The high-pitch notched audiogram: a cohort of patients without causative noise-induced hearing loss

BACKGROUND

One still encounters opinion that hearing loss with high-pitch notched audiogram is invariably due to noise-induced hearing loss. This paper tests this misapprehension.

METHODS

A study was conducted of patients identified in a prospective manner with notched audiograms but no history of noise exposure occurring in an otolaryngological practice over a 20-year period.

RESULTS

A cohort of 26 hearing loss patients, in whom notched audiograms were not associated with historical evidence of noise exposure, was documented.

CONCLUSION

The findings confirm that a notched audiogram is not pathognomonic of noise-induced hearing loss.

Using artificial intelligence to identify the top 50 independent predictors of subjective well-being in a multinational sample of 37,991 older European & Israeli adults

Subjective well-being (SWB) is widely recognized as an important health outcome, but its complexity, myriad predictors, and analytic requirements pose significant challenges to identifying the relative order and impact of SWB determinants. This study involved a representative sample of 37,991 older adults from 17 European countries and Israel. An aggregate index of SWB was developed and compared across countries, and machine-learning algorithms were used to rank-order the strongest 50 (of an initial 94) SWB predictors from 15 categories. General Additive Modeling (GAM) and low-degree polynomials (i.e., splines) were used to determine the independent effect sizes and significance levels for each of these top-50 SWB predictors. Of the 18 countries included in this study, Denmark had the highest mean SWB, while Greece had the lowest. The two top-ranked SWB predictors (loneliness, social activity satisfaction) were social factors, which also had the highest overall group ranking, followed by physical health, demographics, financial status and personality. Self-reported health was the strongest health-related predictor, neuroticism was the strongest personality predictor, and women reported higher SWB than men. SWB decreased with age, and increased with income up to 350,000 euros/year, after which it declined. Social factors were of primary importance for subjective well-being in this research, while childhood experiences and healthcare status exerted the smallest effects. The vast majority of the top 50 SWB predictors were statistically significant, with the notable exceptions of body mass index and most health behaviors, which may impact SWB indirectly through their effects on physical health. Future multivariate modeling is recommended to clarify the mechanisms for these and other observed relationships.

The Effects of Implicit Theories on Body Weight Information Avoidance

Regular self-weighing is associated with more effective weight control, yet many individuals avoid weight-related information. Implicit theories about weight, or perceptions of how malleable weight is, predict more effortful weight management and may also influence weight-related information avoidance. Participants (N = 209) were randomly assigned to read an article stressing an incremental theory of weight (i.e., weight is malleable), an article stressing an entity theory (i.e., weight is fixed), or to a control condition. We then examined their self-reported preference to avoid their body composition (i.e., body fat, weight, and muscle composition), their willingness to have their body composition measured during the lab visit, and their eating and exercise intentions. There were no notable differences across conditions, but higher self-reported incremental beliefs predicted less self-reported avoidance of body composition. The findings suggest that implicit theories may influence weight-related information avoidance, but a brief manipulation is not powerful enough to create meaningful change.

Multilevel mobile health approach to improve cardiovascular health in resource-limited communities with Step It Up: a randomised controlled trial protocol targeting physical activity

INTRODUCTION

Although physical activity (PA) reduces cardiovascular disease (CVD) risk, physical inactivity remains a pressing public health concern, especially among African American (AA) women in the USA. PA interventions focused on AA women living in resource-limited communities with scarce PA infrastructure are needed. Mobile health (mHealth) technology can increase access to PA interventions. We describe the development of a clinical protocol for a multilevel, community-based, mHealth PA intervention for AA women.

METHODS AND ANALYSIS

An mHealth intervention targeting AA women living in resource-limited Washington, DC communities was developed based on the socioecological framework for PA. Over 6 months, we will use a Sequential Multi-Assignment, Randomized Trial approach to compare the effects on PA of location-based remote messaging (named 'tailored-to-place') to standard remote messaging in an mHealth intervention. Participants will be randomised to a remote messaging intervention for 3 months, at which point the intervention strategy will adapt based on individuals' PA levels. Those who do not meet the PA goal will be rerandomised to more intensive treatment. Participants will be followed for another 3 months to determine the contribution of each mHealth intervention to PA level. This protocol will use novel statistical approaches to account for the adaptive strategy. Finally, effects of PA changes on CVD risk biomarkers will be characterised.

ETHICS AND DISSEMINATION

This protocol has been developed in partnership with a Washington, DC-area community advisory board to ensure feasibility and acceptability to community members. The National Institutes of Health Intramural IRB approved this research and the National Heart, Lung, and Blood Institute provided funding. Once published, results of this work will be disseminated to community members through presentations at community advisory board meetings and our quarterly newsletter.

TRIAL REGISTRATION NUMBER

NCT03288207.

