Designing optimal food intake patterns to achieve nutritional goals for Japanese adults through the use of linear programming optimization models.

PubMed

Okubo, Hitomi; Sasaki, Satoshi; Murakami, Kentaro; Yokoyama, Tetsuji; Hirota, Naoko; Notsu, Akiko; Fukui, Mitsuru; Date, Chigusa

2015-06-06

Simultaneous dietary achievement of a full set of nutritional recommendations is difficult. Diet optimization model using linear programming is a useful mathematical means of translating nutrient-based recommendations into realistic nutritionally-optimal food combinations incorporating local and culture-specific foods. We used this approach to explore optimal food intake patterns that meet the nutrient recommendations of the Dietary Reference Intakes (DRIs) while incorporating typical Japanese food selections. As observed intake values, we used the food and nutrient intake data of 92 women aged 31-69 years and 82 men aged 32-69 years living in three regions of Japan. Dietary data were collected with semi-weighed dietary record on four non-consecutive days in each season of the year (16 days total). The linear programming models were constructed to minimize the differences between observed and optimized food intake patterns while also meeting the DRIs for a set of 28 nutrients, setting energy equal to estimated requirements, and not exceeding typical quantities of each food consumed by each age (30-49 or 50-69 years) and gender group. We successfully developed mathematically optimized food intake patterns that met the DRIs for all 28 nutrients studied in each sex and age group. Achieving nutritional goals required minor modifications of existing diets in older groups, particularly women, while major modifications were required to increase intake of fruit and vegetables in younger groups of both sexes. Across all sex and age groups, optimized food intake patterns demanded greatly increased intake of whole grains and reduced-fat dairy products in place of intake of refined grains and full-fat dairy products. Salt intake goals were the most difficult to achieve, requiring marked reduction of salt-containing seasoning (65-80%) in all sex and age groups. Using a linear programming model, we identified optimal food intake patterns providing practical food choices and

Translational Geroscience: Emphasizing function to achieve optimal longevity

PubMed Central

Seals, Douglas R.; Melov, Simon

2014-01-01

Among individuals, biological aging leads to cellular and organismal dysfunction and an increased risk of chronic degenerative diseases and disability. This sequence of events in combination with the projected increases in the number of older adults will result in a worldwide healthcare burden with dire consequences. Superimposed on this setting are the adults now reaching traditional retirement ages--the baby boomers--a group that wishes to remain active, productive and physically and cognitively fit as they grow older. Together, these conditions are producing an unprecedented demand for increased healthspan or what might be termed “optimal longevity”—to live long, but well. To meet this demand, investigators with interests in the biological aspects of aging from model organisms to human epidemiology (population aging) must work together within an interactive process that we describe as translational geroscience. An essential goal of this new investigational platform should be the optimization and preservation of physiological function throughout the lifespan, including integrative physical and cognitive function, which would serve to increase healthspan, compress morbidity and disability into a shorter period of late-life, and help achieve optimal longevity. To most effectively utilize this new approach, we must rethink how investigators and administrators working at different levels of the translational research continuum communicate and collaborate with each other, how best to train the next generation of scientists in this new field, and how contemporary biological-biomedical aging research should be organized and funded. PMID:25324468

Optimizing patient/caregiver satisfaction through quality of communication in the pediatric emergency department.

PubMed

Locke, Robert; Stefano, Mariane; Koster, Alex; Taylor, Beth; Greenspan, Jay

2011-11-01

Optimizing patient/family caregiver satisfaction with emergency department (ED) encounters has advantages for improving patient health outcomes, adherence with medical plans, patient rights, and shared participation in care, provider satisfaction, improved health economics, institutional market share, and liability reduction. The variables that contribute to an optimal outcome in the pediatric ED setting have been less well investigated. The specific hypothesis tested was that patient/family caregiver-provider communication and 24-hour postdischarge phone contact would be associated with an increased frequency of highest possible satisfaction scores. A consecutive set of Press Ganey satisfaction survey responses between June and December 2009 in a large tertiary referral pediatric ED was evaluated. Press Ganey responses were subsequently linked to defined components of the electronic medical record associated with each survey respondent's ED visit to ascertain specific objective ED data. Multivariate modeling utilizing generalized linear equations was achieved to obtain a composite model of drivers of patient/caregiver satisfaction. Primary drivers of satisfaction and willingness to return or refer others to the ED were as follows: being informed about delays, ease of the insurance process, overall physician rating, registered nurse attention to needs, control of pain, and successful completion of postdischarge phone call to a family caregiver. Multiple wait time variables that were statistically significant in univariate modeling, including total length of time in the ED, time in waiting room, comfort of waiting room, time in treatment room, and play items, were not statistically significant once controlling for the other variables in the model. Type of insurance, race, patient age, or time of year did not influence the models. Achieving optimal patient/caregiver satisfaction scores in the pediatric ED is highly dependent on the quality of the interpersonal

