Teaching early breast cancer detection strategies

Breast cancer is the most common cancer occurring among women. Currently, breast cancer can be detected early and treated effectively if all asymptomatic women participate in the screening program. Screening strategies include a mammogram, medical examination of the breast, and breast self-examination. This article describes the nurse's role in promoting and decreasing barriers to these strategies for early detection of breast cancer.

Teaching osteoporosis prevention

The role of nutrition is critical in the prevention of osteoporosis. Teenagers and women, who consume adequate calcium throughout life and consider nutritional factors that may impair their bodies' use of calcium, can do much to prevent the onset of osteoporosis. The nurse's role in this prevention is described.