Nova Scotia Hospital

We analyzed a two- to seven-year follow-up of 1145 infertile couples to determine the frequency of pregnancy occurring independently of treatment. Pregnancy occurred in 246 of 597 treated couples (41 per cent) and in 191 of 548 untreated couples (35 per cent). Thirty-one per cent of the pregnancies in treated couples occurred more than 3 months after the last medical treatment or more than 12 months after adnexal surgery. These pregnancies plus the 191 pregnancies in untreated couples constituted the category of "treatment-independent pregnancies" and accounted for 61 per cent of all pregnancies; for 44 per cent of those among couples with ovulation deficiency; for 61 per cent of those in couples with endometriosis, tubal defects, or seminal deficiencies; and for 96 per cent of those in couples with cervical factors or idiopathic infertility. We conclude that the potential for a spontaneous cure of infertility is high, that treatment for many classes of infertility should be evaluated by randomized clinical trials, and that in such trials random assignment of subjects to untreated control groups would be ethically acceptable.

Satisfaction is increasingly employed as an outcome measure for a successful total knee replacement (TKR). Satisfaction as an outcome measure encompasses many different intrinsic and extrinsic factors related to a person's experience before and after TKR. The Swedish Knee Arthroplasty Registry has previously demonstrated on a large population study that 17% of TKR recipients are not satisfied with their TKR outcome. This finding has been replicated in other countries. Similar significant factors emerged from these registry studies that are related to satisfaction. It would appear that satisfaction is better after more chronic diseases and whether the TKR results in pain relief or improved function. Importantly, unmet pre-operative expectations are a significant predictor for dissatisfaction following a TKR. It may be possible to improve rates by addressing the issues surrounding pain, function and expectation before embarking on surgery.

OBJECTIVE: To assess the antecedents of shoulder dystocia, the risk of recurrence, and the perinatal morbidity associated with the different maneuvers used for its management. METHODS: We conducted a 10-year (1980-1989) retrospective case record review of all instances of shoulder dystocia in a teaching maternity hospital. RESULTS: There were 254 cases of shoulder dystocia in 40,518 vaginal cephalic deliveries (0.6%), with 33 cases (13.0%) of brachial plexus palsy and 13 fractures (5.1%). There were no perinatal deaths attributable to shoulder dystocia. The risk of shoulder dystocia was increased with prolonged pregnancy (threefold), prolonged second stage of labor (threefold), mid-forceps deliveries (tenfold), and increasing birth weight. Of the maneuvers used to deal with shoulder dystocia, strong downward traction on the head was significantly correlated with brachial plexus palsy compared with other individual methods of delivering the shoulders. There was only one case of recurrent shoulder dystocia in 80 women having 93 cephalic vaginal deliveries after their original delivery coded with shoulder dystocia. CONCLUSION: Shoulder dystocia is not a reliably predictable event in labor. Although the risk of shoulder dystocia is increased with prolonged pregnancy, prolonged second stage of labor, increasing birth weight, and mid-forcepts delivery, the majority of cases occur without these risk factors. Strong downward traction on the head is associated with the greatest degree of neonatal trauma, whereas McRoberts maneuver has the least. The risk of recurrent shoulder dystocia is low.

The effects of 100 mg indomethacin daily for three weeks on blood pressure and urinary excretion of prostaglandin F2 alpha were studied in a double-blind, placebo-controlled comparison of two groups of patients with essential hypertension, eight receiving propranolol and seven thiazide diuretics. Compared with placebo, adding indomethacin to the patients' established antihypertensive treatment increased blood pressure by 14/5 Hg supine and 16/9 mm Hg erect in the patients receiving propranolol, and by 13/9 mm Hg supine and 16/9 mm Hg erect in the patients receiving thiazide diuretics (all p less than or equal to 0.05). The excretion of the major urinary metabolite of prostaglandin F2 alpha was reduced by 67% in the propranolol-treated patients and by 57% in those receiving a thiazide diuretic. Body weight increased by 0 . 8 kg (propranolol) and 1 . 1 kg (thiazide diuretic) when indomethacin was given, but there were no significant changes in creatinine clearance, urinary sodium excretion, or packed cell volume in either treatment group. These results suggest that products formed by the arachidonic acid cyclo-oxygenase contribute to the regulation of blood pressure during treatment with both propranolol and thiazide diuretics. Inhibition of the cyclo-oxygenase with indomethacin partially antagonises the hypotensive effect of these drugs.