Optimized Delivery System Achieves Enhanced Endomyocardial Stem Cell Retention

PubMed Central

Behfar, Atta; Latere, Jean-Pierre; Bartunek, Jozef; Homsy, Christian; Daro, Dorothee; Crespo-Diaz, Ruben J.; Stalboerger, Paul G.; Steenwinckel, Valerie; Seron, Aymeric; Redfield, Margaret M.; Terzic, Andre

2014-01-01

Background Regenerative cell-based therapies are associated with limited myocardial retention of delivered stem cells. The objective of this study is to develop an endocardial delivery system for enhanced cell retention. Methods and Results Stem cell retention was simulated in silico using one and three-dimensional models of tissue distortion and compliance associated with delivery. Needle designs, predicted to be optimal, were accordingly engineered using nitinol – a nickel and titanium alloy displaying shape memory and super-elasticity. Biocompatibility was tested with human mesenchymal stem cells. Experimental validation was performed with species-matched cells directly delivered into Langendorff-perfused porcine hearts or administered percutaneously into the endocardium of infarcted pigs. Cell retention was quantified by flow cytometry and real time quantitative polymerase chain reaction methodology. Models, computing optimal distribution of distortion calibrated to favor tissue compliance, predicted that a 75°-curved needle featuring small-to-large graded side holes would ensure the highest cell retention profile. In isolated hearts, the nitinol curved needle catheter (C-Cath) design ensured 3-fold superior stem cell retention compared to a standard needle. In the setting of chronic infarction, percutaneous delivery of stem cells with C-Cath yielded a 37.7±7.1% versus 10.0±2.8% retention achieved with a traditional needle, without impact on biocompatibility or safety. Conclusions Modeling guided development of a nitinol-based curved needle delivery system with incremental side holes achieved enhanced myocardial stem cell retention. PMID:24326777

A new perspective on optimal care for patients with COPD.

PubMed

Postma, Dirkje; Anzueto, Antonio; Calverley, Peter; Jenkins, Christine; Make, Barry J; Sciurba, Frank C; Similowski, Thomas; van der Molen, Thys; Eriksson, Göran

2011-06-01

Worldwide, clinicians face the task of providing millions of patients with the best possible treatment and management of COPD. Currently, management primarily involves short-term 'here-and-now' goals, targeting immediate patient benefit. However, although there is considerable knowledge available to assist clinicians in minimising the current impact of COPD on patients, relatively little is known about which dominant factors predict future risks. These predictors may vary for different outcomes, such as exacerbations, mortality, co-morbidities, and the long-term consequences of COPD. We propose a new paradigm to achieve 'optimal COPD care' based on the concept that here-and-now goals should be integrated with goals to improve long-term outcomes and reduce future risks. Whilst knowledge on risk factors for poorer outcomes in COPD is growing and some data exist on positive effects of pharmacological interventions, information on defining the benefits of all commonly used interventions for reducing the risk of various future disease outcomes is still scarce. Greater insight is needed into the relationships between the two pillars of optimal COPD care: 'best current control' and 'future risk reduction'. This broader approach to disease management should result in improved care for every COPD patient now and into the future.

Optimizing health system response to patient's needs: an argument for the importance of functioning information.