Anxiety and depression in Klinefelter syndrome: The impact of personality and social engagement

Klinefelter syndrome (KS) (47, XXY) is the most common sex chromosome disorder, with a prevalence of 1 in every 660 newborn males. Despite the profound adverse effects of anxiety and depression, and their greater prevalence in KS populations, no research has been conducted to date to identify the determinants of anxiety and depression among patients with KS. We examined the relationships between personality traits, social engagement, and anxiety and depression symptoms among KS patients (n = 69) and a group of male controls (n = 69) matched for age and years of education. KS patients experienced more anxiety and depression symptoms than control participants. Neuroticism was the strongest and most consistent mediator between KS and both anxiety and depression symptoms. This research suggests that neuroticism may play a central role in attention switching, anxiety and depression among patients with Klinefelter syndrome. The central role of neuroticism suggests that it may be used to help identify and treat KS patients at particularly high-risk for attention-switching deficits, anxiety and depression.

Assessing Mozambicans' willingness and determinants to use pre-exposure prophylactic HIV medication

In anticipation of the introduction of the pre-exposure prophylaxis drugs as an additional HIV prevention tool, we mapped the different positions of Mozambicans' willingness to use it. Overall, 507 adults indicated willingness to use under different conditions varying as a function of perceived susceptibility to and severity of infection, side effects, administration protocol, and cost. Three qualitatively different positions were found: Unwillingness irrespective of conditions (4%), depend on circumstances (76%), and unconditional willingness (8%). A large majority of participants were willing to use pre-exposure prophylaxis drugs, provided that the administration is not too constraining, and the adverse side effects can be minimized.

Distinguishing globally-driven changes from regional- and local-scale impacts: The case for long-term and broad-scale studies of recovery from pollution

Marine ecosystems are subject to anthropogenic change at global, regional and local scales. Global drivers interact with regional- and local-scale impacts of both a chronic and acute nature. Natural fluctuations and those driven by climate change need to be understood to diagnose local- and regional-scale impacts, and to inform assessments of recovery. Three case studies are used to illustrate the need for long-term studies: (i) separation of the influence of fishing pressure from climate change on bottom fish in the English Channel; (ii) recovery of rocky shore assemblages from the Torrey Canyon oil spill in the southwest of England; (iii) interaction of climate change and chronic Tributyltin pollution affecting recovery of rocky shore populations following the Torrey Canyon oil spill. We emphasize that "baselines" or "reference states" are better viewed as envelopes that are dependent on the time window of observation. Recommendations are made for adaptive management in a rapidly changing world.

The Impact of E-diaries and Accelerometers on Young Adults' Perceived and Objectively Assessed Physical Activity

OBJECTIVE

E-diaries and accelerometers promise more objective, real-time measurements of health behavior. However, social-psychological theory suggests that using electronic behavioral monitoring may influence rather than just record physical activity (PA), especially when a device is novel.

DESIGN

Participants (n=146) were randomly assigned to either an accelerometer-only, e-diary-only, accelerometer+e-diary, or a no-technology control group for one week to assess how these technologies influenced PA, both perceived and actual, in young adults.

METHOD

Participants reported their PA, overall and number of discrete exercise sessions (DES) at baseline and follow-up; accelerometers provided daily step counts and e-diaries captured daily reports of PA for the active week of the study.

RESULTS

Average daily steps in the accelerometer-only and accelerometer+e-diary groups did not differ nor did daily reports of PA via e-diary compared to accelerometer+e-diary group, showing that neither technology affected actual PA. ANCOVAS tested group differences in perceived PA; The accelerometer-only group had increased perceived overall PA but not DES compared to no-technology control.

CONCLUSIONS

Accelerometers may increase perceived overall PA, but the tested technologies did not increase DES or actual PA, suggesting that they may be viable unbiased measures of PA.

The role of genes, intelligence, personality, and social engagement in cognitive performance in Klinefelter syndrome

INTRODUCTION

The determinants of cognitive deficits among individuals with Klinefelter syndrome (KS) are not well understood. This study was conducted to assess the impact of general intelligence, personality, and social engagement on cognitive performance among patients with KS and a group of controls matched for age and years of education.

METHODS

Sixty-nine patients with KS and 69 controls were assessed in terms of IQ, NEO personality inventory, the Autism Spectrum Quotient (AQ) scale, and measures of cognitive performance reflecting working memory and executive function.

RESULTS

Patients with KS performed more poorly on memory and executive-function tasks. Patients with KS also exhibited greater neuroticism and less extraversion, openness, and conscientiousness than controls. Memory deficits among patients with KS were associated with lower intelligence, while diminished executive functioning was mediated by both lower intelligence and less social engagement.

CONCLUSION

Our results suggest that among patients with KS, memory deficits are principally a function of lower general intelligence, while executive-function deficits are associated with both lower intelligence and poorer social skills. This suggests a potential influence of social engagement on executive cognitive functioning (and/or vice-versa) among individuals with KS, and perhaps those with other genetic disorders. Future longitudinal research would be important to further clarify this and other issues discussed in this research.

The Long-term Physical Health and Healthcare Utilization of Women Who Were Sexually Abused as Children

This article addresses the relationship between childhood sexual abuse and the long-term physical health and healthcare utilization of 148 female participants in an eight-year prospective study. Five factors of physical health emerged: General Health; Vegetative Health Symptoms; Colds and Flu; Gastrointestinal/Gynecological; and Healthcare Utilization. Abused females scored higher on the healthcare utilization and gastrointestinal/gynecological factors than comparison females. Abused females experiencing multiple perpetrators, violence, longer duration and older age at onset endorsed significantly more gastrointestinal/gynecological problems than did the other abused females and the comparison group. Findings suggest that: (1) sexual abuse affects long-term health outcomes and healthcare utilization; and (2) physical health sequelae of abuse may differentially affect females, depending upon the pattern of abuse characteristics.