Hepatitis E virus (HEV) is a major public health concern in developing countries where the primary transmission is via contaminated water. Zoonotic HEV cases have been increasingly described in Europe, Japan, and the United States, with pigs representing the main animal reservoir of infection. We report an unusual acute hepatitis infection in a previously healthy man caused by a rat HEV with a considerably divergent genomic sequence compared with other rat HEV strains. It is possible that rat HEV is an underrecognized cause of hepatitis infection, and further studies are necessary to elucidate its potential risk and mode of transmission.

United States and Canadian governments have responded to legal requirements to reduce human induced whale mortality via vessel strikes and entanglement in fishing gear by implementing a suite of regulatory actions. We analyzed the spatial and temporal patterns of mortality of large whales in the Northwest Atlantic (23.5°N to 48.0°N), 1970 through 2009, in the context of management changes. We used a multinomial logistic model fitted by maximum likelihood to detect trends in cause-specific mortalities with time. We compared the number of human-caused mortalities with U.S. federally established levels of potential biological removal (i.e., species-specific sustainable human-caused mortality). From 1970 through 2009, 1762 mortalities (all known) and serious injuries (likely fatal) involved 8 species of large whales. We determined cause of death for 43% of all mortalities; of those, 67% (502) resulted from human interactions. Entanglement in fishing gear was the primary cause of death across all species (n = 323), followed by natural causes (n = 248) and vessel strikes (n = 171). Established sustainable levels of mortality were consistently exceeded in 2 species by up to 650%. Probabilities of entanglement and vessel-strike mortality increased significantly from 1990 through 2009. There was no significant change in the local intensity of all or vessel-strike mortalities before and after 2003, the year after which numerous mitigation efforts were enacted. So far, regulatory efforts have not reduced the lethal effects of human activities to large whales on a population-range basis, although we do not exclude the possibility of success of targeted measures for specific local habitats that were not within the resolution of our analyses. It is unclear how shortfalls in management design or compliance relate to our findings. Analyses such as the one we conducted are crucial in critically evaluating wildlife-management decisions. The results of these analyses can provide managers with direction for modifying regulated measures and can be applied globally to mortality-driven conservation issues.

We hypothesize that innate immune signals from infectious organisms and/or injured tissues may activate peripheral neuronal pain signals. In this study, we demonstrated that TLRs 3, 7, and 9 are expressed by human dorsal root ganglion neurons (DRGNs) and in cultures of primary mouse DRGNs. Stimulation of murine DRGNs with TLR ligands induced expression and production of proinflammatory chemokines and cytokines CCL5 (RANTES), CXCL10 (IP-10), IL-1α, IL-1β, and PGE(2), which have previously been shown to augment pain. Further, TLR ligands upregulated the expression of a nociceptive receptor, transient receptor potential vanilloid type 1 (TRPV1), and enhanced calcium flux by TRPV1-expressing DRGNs. Using a tumor-induced temperature sensitivity model, we showed that in vivo administration of a TLR9 antagonist, known as a suppressive oligodeoxynucleotide, blocked tumor-induced temperature sensitivity. Taken together, these data indicate that stimulation of peripheral neurons by TLR ligands can induce nerve pain.