PubMed

Hopfe, Maren; Prodinger, Birgit; Bickenbach, Jerome E; Stucki, Gerold

2017-06-06

Current health systems are increasingly challenged to meet the needs of a growing number of patients living with chronic and often multiple health conditions. The primary outcome of care, it is argued, is not merely curing disease but also optimizing functioning over a person's life span. According to the World Health Organization, functioning can serve as foundation for a comprehensive picture of health and augment the biomedical perspective with a broader and more comprehensive picture of health as it plays out in people's lives. The crucial importance of information about patient's functioning for a well-performing health system, however, has yet to be sufficiently appreciated. This paper argues that functioning information is fundamental in all components of health systems and enhances the capacity of health systems to optimize patients' health and health-related needs. Beyond making sense of biomedical disease patterns, health systems can profit from using functioning information to improve interprofessional collaboration and achieve cross-cutting disease treatment outcomes. Implications for rehabilitation Functioning is a key health outcome for rehabilitation within health systems. Information on restoring, maintaining, and optimizing human functioning can strengthen health system response to patients' health and rehabilitative needs. Functioning information guides health systems to achieve cross-cutting health outcomes that respond to the needs of the growing number of individuals living with chronic and multiple health conditions. Accounting for individuals functioning helps to overcome fragmentation of care and to improve interprofessional collaboration across settings.

Achieving Optimal Best: Instructional Efficiency and the Use of Cognitive Load Theory in Mathematical Problem Solving

ERIC Educational Resources Information Center

Phan, Huy P.; Ngu, Bing H.; Yeung, Alexander S.

2017-01-01

We recently developed the "Framework of Achievement Bests" to explain the importance of effective functioning, personal growth, and enrichment of well-being experiences. This framework postulates a concept known as "optimal achievement best," which stipulates the idea that individuals may, in general, strive to achieve personal…

Faculty Sense of Academic Optimism and Its Relationship to Students' Achievement in Well Performing High Schools

ERIC Educational Resources Information Center

Cromartie, Michael Tyrone

2013-01-01

The aim of this study was to determine the organizational characteristics and behaviors that contribute to sustaining a culture of academic optimism as a mechanism of student achievement. While there is a developing research base identifying both the individual elements of academic optimism as well as the academic optimism construct itself as…

Determination of Optimal Amikacin Dosing Regimens for Pediatric Patients With Burn Wound Sepsis.

PubMed

Yu, Tian; Stockmann, Chris; Healy, Daniel P; Olson, Jared; Wead, Stephanie; Neely, Alice N; Kagan, Richard J; Spigarelli, Michael G; Sherwin, Catherine M T

2015-01-01

This study aimed to develop optimal amikacin dosing regimens for the empirical treatment of Gram-negative bacterial sepsis in pediatric patients with burn injuries. A pharmacodynamic (PD) target in which the peak concentration (Cmax) is ≥8 times the minimum inhibitory concentration (MIC) (Cmax/MIC ≥ 8) is reflective of optimal bactericidal activity and has been used to predict clinical outcomes. Population pharmacokinetic modeling was performed in NONMEM 7.2 for pediatric patients with and without burn injuries. Amikacin pharmacokinetic parameters were compared between the two groups and multiple dosing regimens were simulated using MATLAB to achieve the PD target in ≥90% of patients with burn injuries. The pharmacokinetic analysis included 282 amikacin concentrations from 70 pediatric patients with burn injuries and 99 concentrations from 32 pediatric patients without burns. A one-compartment model with first-order elimination described amikacin pharmacokinetics well for both groups. Clearance (CL) was significantly higher in patients with burn injuries than in patients without (7.22 vs 5.36 L/h, P < .001). The volume of distribution (V) was also significantly increased in patients with burn injuries (22.7 vs 18.7 L, P < .01). Weight significantly influenced amikacin CL (P < .001) and V (P < .001) for both groups. Model-based simulations showed that a higher amikacin dose (≥25 mg/kg) achieved a Cmax/MIC ≥8 in ≥90% of patients with assumed infections of organisms with an MIC = 8 mg/L. Amikacin pharmacokinetics are altered in patients with burn injuries, including a significant increase in CL and V. In simulations, increased doses (≥25 mg/kg) led to improved PD target attainment rates. Further clinical evaluation of this proposed dosing regimen is warranted to assess clinical and microbiological outcomes in pediatric patients with burn wound sepsis.

Achieving recovery in patients with schizophrenia through psychosocial interventions: A retrospective study.