Lay theories of smoking and young adult nonsmokers' and smokers' smoking expectations

This study investigated the relationship between lay theories of cigarette smoking and expectations to smoke. An incremental lay theory of smoking entails the belief that smoking behavior can change; an entity theory entails the belief that smoking behavior cannot change. Undergraduate nonsmokers and smokers completed a survey that assessed lay theories of smoking and smoking expectations. Results demonstrated that lay theories of smoking were differentially associated with smoking expectations for nonsmokers and smokers: stronger incremental beliefs were associated with greater expectations of trying smoking for nonsmokers but lower expectations of becoming a regular smoker for smokers. Implications for interventions are discussed.

Psychological resilience: the impact of affectivity and coping on state anxiety and positive emotions during and after the Washington, DC sniper killings

This research examined the impact of affectivity and coping on state anxiety and positive emotions among young adults living in the Washington, DC metro area both during and after the Washington, DC sniper killings. Participants completed questionnaires during three waves of data collection: (1) during the sniper attacks (n=92); (2) within two weeks after the snipers were captured (n=45); and (3) six months later (n=43). Affectivity (measured by neuroticism) was significantly associated with state anxiety and positive emotions during all three time periods. Coping (measured by constructive thinking) predicted state anxiety and positive emotions during the shootings, but was unrelated to either outcome immediately after the attacks, and marginally related to them six months later. Consistent with the Dynamic Model of Affect, state anxiety and positive emotions were more strongly (and negatively) correlated with each other during the killings than they were after the snipers were apprehended. Taken together, these results support transactional models of stress that emphasize the interaction between dispositional and situational influences, and they suggest that affectivity reflects a fundamental set of reactions to one's environment, while coping dispositions result in more stress-specific responses. Additional theoretical and practical implications of these findings are also discussed.

Reproduction-longevity trade-offs reflect diet, not adaptation

A tenet of life history evolution is that allocation of limited resources results in trade-offs, such as that between reproduction and lifespan. Reproduction and lifespan are also influenced proximately by differences in the availability of specific nutrients. What is unknown is how the evolution of the ability to use a nutritionally novel diet is reflected in this fundamental trade-off. Does the evolution of the ability to use a nutritionally novel food maintain the trade-off in reproduction and longevity, or do the proximate effects of nutrition alter the adapted trade-off? We tested this by measuring trade-offs in male milkweed bugs, Oncopeltus fasciatus, fed either an adapted diet of sunflower or the ancestral diet of milkweed. Sunflower-fed males lived longer but invested less in reproduction, both in mating and fertility. Milkweed-fed males invested in both mating and fertility at the expense of survival. The evolution of an expanded diet was not constrained by the existing trade-off, but instead was accompanied by a different trade-off between reproduction and longevity. We suggest that this occurs because diets differ in promoting germ line development or longevity.

What makes people anxious about pain? How personality and perception combine to determine pain anxiety responses in clinical and non-clinical populations

Although anxiety has both dispositional and situational determinants, little is known about how individuals' anxiety-related sensitivities and their expectations about stressful events actually combine to determine anxiety. This research used Information Integration Theory and Functional Measurement to assess how participants' physical concerns sensitivity (PCS) and event expectancy are cognitively integrated to determine their anxiety about physical pain. Two studies were conducted - one with university students and other with anxiety clinic patients - in which participants were presented with multiple scenarios of a physically painful event, each representing a different degree of event probability from which subjective expectancies were derived. Independent variables included PCS (low, moderate, and high) and event expectancy (low-, medium-, high-, and non-probability information). Participants were asked to indicate their projected anxiety (dependent measure) in each expectancy condition in this 3 × 4 mixed, quasi-experimental design. The results of both studies strongly suggest that PCS and event expectancy are integrated additively to produce these pain anxiety scores. Additional results and their implications for the treatment of anxiety-related disorders are also discussed.

Day case surgery training for surgical trainees: a disappearing act?

INTRODUCTION

Over the past decade there has been considerable change to surgical training such as modernising medical careers which have raised concerns over exposure to operative experience. With the National Health Service (NHS) plan aiming for the majority of elective surgical cases to be performed as day cases we sought to assess the level of exposure modern day surgical trainees obtain in day case surgery.

METHODS

An anonymous electronic questionnaire survey was completed by 100 surgical trainees in surgical training across the United Kingdom (UK) from a variety of sub-specialities. 16 questions pertinent to day case surgery exposure were answered.

RESULTS

The majority of the trainees who completed the survey felt day case surgery is a vital part of their training as a surgeon. Only less than one-third of all the trainees had formal timetabled day case surgery lists. Of the 31 trainees who had scheduled day lists only 58% (n = 18) were consistently able to attend. The most common reasons for being unable to attend were rota issues and lack of encouragement from seniors. 90 trainees (90%) were not satisfied with their overall Day Case Surgery training.