Rare earth element (REE) concentrations were analysed by atom emission spectrometry (ICP–AES) in whole–rock samples and mineral separates of plutonic carbonatites from different localities. Calcite, dolomite, apatite, and unaltered pyrochlore show parallel to subparallel REE distribution patterns at different enrichment levels. The REE distribution in the whole rocks is controlled by that of the carbonates because of their high modal amounts and by that of apatite because of its high REE abundances. REE–rich accessory phases such as pyrochlore will influence the whole-rock pattern only when present in sufficient amounts. On the basis of variations in REE distributions and mineral chemistry, several groups of sövites can be distinguished among the samples studied here. The highest REE concentrations and the strongest light REE (LREE) enrichment is found in sövites from Oka, Kaiserstuhl, and Alnö that contain Mg-poor calcites, Si–rich apatites and Ca–bearing silicates. These sövites are associated with melilititic or nephelinitic rocks. Less pronounced LREE enrichment is found in sövites, dolomitic carbonatites and phoscorites from Sokli, Siilinjärvi, Phalaborwa, Jacupiranga and Fen, which contain Mg-rich calcites and/or dolomite, Si–poor apatite and Mg,Fe–silicates (olivine, phlogopite). These carbonatites are associated with potassium-rich peralkaline ultramafic rocks and lamprophyres.

Sixty-three adults with the diagnosis of the postviral fatigue syndrome were enrolled in a double-blind, placebo-controlled study of essential fatty acid therapy. The patients had been ill for from one to three years after an apparently viral infection, suffering from severe fatigue, myalgia and a variety of psychiatric symptoms. The preparation given contained linoleic, gamma-linolenic, eicosapentaenoic and docosahexaenoic acids and either it, or the placebo, was given as 8 x 500 mg capsules per day over a 3-month period. The trial was parallel in design and patients were evaluated at entry, one month and three months. In consultation with the patient the doctors assessed overall condition, fatigue, myalgia, dizziness, poor concentration and depression on a 3-point scale. The essential fatty acid composition of their red cell membrane phospholipids was analysed at the first and last visits. At 1 month, 74% of patients on active treatment and 23% of those on placebo assessed themselves as improved over the baseline, with the improvement being much greater in the former. At 3 months the corresponding figures were 85% and 17% (p less than 0.0001) since the placebo group had reverted towards the baseline state while those in the active group showed continued improvement. The essential fatty acid levels were abnormal at the baseline and corrected by active treatment. There were no adverse events. We conclude that essential fatty acids provide a rational, safe and effective treatment for patients with the post-viral fatigue syndrome.

The emergency department (ED) is a complex environment. Its equilibrium, or homeostasis, is critically dependent on the continuous action of feedback processes. For any system to function efficiently, it needs to know the outcomes of specific actions in a consistent, reliable, and expeditious way. Historical attitudes and the unique operating characteristics of the ED have combined to impose sanctions on the proper provision of feedback. The following features have been identified as obstructive to optimal feedback operation: incomplete awareness of the significance of the problem, excessive time and work pressures, case infrequency, deficiencies in specialty follow-up, communication failures, deficient reporting systems for near-misses, error, and adverse events, biases in case review processes, shift changeover times, and shiftwork. The result is that clinicians, nurses, and trainees are working in conditions that are suboptimal for the provision of safe care, as well as for learning and job fulfillment. Good feedback is a necessary condition for well-calibrated performance by individuals, and is integral to effective team function. More needs to be known about outcomes for feedback to work efficiently. The critical role of feedback in other aspects of ED function, such as education and human factors engineering, should be emphasized. The current interest in medical error and evolving attitudes toward a new culture of patient safety provide a unique opportunity to examine feedback and the critical role it plays in ED function.

Marine bivalves are sessile or sedentary as adults but have planktonic larvae which can potentially disperse over large distances. Consequently larval transport is expected to play a prominent role in facilitating gene flow and determining population structure. The sea scallop (Placopecten magellanicus) is a dioecious species with high fecundity, broadcast spawning and a c. 30-day planktonic larval stage, yet it forms discrete populations or 'beds' which have significantly different dynamics and characteristics. We analysed variation at six microsatellite loci in 12 locations throughout the geographic range of the species from Newfoundland, Canada, to New Jersey, USA. Significant differentiation was present and the maximum pairwise theta value, between one of the Newfoundland samples in the north and a sample from the southern portion of the range, was high at 0.061. Other proximate pairs of samples had no detectable genetic differentiation. Mantel tests indicated a significant isolation by distance, but only when one of the populations was excluded. A landscape genetic approach was used to detect areas of low gene flow using a joint analysis of spatial and genetic information. The two major putative barriers inferred by Monmonier's algorithm were then used to define regions for an analysis of molecular variance (amova). That analysis showed a significant but low percentage (1.2%) of the variation to be partitioned among regions, negligible variation among populations within regions, and the majority of the variance distributed between individuals within populations. Prominent currents were concordant with the demarcation of the regions, while a novel approach of using particle tracking software to mimic scallop larval dispersal was employed to interpret within-region genetic patterns.