PubMed

Buonocore, Mariachiara; Bosia, Marta; Baraldi, Maria A; Bechi, Margherita; Spangaro, Marco; Cocchi, Federica; Bianchi, Laura; Guglielmino, Carmelo; Mastromatteo, Antonella R; Cavallaro, Roberto

2018-01-01

Recovery, or functional remission, represents the ultimate treatment goal in schizophrenia. Despite its importance, a standardized definition of remission is still lacking, thus reported rates significantly vary across studies. Moreover, the effects of rehabilitative interventions on recovery have not been thoroughly investigated. This study aimed to evaluate recovery in a sample of patients with chronic schizophrenia engaged in rehabilitation programs and to explore contributing factors, with a focus on sociocognitive rehabilitative interventions. Data from 104 patients with schizophrenia treated either with a standard rehabilitation program, including cognitive remediation (n = 46), or the latter plus a specific sociocognitive intervention (n = 58), and assessed for psychopathology, cognition, social cognition, and Quality of Life Scale, were retrospectively analyzed for this study. Recovery, evaluated with the Quality of Life Scale, was achieved by 56.76% of patients in our sample. While no effects were observed for clinical, cognitive, or sociocognitive variables, participation in the sociocognitive rehabilitative interventions was positively associated with recovery. Our results indicate that high rates of recovery can be achieved in patients treated with psychosocial interventions and suggest that rehabilitative programs targeting social cognition may further facilitate the process of recovery. If confirmed, these results may have relevant implications for daily clinical practice and service provision, allowing clinicians to develop and optimize specific rehabilitation programs in order to promote recovery. © 2017 The Authors. Psychiatry and Clinical Neurosciences © 2017 Japanese Society of Psychiatry and Neurology.

Defining and achieving treatment success in patients with type 2 diabetes mellitus.

PubMed

Stolar, Mark W

2010-12-01

Traditionally, successful treatment of patients with type 2 diabetes mellitus (DM) has been defined strictly by achievement of targeted glycemic control, primarily using a stepped-care approach that begins with changes in lifestyle combined with oral therapy that is slowly intensified as disease progression advances and β-cell function declines. However, stepped care is often adjusted without regard to the mechanism of hyperglycemia or without long-term objectives. A more comprehensive definition of treatment success in patients with type 2 DM should include slowing or stopping disease progression and optimizing the reduction of all risk factors associated with microvascular and macrovascular disease complications. To achieve these broader goals, it is important to diagnose diabetes earlier in the disease course and to consider use of more aggressive combination therapy much earlier with agents that have the potential to slow or halt the progressive β-cell dysfunction and loss characteristic of type 2 DM. A new paradigm for managing patients with type 2 DM should address the concomitant risk factors and morbidities of obesity, hypertension, and dyslipidemia with equal or occasionally even greater aggressiveness than for hyperglycemia. The use of antidiabetes agents that may favorably address cardiovascular risk factors should be considered more strongly in treatment algorithms, although no pharmacological therapy is likely to be ultimately successful without concomitant synergistic lifestyle changes. Newer incretin-based therapies, such as glucagon-like peptide 1 receptor agonists and dipeptidyl peptidase 4 inhibitors, which appear to have a favorable cardiovascular safety profile as well as the mechanistic possibility for a favorable cardiovascular risk impact, are suitable for earlier inclusion as part of combination regimens aimed at achieving comprehensive treatment success in patients with type 2 DM.

Regulating thrombus growth and stability to achieve an optimal response to injury

PubMed Central

Brass, Lawrence F.; Wannemacher, Kenneth M.; Ma, Peisong; Stalker, Timothy J.

2012-01-01

An optimal platelet response to injury can be defined as one in which blood loss is restrained and haemostasis is achieved without the penalty of further tissue damage caused by unwarranted vascular occlusion. This brief review considers some of the ways in which thrombus growth and stability can be regulated so that an optimal platelet response can be achieved in vivo. Three related topics are considered. The first focuses on intracellular mechanisms that regulate the early events of platelet activation downstream of G protein coupled receptors for agonists such as thrombin, thromboxane A2 and ADP. The second considers the ways in which signalling events that are dependent on stable contacts between platelets can influence the state of platelet activation and thus affect thrombus growth and stability. The third focuses on the changes that are experienced by platelets as they move from their normal environment in freely-flowing plasma to a very different environment within the growing haemostatic plug, an environment in which the narrowing gaps and junctions between platelets not only facilitate communication, but also increasingly limit both the penetration of plasma and the exodus of platelet-derived bioactive molecules. PMID:21781243

Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease

PubMed Central

Gale, R; Scanlon, P H; Evans, M; Ghanchi, F; Yang, Y; Silvestri, G; Freeman, M; Maisey, A; Napier, J

2017-01-01

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016. PMID:28490797

Action on diabetic macular oedema: achieving optimal patient management in treating visual impairment due to diabetic eye disease.