CONCLUSIONS

The survey reveals that the modern surgical trainee is gaining a low and inconsistent level of exposure to day case surgery despite being aware of the importance of this modality of training. An urgent review is required to ensure trainees become actively involved in day case surgery and are not missing on this vital training opportunity.

Sperm competition within a dominance hierarchy: investment in social status vs. investment in ejaculates

There is increasing recognition that male-male competition can take many forms, but as yet the form is not predictable a priori. Many recent studies have focused attention on how males in disadvantaged mating roles compensate through sperm competition. However, mating systems in which subordinate males are reproductively suppressed, particularly through the stress of social interactions, may limit the ability of males to respond by increasing investment in sperm quality. We examined the interaction between social status and ejaculate tactics in Nauphoeta cinerea, a cockroach that has a mating system with well-characterized dominance hierarchies. Both social experience with other males and social status influenced aspects of ejaculates. The stress of social interactions reduced the size of the ejaculate and number of sperm inseminated. In ejaculates formed prior to social experience, however, males that go on to become dominant inseminated more sperm than males that go on to become subordinate, suggesting innate differences among males. Our results show that though selection for increased success in sperm competition for subordinate males in a hierarchy can occur, both the traits and the way in which the balance between pre- and post-copulatory strategies is negotiated will depend on specific details of the mating system. These details will include how the physiological effects of social interactions may limit selection through male-male competition.

The 'modified triple staple' technique: a variant stapling technique for anastomosis after low anterior resection

INTRODUCTION

Stapled techniques of coloanal anastomosis in anterior resection have gained widespread acceptance over hand anastomosis. We believe a modification of the 'triple staple technique' has ergonomic advantages over existing stapling methods and present our technique and experience here.

METHODS

Fifty consecutive patients underwent anterior resection with a concomitant defunctioning ileostomy in 44 (86%) patients. A modified triple staple technique of side to end coloanal anastomosis was performed without the need of a purse string suture on the proximal and the distal segments.

RESULTS

There were no major intra-operative complications. 2/50 (4%) clinical leaks and 2/37 (5.4%) radiological leaks were noted. A combined leak rate of 4/50 (8%) was reported. The incidence of anastomotic stricture encountered was 1/50 (2%).

CONCLUSION

The modified triple staple technique for side to end anastomosis in anterior resection has ergonomic advantages and comparable safety to the existing techniques of stapling coloanal anastomosis. We believe this technique can be widely adopted as an added alternative to the current techniques of stapled anastomosis after anterior resection.

A blinded, randomised, controlled trial of stapled versus tissue glue closure of neck surgery incisions

INTRODUCTION

Cosmetic acceptability of scar and neck mobility are important outcomes after collar line incision for neck surgery. This randomised, controlled trial compares these parameters in closures using tissue glue (Dermabond, Ethicon, UK) and skin staples.

PATIENTS AND METHODS

Patients requiring a collar line incision were randomised to receiving tissue glue or staples for skin closure. Time for closure to be completed was recorded. Mobility of the neck was assessed using a visual analogue scale at 48 h and 1 week after surgery. At 6 weeks, cosmetic appearance was assessed using a linear 1-10 visual analogue scale by the patient, surgeon and an independent blinded assessor. Results were compared using appropriate statistical tests.

RESULTS

Glued (n = 14) and stapled (n = 15) closures were performed for hemithyroidectomy (n = 8 versus 6), sub-total thyroidectomy (n = 2 versus 4), total thyroidectomy (n = 1 versus 4) and parathyroidectomy (n = 3 versus 1). Closure with tissue glue took significantly longer than with staples (mean, 95 versus 28 s; P < 0.001). Neck mobility scores were comparable at 48 h and 1 week (mean, 4.8 versus 4.4; P = 0.552: and 2.7 versus 2.6; P = 0.886). Cosmetic appearance at 6 weeks was comparable when patient (mean, 1.7 versus 1.8; P = 0.898), surgeon (mean, 2.6 versus 2.3; P = 0.633) and independent assessment (mean, 1.4 versus 1.9; P = 0.365) was performed.

CONCLUSIONS

The use of glued skin closure may increase the duration of surgery but acceptable neck mobility and wound cosmesis can be achieved by the more rapid application of stapled skin closure in cervicotomy incisions.

Depression, constructive thinking and patient satisfaction in cardiac treatment adherence

Many patients fail to adhere to prescribed treatment regimens, particularly patients who are depressed. This study examined the link between depression and adherence among 92 patients undergoing post-operative cardiac rehabilitation. Self-reported adherence was measured in terms of both general recommendations and specific health behaviours. Greater depression was associated with general - but not specific - adherence, and this relationship was mediated by lower satisfaction with their doctor - patient interactions. The link between depression and patient satisfaction was itself mediated by less constructive thinking among patients. These results suggest that adherence among cardiac rehabilitation patients may be enhanced by addressing patients' cognitive coping, and by improving the quality of their doctor - patient interactions.