Nineteen papillary, non-invasive tumors arising from the bronchial epithelium but excluding carcinoid tumors are reviewed. Eight were solitary papillomas of which three were covered with a mixture of epithelial types. Seven were benign but one had a focus of carcinoma in situ. A similar change was seen in bronchial epithelium adjacent to a papilloma. Two cases of recurrent papillomas were seen and in one, carcinomatous changes eventually occurred. Two combined benign brochial cystadenomas with papillomas are described. One transitional celled papillary carcinoma in situ and five other papillary carcinomas in situ are described. One bronchial papilloma covered with dysplastic epithelium was considered an intermediate stage in the development of carcinoma in situ. Two papillary tumors may have arisen from peripheral bronchi or brochioles. Their lining cells resembled Clara cells, they grew by local expansion, and there was an absence of malignant features. The differential characteristics of two secondary carcinomatous polypoidal tumors are described.

Cumulative effects assessment (CEA) became an increasingly important component of environmental impact assessment (EIA; or simply environment assessment (EA)) shortly after formal processes for EIA were established in North America in the 1970s. Despite a growing body of literature addressing science requirements of exemplary EIA and CEA, practice remains contested. Our mission in preparing this review was to provide a critical update on progress in scientific developments associated with CEA and also to guide practitioners to a broad selection of the recent relevant peer-reviewed formal literature on CEA. In addition, we point to ways in which guidance for CEA practice could be improved. The study canvassed widely for refereed papers in journals and edited books as far back as 2000. On the matter of key concepts related to CEA, the paper addresses the definition of other activities to be assessed, establishment of time and space bounds, impact thresholds, methods for impact prediction, and stressor-based versus effect-based approaches. Definitions of cumulative effect are reviewed, with encouragement for continued work to elaborate the concept. Contributions from science to CEA practice are identified as follows: retrospective and prospective investigative protocols; basic ecological knowledge; effects knowledge; tools and methods; ecological grounds for threshold establishment; and analytically competent practitioners. We observe that the plethora of CEA frameworks populating the scientific literature offer practitioners helpful ways to think about the CEA process. CEA methods are then reviewed, with specific emphasis on geographic information systems, scenario-building, thresholds, indicators, simulation, and public engagement. Several case examples of CEA in practice are summarized, with the observation that none of the published case studies arises from work done to support CEA that is part of the regulated EIA process. The paper reflects on the role of CEA in project-specific EIA (or project EA) as well as class EA, strategic EA, and regional EA. CEA is needed in all forms of EA, but it seems to be particularly difficult to implement well in project-specific EIAs. Recommendations for improvements in guidance materials for practitioners address definitions, scenarios, analytical methods, collaborative methods, thresholds, knowledge accumulation, accidents and malfunctions, project scale, and knowledge integration. We conclude that competent CEA is a vital requirement for securing the sustainability of valued ecosystems and their components.

The experiences of lesbian, gay, and transgender (LGT) individuals with severe mental illness (SMI) have received minimal attention within the clinical and research literatures despite evidence to suggest that these groups receive inadequate psychiatric services. In the present study, 11 individuals from a midsized Canadian city who self-identified as lesbian, gay, or transgender were interviewed about their experiences of sexual identity, gender, mental illness, and psychiatric services. Their narratives were analyzed using grounded theory methods. The findings highlight the complex interactions of the stigma associated with mental illness and LGT identities, as well as the illness and identity-related challenges these persons face in psychiatric services. The participant narratives also speak to resilience and wellness, suggesting that these are cultivated through connection and community. Finally, strategies that service providers can use to deliver more effective services for this population are discussed.