PubMed

Gale, R; Scanlon, P H; Evans, M; Ghanchi, F; Yang, Y; Silvestri, G; Freeman, M; Maisey, A; Napier, J

2017-05-01

This paper identifies best practice recommendations for managing diabetes and sight-threatening diabetic eye disease. The authors provide an update for ophthalmologists and allied healthcare professionals on key aspects of diabetes management, supported by a review of the pertinent literature, and recommend practice principles for optimal patient management in treating visual impairment due to diabetic eye disease. In people with diabetes, early optimal glycaemic control reduces the long-term risk of both microvascular and macrovascular complications. The authors propose more can and should be done to maximise metabolic control, promote appropriate behavioural modifications and encourage timely treatment intensification when indicated to ameliorate diabetes-related complications. All people with diabetes should be screened for sight-threatening diabetic retinopathy promptly and regularly. It is shown that attitudes towards treatment adherence in diabetic macular oedema appear to mirror patients' views and health behaviours towards the management of their own diabetes. Awareness of diabetic macular oedema remains low among people with diabetes, who need access to education early in their disease about how to manage their diabetes to delay progression and possibly avoid eye-related complications. Ophthalmologists and allied healthcare professionals play a vital role in multidisciplinary diabetes management and establishment of dedicated diabetic macular oedema clinics is proposed. A broader understanding of the role of the diabetes specialist nurse may strengthen the case for comprehensive integrated care in ophthalmic practice. The recommendations are based on round table presentations and discussions held in London, UK, September 2016.

Online stochastic optimization of radiotherapy patient scheduling.

PubMed

Legrain, Antoine; Fortin, Marie-Andrée; Lahrichi, Nadia; Rousseau, Louis-Martin

2015-06-01

The effective management of a cancer treatment facility for radiation therapy depends mainly on optimizing the use of the linear accelerators. In this project, we schedule patients on these machines taking into account their priority for treatment, the maximum waiting time before the first treatment, and the treatment duration. We collaborate with the Centre Intégré de Cancérologie de Laval to determine the best scheduling policy. Furthermore, we integrate the uncertainty related to the arrival of patients at the center. We develop a hybrid method combining stochastic optimization and online optimization to better meet the needs of central planning. We use information on the future arrivals of patients to provide an accurate picture of the expected utilization of resources. Results based on real data show that our method outperforms the policies typically used in treatment centers.

Using tailored methodical approaches to achieve optimal science outcomes

NASA Astrophysics Data System (ADS)

Wingate, Lory M.

2016-08-01

The science community is actively engaged in research, development, and construction of instrumentation projects that they anticipate will lead to new science discoveries. There appears to be very strong link between the quality of the activities used to complete these projects, and having a fully functioning science instrument that will facilitate these investigations.[2] The combination of using internationally recognized standards within the disciplines of project management (PM) and systems engineering (SE) has been demonstrated to lead to achievement of positive net effects and optimal project outcomes. Conversely, unstructured, poorly managed projects will lead to unpredictable, suboptimal project outcomes ultimately affecting the quality of the science that can be done with the new instruments. The proposed application of these two specific methodical approaches, implemented as a tailorable suite of processes, are presented in this paper. Project management (PM) is accepted worldwide as an effective methodology used to control project cost, schedule, and scope. Systems engineering (SE) is an accepted method that is used to ensure that the outcomes of a project match the intent of the stakeholders, or if they diverge, that the changes are understood, captured, and controlled. An appropriate application, or tailoring, of these disciplines can be the foundation upon which success in projects that support science can be optimized.

Inverse-optimized 3D conformal planning: Minimizing complexity while achieving equivalence with beamlet IMRT in multiple clinical sites

PubMed Central

Fraass, Benedick A.; Steers, Jennifer M.; Matuszak, Martha M.; McShan, Daniel L.