Comparison of rigid vs flexible sigmoidoscopy in detection of significant anorectal lesions

OBJECTIVE

Sigmoidoscopy is an essential tool in colorectal clinics in the detection of anorectal lesions including rectosigmoid adenomas and carcinomas. However, rigid sigmoidoscope (RS) is still more widely used than flexible sigmoidoscope (FS) as the primary investigation, despite the fact that the latter is more comfortable to the patient and has greater diagnostic yield. Hence we wanted to compare the two modalities in terms of diagnostic use for picking up significant anorectal lesions.

METHODS

A retrospective review of all patients referred to the colorectal clinic who had undergone both rigid and flexible sigmoidoscopy for investigation of colorectal symptoms in 2001 was done. Findings recorded during rigid and flexible sigmoidoscopy including depth of insertion, site of lesion and complications were analysed.

RESULTS

152 patients underwent both rigid and flexible sigmoidoscopy as part of investigation of colorectal symptoms. Of the 115 (75.6%) declared normal by RS, 39 (33.9%) had significant lesions including 7 polyps and 4 malignant lesions within 20 cm of the anal verge during FS. Of the 31 patients (20.4%) in whom RS was not helpful due to faecal loading, 15 (48.4%) had significant lesions including 4 malignancies and 1 polyp --all within 20 cm of the anal verge during FS. Only 2 polyps and 1 malignant lesion were picked up by both flexible and rigid sigmoidoscopy. There were no complications in both procedures.

CONCLUSION

Since flexible sigmoidoscopy is superior to rigid sigmoidoscopy in terms of patient comfort, diagnostic value and ease of doing procedures like biopsy and polypectomy; it can be used as a front line investigation to exclude colorectal pathology in out patient clinics. The utility of rigid sigmoidoscope is in question and in view of obvious shortcomings, may be replaced by flexible sigmoidoscopy, though obvious resource constraints need to be considered.

Endoscopic laser ablation of advanced rectal carcinoma--a DGH experience

BACKGROUND

Patients with inoperable advanced rectal carcinoma require palliation for local symptoms. Endoscopic Nd-Yag laser ablation is a valid palliative treatment option in patients with advanced rectal carcinoma who are poor operative risks due to coexistent multiple comorbidities.

METHODS

All patients who cannot undergo radical surgery due to various factors such as tumour size, poor risk patients, distant metastasis and refusal to undergo surgery were offered palliation with endoscopic Nd-YAG laser ablation. Indications included troublesome bleeding, local recurrence, mucous discharge and impending obstruction. Patients were admitted on the day of treatment, phosphate enema given for bowel preparation and endoscopic ablation done through a flexible sigmoidoscope under intravenous sedation with midazolam. All patients were discharged the next day after overnight observation. Patients were reviewed every 3 months and laser ablation repeated if deemed necessary.

RESULTS

Eleven patients (7 males, 4 females; mean age 83.6 years, range 77-90 years) underwent endoscopic laser ablation in a District General Hospital --8 for rectal carcinoma, 2 for rectosigmoid tumour and 1 for recurrent tubulovillous adenoma. The number of treatment episodes varied from 1 to 12 with symptom free interval from 2 to 18 months between treatment episodes. There were 3 failures, one patient required defunctioning colostomy, one patient was referred for radiotherapy due to persistent symptoms and in one patient laser treatment had to be abandoned due to local extent. There were no immediate post-treatment complications, but one patient developed incontinence after 5 episodes which might be attributable to tumour infiltration.

DISCUSSION

Endoscopic laser ablation is a practical and feasible alternative to other palliative treatment modalities in the management of this unfortunate category of patients due to low morbidity and mortality, short hospitalization and low complication rates.

Sexual conflict and cooperation under naturally occurring male enforced monogamy

An evolutionary conflict often exists between the sexes in regard to female mating patterns. Females can benefit from polyandry, whereas males mating with polyandrous females lose reproductive opportunities because of sperm competition. Where this conflict occurs, the evolution of mechanisms whereby males can control female remating, often at a fitness cost to the female, are expected to evolve. The fitness cost to the female will be increased in systems where a few high status males monopolise mating opportunities and thus have limited sperm supplies. Here we show that in the cockroach Nauphoeta cinerea, a species where males enforce female monogamy in the first reproductive cycle, males that have become sperm depleted continue to be able to manipulate female remating behaviour. Although the manipulation severely decreases fecundity in females mated to sperm-depleted males, males benefit, increasing their relative fitness by preventing other males from reproducing. Our results suggest that there is selection on maintaining the mechanism of manipulation rather than maintaining sperm numbers. Taken with previous research on sexual conflict in N. cinerea, this study suggests that the causes and consequences of sexual conflict are complex and can change across the life history of an individual.

Sperm competition and male ejaculate investment in Nauphoeta cinerea: effects of social environment during development

Selective pressure arising from sperm competition has been predicted to influence evolutionary and behavioural adjustment of ejaculate investment, but also may influence developmental adjustment of ejaculate investment. Immature males able to target resources strategically based on the competitive environment they will experience when they become sexually mature should be at a selective advantage. In our study we investigated how the presence of potential competitors or mates affects ejaculate and testes investment during development in the cockroach Nauphoeta cinerea, a species where males control female remating via their ejaculate size (large spermatophores prevent females from remating and therefore function to avoid sperm competition for males) and females store sperm. Our aim was to determine whether the social environment influences developmental adjustment of ejaculate investment and the relative importance of ejaculate components with different functions; avoidance of or engagement in sperm competition. We conclude that the social environment can influence developmental and behavioural flexibility in specific ejaculate components that may function to avoid or engage in sperm competition.