In brief, therefore, we are dealing with an illness characterised by a single delusional system - in this instance with hypochondriacal content - which can occur at any age from late adolescence onwards, appears to affect the sexes equally, and has a very poor prognosis without treatment. Its presentation appears to be relatively independent of cultural factors. A previous history, or a family history, of psychotic illness seems very uncommon. However, substance abuse and/or head injury seem to be background factors in a high proportion of younger patients and I would speculate about the role of the ageing brain in the more elderly patients. Within the delusional system, the patient shows marked illogicality insisting, against all evidence, on a physical aetiology, going to many physicians, and initiating strange 'cures' of his own. Although paranoid anger is not uncommonly a feature, secondary depression, shame and avoidant behaviour are more frequent. The illness causes great anguish, and sometimes suicide. Folie à deux is relatively common. At present, pimozide appears to be the most specific treatment and can be dramatically effective. There are scattered reports of improvement or even cure with other neuroleptics or tricyclic antidepressants but, in general, these seem less effective than pimozide (Cashman & Pollock, 1983; Brotman & Jenike, 1984; Pylko & Sicignan, 1985). However, a single case report recently from the USA is intriguing: an apparently excellent result with amoxapine, currently perhaps the most antidopaminergic of the antidepressant drugs (Tollefson, 1985). However, although the case description is suggestive of MHP, the author regards it as one of major depressive illness.(ABSTRACT TRUNCATED AT 250 WORDS)

A surgical procedure was developed such that a meniscus could be reimplanted in the medial compartment of canine knees. The medial meniscus was removed and reimplanted in one group of seven animals, removed and reimplanted with a glutaraldehyde-preserved bioprosthesis in a second group of five animals, and removed and replaced by an allograft meniscus preserved 2 to 3 weeks in tissue culture in a final group of ten animals. All animals were autopsied at 2 months and the knees were examined by gross dissection and histologic study of the joint capsule meniscal interface. Results showed that implantation by the surgical technique was effective and no loose bodies or partial detachments were found in the reimplantation or tissue culture-stored allogenic menisci. Allogenic menisci preserved in glutaraldehyde and termed a bioprosthesis attached to the joint capsule less satisfactorily. There was minimal inflammation of the synovium in any group at 2 months; however, the glutaraldehyde group showed repeated effusions at 1 and 2 weeks.

Abstract Permafrost soils currently store approximately 1672 Pg of carbon (C), but as high latitudes warm, this temperature‐protected C reservoir will become vulnerable to higher rates of decomposition. In recent decades, air temperatures in the high latitudes have warmed more than any other region globally, particularly during the winter. Over the coming century, the arctic winter is also expected to experience the most warming of any region or season, yet it is notably understudied. Here we present nonsummer season (NSS) CO 2 flux data from the Carbon in Permafrost Experimental Heating Research project, an ecosystem warming experiment of moist acidic tussock tundra in interior Alaska. Our goals were to quantify the relationship between environmental variables and winter CO 2 production, account for subnivean photosynthesis and late fall plant C uptake in our estimate of NSS CO 2 exchange, constrain NSS CO 2 loss estimates using multiple methods of measuring winter CO 2 flux, and quantify the effect of winter soil warming on total NSS CO 2 balance. We measured CO 2 flux using four methods: two chamber techniques (the snow pit method and one where a chamber is left under the snow for the entire season), eddy covariance, and soda lime adsorption, and found that NSS CO 2 loss varied up to fourfold, depending on the method used. CO 2 production was dependent on soil temperature and day of season but atmospheric pressure and air temperature were also important in explaining CO 2 diffusion out of the soil. Warming stimulated both ecosystem respiration and productivity during the NSS and increased overall CO 2 loss during this period by 14% (this effect varied by year, ranging from 7 to 24%). When combined with the summertime CO 2 fluxes from the same site, our results suggest that this subarctic tundra ecosystem is shifting away from its historical function as a C sink to a C source.

Attempts to prove the usefulness of geriatric consultation teams (GCT) in acute-care settings have been inconclusive. We have completed a prospective, controlled trial of a GCT in an acute-care setting, aiming our interventions at a specific subgroup of elderly patients. One hundred and thirty-two out of 352 (37.5%) patients met the inclusion criteria with 66 each being assigned to the intervention and the control groups. There were no significant differences in baseline characteristics between the two groups. Patients in the intervention group received follow-up after discharge from hospital by the geriatric service. We found that the intervention was associated with improved 6-month survival (p less than 0.01), improved Barthel Index at 1 year (p less than 0.01), and a trend towards decreased reliance on institutional care (hospital or nursing home) during the year of follow-up. The benefits occurred principally in patients who were discharged to a nursing home. Our findings support the utility of GCT and highlight the importance of focusing the intervention and providing follow-up after discharge from hospital.

BACKGROUND: Musculocutaneous perforator flaps, or more simply, perforator flaps, have become increasingly popular in microsurgery because of numerous advantages, including reduced donor-site morbidity. The thoracodorsal artery perforator flap is a cutaneous flap based on cutaneous perforators of the thoracodorsal vessels. The objective of this study was to document the vascular anatomy of this flap in human cadaveric studies. METHODS: The anatomy of the perforators of the thoracodorsal artery was studied using a modified lead oxide-gelatin injection technique in 15 fresh human cadavers. Each fresh cadaver was injected with lead oxide, gelatin, and water, and then cooled to 4 degrees C for 24 hours before dissection. The torso was dissected to identify all cutaneous perforators in the region of the back and flank. RESULTS: The mean area of the primary and secondary zones supplied by the thoracodorsal artery was 255 cm2 and 345 cm2, respectively. The mean length of the major and minor axes was 18 cm and 13 cm, respectively. The maximum dimensions of the skin that could potentially be supplied by the thoracodorsal artery averaged 600 cm2, with a major axis length of 28 cm and a minor axis length of 27 cm. A mean number of 5.5 perforators with a mean diameter of 0.9 mm (range, 0.5 to 1.5 mm) supplied this zone. The ratio of musculocutaneous to septocutaneous perforators from the thoracodorsal artery was 3:2. The length of the thoracodorsal pedicle when harvested along with the perforator was 14.0 cm, with the vessel diameter being 2.8 mm at the origin. The most proximal perforator was seen at the level of the inferior angle of the scapula, 3.0 cm medial to the anterior border of the muscle. The intramuscular course of the perforators averaged 5 cm (range, 3 to 7 cm). Septocutaneous perforators from the thoracodorsal artery supplying the skin in addition to the musculocutaneous perforators were seen in 60 percent of specimens. CONCLUSIONS: The thoracodorsal artery perforator flap is a reliable cutaneous perforator flap that is very useful in a wide variety of clinical applications.

The influence of the time interval (TI) between drug administration and laser activation on selectivity of meta-tetrahydroxyphenylchlorin(mTHPC)-mediated photodynamic therapy (PDT) for tumour tissue was assessed in BALB/c nude mice bearing human malignant mesothelioma xenografts. Following i.p. administration of 0.3 mg/kg mTHPC, a light dose of 10 J/cm2 and 0.1 W/cm2 was delivered at 650 nm on the tumour and an equal-sized area of the hind leg after 4, 12, 24 and 36 hr and 2, 3, 4, 5 and 6 days to groups of 6 animals (surface irradiance). Then, 72 hr after light delivery, the depth of necrosis was measured in the tumour and in the skin and underlying muscle of the hind leg. Photosensitized necrosis occurred in normal tissue at TI from 4 hr to 3 days and in the tumour at TI from 12 hr to 4 days. The therapeutic ratio of mTHPC-PDT varied significantly with the time interval between drug administration and laser activation and was greatest at an interval of 3 days. mTHPC concentration was measured in 3 control unirradiated animals at all time points in normal tissues and in tumour tissue, and found to be the same in both tissues. Thus the tissue concentration of mTHPC was of limited use as regards the prediction of photosensitizing effects in the tumour model.