Psychosocial factors in medical and psychological treatment avoidance: the role of the doctor-patient relationship

A community sample of 1106 adults was examined to assess the impact of the doctor-patient relationship on participants' avoidance of treatment for a recognized medical or psychological problem. Of five aspects of participants' previous experience with their physicians, all but waiting time predicted participants' self-reported treatment avoidance. In two logistic regression models participants who felt their physicians listened more to their concerns were less likely to avoid treatment for both medical and psychological problems during the previous 12 months. These findings suggest that patients' perceptions of how they are treated by physicians may help explain why many people delay or avoid healthcare treatment, even when faced with a significant health problem.

Females avoid manipulative males and live longer

Female mate choice has been demonstrated in a wide variety of species and is now accepted as an important factor in sexual selection. One of the remaining questions, however, is why females prefer specific males. Do females or their offspring benefit from their choice? Or do females choose mates to minimize costs of mating? Here we show that, in the ovoviviparous cockroach Nauphoeta cinerea, where sexual selection has been well documented, females chose mates to avoid costly male manipulation. Females were partnered with preferred or nonpreferred mates, and fitness of the females measured. We found that females lived longer when they mated with preferred males. Female lifespan depended on the rate at which offspring developed from egg to parturition: slower development led to longer life. We manipulated the male pheromone and showed that the component of the pheromone blend that makes males attractive to females also delayed parturition. Thus, like other aspects of sexual conflict in this species, offspring development and thereby the mother's lifespan depended on exposure of females to specific components of the male pheromone. Males benefit from manipulating offspring development because females with accelerated parturition remained unreceptive whereas females with slower developing offspring readily remated after giving birth to their offspring. Our results suggest a hormone-like role for the male pheromone in N. cinerea and provide the first direct evidence of mate choice to avoid male manipulation. This study shows that dominant males may not be preferred males if they are manipulating females, why multiple components with contrasting effects can exist in a sexual signal, and emphasizes the complex fitness relationships that can arise in species with sexual conflict.

Socioeconomic status and health: the role of sleep

OBJECTIVE

Examine the role of sleep in the relationship between socioeconomic status (SES) and health.

METHOD

Self-reported measures of income and education, sleep quantity and quality, and mental and physical health were obtained in a community sample of 1139 adults.

RESULTS

More education was associated with higher income (p <.001), and higher income was associated with better physical health (p <.001) and psychological outcomes (p <.001). The effects of income on both mental and physical health were mediated by sleep quality (p values <.01), and sleep quantity was related to both measures of health (p values <.01) but to neither index of SES.

CONCLUSION

Sleep quality may play a mediating role in translating SES into mental and physical well-being, and income seems to mediate the effect of education on sleep and, in turn, health.

The relationship between fatigue and sleep in cancer patients: a review

Fatigue is a major complaint among cancer patients, yet it is unknown whether cancer-related fatigue experienced during the day relates to sleep/wake cycles or to the quality and quantity of sleep obtained at night. Although it is not well defined or well understood at present, cancer-related fatigue is generally regarded as a form of tiredness that does not improve following rest or sleep. Objectively recorded sleep and biological rhythms have not been well investigated in these patients, but it appears that most cancer patients may in fact not be getting a good night's sleep. Evidence is accumulating that sleep is often disturbed in cancer patients, probably owing to a variety of causes. We posit that some degree of cancer-related fatigue experienced during the day may relate to sleep/wake cycles or to the quality and quantity of sleep obtained at night. Different components or dimensions of fatigue (physical, attentional/cognitive, emotional/affective, etc.) are probably associated in some way with disrupted sleep and desynchronized sleep/wake rhythms. These associations may change in measurable ways prior to treatment, during treatment and after treatment completion. In cancer patients, as in other medically ill patients, sleep that is inadequate or unrefreshing may be important not only to the expression of fatigue, but to the patients' quality of life and their tolerance to treatment, and may influence the development of mood disorders and clinical depression. This review summarizes the state of the literature on fatigue, sleep and circadian rhythms.

Clinical value of postnatal autopsy and genetics consultation in fetal death

The aim of the present study was to investigate the clinical use of postnatal autopsy and genetics consultation in cases of fetal death in a teaching hospital. A retrospective analysis of medical records including pathology and genetics reports was performed in all cases of fetal death in which a woman delivered at Ben Taub General Hospital, Houston, Texas over a 2-year period. Cases were excluded when gestational age of the fetus was less than 20 weeks. Fetuses were only included when the 1- and 5-min Apgar scores were 0 and 0, respectively. There were 139 fetal deaths and 12,209 live born infants during the study period (stillbirth rate 1.125%). Although pathology services were used in 96.2%, a genetics consultation was obtained in only 12% of cases. Fetal autopsy provided a certain cause of fetal death in 19.4%, a probable cause for death in 36.3%, and was inconclusive in 44.3%. Among the cases in which a genetics consultation was obtained, a certain and probable cause for fetal death was found in 20% and 20% of cases, respectively. The utilization of genetics consultation was found to be independent of multiple clinical variables examined including ultrasound data, identification of maceration, and training level of resident. Our data show a frequent use of pathologic examination in cases of fetal death and an infrequent use of genetics consultation services. The request for genetics consultation seemed to have been made at random.

Reproductive aging and mating: the ticking of the biological clock in female cockroaches

Females are expected to have different mating preferences because of the variation in costs and benefits of mate choice both between females and within individual females over a lifetime. Workers have begun to look for, and find, the expected variation among females in expressed mating preferences. However, variation within females caused by changes in intrinsic influences has not been examined in detail. Here we show that reproductive aging caused by delayed mating resulted in reduced choosiness by female Nauphoeta cinerea, a cockroach that has reproductive cycles and gives live birth. Male willingness to mate was unaffected by variation in female age. Females who were beyond the optimal mating age, 6 days postadult molt, required considerably less courtship than their younger counterparts. Females who were older when they mated had fewer offspring per clutch and fewer clutches than females who mated young. Thus, reduced choosiness was correlated with a permanent reduction in fertility. There was no difference in overall senescence among females, and thus the reduction in clutch size did not result in the expected increased lifespan. We suggest that reproductive aging in N. cinerea, similar to aging in general, occurs because the maintenance of oocytes is costly, and selection is relaxed after the optimal mating period. Our results further suggest that selection for continued choosiness is also relaxed and supports direct selection on female choosiness and a cost to choosiness.

Sexual conflict and the evolution of female mate choice and male social dominance

Conflicts between the sexes over control of reproduction are thought to lead to a cost of sexual selection through the evolution of male traits that manipulate female reproductive physiology and behaviour, and female traits that resist this manipulation. Although studies have begun to document negative fitness effects of sexual conflict, studies showing the expected association between sexual conflict and the specific behavioural mechanisms of sexual selection are lacking. Here we experimentally manipulated the opportunity for sexual conflict in the cockroach. Nauphoeta cinerea and showed that, for this species, odour cues in the social environment influence the behavioural strategies and fitness of males and females during sexual selection. Females provided with the opportunity for discriminating between males but not necessarily mating with preferred males produced fewer male offspring than females mated at random. The number of female offspring produced was not affected, nor was the viability of the offspring. Experimental modification of the composition of the males' pheromone showed that the fecundity effects were caused by exposure to the pheromone component that makes males attractive to females but also makes males less likely to be dominant. Female mate choice therefore carries a demographic cost but functions to avoid male manipulation and aggression. Male-male competition appears to function to circumvent mate choice rather than directly manipulating females, as the mate choice can be cryptic. The dynamic struggle between the sexes for control of mating opportunities and outcomes in N. cinerea therefore reveals a unique role for sexual conflict in the evolution of the behavioural components of sexual selection.

Medical malpractice: the effect of doctor-patient relations on medical patient perceptions and malpractice intentions

OBJECTIVE

To examine the causal effects of doctor-patient relations and the severity of a medical outcome on medical patient perceptions and malpractice intentions in the event of an adverse medical outcome.

DESIGN

Randomized between-subjects experimental design. Patients were given scenarios depicting interactions between an obstetric patient and her physician throughout the patient's pregnancy, labor, and delivery.

PARTICIPANTS

One hundred twenty-eight postpartum obstetric patients were approached for participation, of whom 104 completed the study. Main outcome measures Patients' perceptions of physician competence and intentions to file a malpractice claim.

RESULTS

Positive physician communication behaviors increased patients' perceptions of physician competence and decreased malpractice claim intentions toward both the physician and the hospital. A more severe outcome increased only patients' intentions to sue the hospital.

CONCLUSION

These results provide empiric evidence for a direct, causal effect of the doctor-patient relationship on medical patients' treatment perceptions and malpractice claim intentions in the event of an adverse medical outcome.

Cost benefits of two dressings in the management of surgical wounds

In this prospective randomized controlled trial of the cost benefits of the choice of dressings in acute surgical wounds left to heal by secondary intention, patients had their wounds dressed with either a traditional dressing (ribbon gauze soaked in proflavine) or a modern hydrofibre dressing. Results showed that the hydrofibre dressing, although more expensive than the ribbon gauze, facilitated an earlier discharge from hospital (P = 0.001). The total cost of the patient episode was less in the hydrofibre group (P = 0.01). In an average UK health authority of 300,000 population, 100 bed days a year could be saved releasing an overall potential saving of 55,000 Pounds. A modern hydrofibre dressing allows more effective use of scarce hospital beds and precious financial resources, while still maintaining high quality patient care. It is important that clinical specialists and purchasers of health care should be aware of this clinical and cost-effective advance in the management of acute surgical wounds.

The role of photodynamic therapy (PDT) in inoperable oesophageal cancer

OBJECTIVE

To evaluate the role of PDT in palliation of patients with inoperable oesophageal cancer and to identify subgroups in which this role is of particular significance.

METHODS

Sixty-five patients (37 male, 28 female) aged 42-89 (mean 65.6) with advanced and inoperable oesophageal cancer were the subjects of this study. Inoperability was due to advanced stage of the disease in 61 and because of general condition in 4. Fifty-eight (89%) had previous treatments, other than PDT. All patients had dysphagia of whom 20 could not swallow fluid. Pre-PDT clinical, radiological and endoscopic examinations were carried out. Performance status (PS) and clinical staging was assessed. PDT protocol consisted of: intravenous injection of 2 mg/kg; photofrin (or equivalent polyhaematoporphyrin) followed 24-72 h later by endoscopic illumination using 630 nm laser light.

MAIN OUTCOME MEASUREMENTS

(1) Relief of dysphagia generally and specifically in those with cervical and post-cricoid carcinoma who were previously treated by external beam radiotherapy (EBR) (n=6) and those with previous intubation or stent (n=9); (2) Survival.

RESULTS

There was no PDT related mortality. Three patients (4.6%) developed a mild skin photosensitivity reaction. Dysphagia was relieved in all patients. The mean and median survival of the 58 patients who have died was 7. 7 and 6 months respectively. Seven patients are alive from 2-30 months (mean 16). Survival was not significantly influenced by tumour histology, location in the oesophagus, severity of dysphagia on admission, or by previous therapy. Survival was significantly influenced by Performance Status prior to treatment (P=0.03 log rank, for PS < or =2 vs. PS=3), an most significantly by the stage of the disease (P=0.0001 log rank, for Stage III vs. Stage IV).

CONCLUSIONS

(1) PDT is safe and effective for palliation of dysphagia in inoperable oesophageal cancer. This is particularly important in post-cricoid and cervical oesophageal cancer previously treated by other methods and for patients with recurrent malignant obstruction who previously had intubation or stent placement. (2) Survival is influenced by better PS (< or =2) and in those with disease Stage III rather than patients in Stage IV. This study has not been able to determine the influence of complete tumour staging on survival because, apart from four patients, all others were Stages III and IV cancer.

Developmental constraints on the mode of reproduction in the facultatively parthenogenetic cockroach Nauphoeta cinerea

Considerable work in evolutionary biology has focused on the question of why sex persists. Both advantages to sex and constraints limiting a return to asexual reproduction are hypothesized to maintain sex once it evolves. Developmental constraints would limit asexual reproduction from a sexual species if it were difficult for females to switch from making eggs that do not develop without fertilization to making zygotes that are capable of developing in the absence of fertilization. Nauphoeta cinerea is an ovoviviparous cockroach in which some females are capable of switching from a sexual mode of reproduction to an asexual mode when isolated from males. Yet, while facultative parthenogenesis can occur in individuals, few females make the switch. Thus, this cockroach provides an ideal system for examining the potential role of developmental constraints in maintaining sex. Here we compare the cytogenetics and embryonic development of sexual and parthenogenetic offspring in N. cinerea. We find that deviations from normal ploidy levels are associated with abnormal development. All viable N. cinerea embryos exhibit typically hemimetabolous insect embryogenesis. Although there is no variation among embryos in development within a sexually produced clutch, we see extreme variation in asexually derived clutches. These results suggest that developmental constraints limit the success of asexual reproduction in this facultatively parthenogenetic cockroach. Our data further suggest that the specific constraint occurs in the switch from a meiotic mode of reproduction requiring fertilization to diploid zygotes that develop in the absence of fertilization.

Severe hypertensive sequelae in a child with Seckel syndrome (bird-like dwarfism)

We report a 19-year-old male with Seckel syndrome (bird-like dwarfism) who presents with malignant hypertension associated with hypertensive nephrosclerosis, dilated cardiomyopathy, and a ruptured cerebral artery aneurysm. Although end-organ injury due to chronic hypertension occurs frequently in adults, no previous reports of renal insufficiency due to hypertension exist in children or adolescents. We speculate that this patient may have been particularly prone to hypertensive end-organ injury due to his extreme short stature.

Correlation of ultrasound with postmortem neuropathologic studies in neonates

We examined the correlation between cranial sonogram and postmortem examination neurodiagnoses in 51 infants (30 boys and 21 girls) who underwent cranial sonogram before death. The mean gestation of the infants at birth was 32 weeks 6 days; the mean birth weight, 1,992 gm; and the mean survival, 27 days. Most infants had several postmortem examination neurodiagnoses; therefore the postmortem examination diagnosis considered to be most significant in terms of clinical management and long-term neurologic function was chosen for each infant and designated as the primary diagnosis. The ability of the cranial sonogram to diagnose the primary diagnosis was then evaluated. The accuracy of the cranial sonogram in defining primary diagnoses was 59%. There were 21 cases (41%) in which cranial sonogram failed to define the primary diagnosis; nine of these could be explained on the basis of the timing of the ultrasound in relation to the age of the lesion or to the microscopic nature of the lesion. In 12 patients the factors causing the failure of cranial sonogram to define primary postmortem examination diagnoses could not be identified. The positive predictive value of a cranial sonogram diagnosis was 77%; the negative predictive value was 19%.