2012-01-01

user-controllable search strategies which optimize plans without beamlet or pencil beam approximations. IO-3D allows comparisons of beamlet, multisegment, and conformal plans optimized using the same cost functions, dose points, and plan evaluation metrics, so quantitative comparisons are straightforward. Here, comparisons of IO-3D and beamlet IMRT techniques are presented for breast, brain, liver, and lung plans. Results: IO-3D achieves high quality results comparable to beamlet IMRT, for many situations. Though the IO-3D plans have many fewer degrees of freedom for the optimization, this work finds that IO-3D plans with only one to two segments per beam are dosimetrically equivalent (or nearly so) to the beamlet IMRT plans, for several sites. IO-3D also reduces plan complexity significantly. Here, monitor units per fraction (MU/Fx) for IO-3D plans were 22%–68% less than that for the 1 cm × 1 cm beamlet IMRT plans and 72%–84% than the 0.5 cm × 0.5 cm beamlet IMRT plans. Conclusions: The unique IO-3D algorithm illustrates that inverse planning can achieve high quality 3D conformal plans equivalent (or nearly so) to unconstrained beamlet IMRT plans, for many sites. IO-3D thus provides the potential to optimize flat or few-segment 3DCRT plans, creating less complex optimized plans which are efficient and simple to deliver. The less complex IO-3D plans have operational advantages for scenarios including adaptive replanning, cases with interfraction and intrafraction motion, and pediatric patients. PMID:22755717

Target weight achievement and ultrafiltration rate thresholds: potential patient implications.

PubMed

Flythe, Jennifer E; Assimon, Magdalene M; Overman, Robert A

2017-06-02

Higher ultrafiltration (UF) rates and extracellular hypo- and hypervolemia are associated with adverse outcomes among maintenance hemodialysis patients. The Centers for Medicare and Medicaid Services recently considered UF rate and target weight achievement measures for ESRD Quality Incentive Program inclusion. The dual measures were intended to promote balance between too aggressive and too conservative fluid removal. The National Quality Forum endorsed the UF rate measure but not the target weight measure. We examined the proposed target weight measure and quantified weight gains if UF rate thresholds were applied without treatment time (TT) extension or interdialytic weight gain (IDWG) reduction. Data were taken from the 2012 database of a large dialysis organization. Analyses considered 152,196 United States hemodialysis patients. We described monthly patient and dialysis facility target weight achievement patterns and examined differences in patient characteristics across target weight achievement status and differences in facilities across target weight measure scores. We computed the cumulative, theoretical 1-month fluid-related weight gain that would occur if UF rates were capped at 13 mL/h/kg without concurrent TT extension or IDWG reduction. Target weight achievement patterns were stable over the year. Patients who did not achieve target weight (post-dialysis weight ≥ 1 kg above or below target weight) tended to be younger, black and dialyze via catheter, and had shorter dialysis vintage, greater body weight, higher UF rate and more missed treatments compared with patients who achieved target weight. Facilities had, on average, 27.1 ± 9.7% of patients with average post-dialysis weight ≥ 1 kg above or below the prescribed target weight. In adjusted analyses, facilities located in the midwest and south and facilities with higher proportions of black and Hispanic patients and higher proportions of patients with shorter TTs were more likely to

Optimizing Aesthetic Outcomes in Delayed Breast Reconstruction

PubMed Central

2017-01-01

Background: The need to restore both the missing breast volume and breast surface area makes achieving excellent aesthetic outcomes in delayed breast reconstruction especially challenging. Autologous breast reconstruction can be used to achieve both goals. The aim of this study was to identify surgical maneuvers that can optimize aesthetic outcomes in delayed breast reconstruction. Methods: This is a retrospective review of operative and clinical records of all patients who underwent unilateral or bilateral delayed breast reconstruction with autologous tissue between April 2014 and January 2017. Three groups of delayed breast reconstruction patients were identified based on patient characteristics. Results: A total of 26 flaps were successfully performed in 17 patients. Key surgical maneuvers for achieving aesthetically optimal results were identified. A statistically significant difference for volume requirements was identified in cases where a delayed breast reconstruction and a contralateral immediate breast reconstruction were performed simultaneously. Conclusions: Optimal aesthetic results can be achieved with: (1) restoration of breast skin envelope with tissue expansion when possible, (2) optimal positioning of a small skin paddle to be later incorporated entirely into a nipple areola reconstruction when adequate breast skin surface area is present, (3) limiting the reconstructed breast mound to 2 skin tones when large area skin resurfacing is required, (4) increasing breast volume by deepithelializing, not discarding, the inferior mastectomy flap skin, (5) eccentric division of abdominal flaps when an immediate and delayed bilateral breast reconstructions are performed simultaneously; and (6) performing second-stage breast reconstruction revisions and fat grafting. PMID:28894666

Achieving patient engagement in multiple sclerosis: A perspective from the multiple sclerosis in the 21st Century Steering Group.

PubMed

Rieckmann, Peter; Boyko, Alexey; Centonze, Diego; Elovaara, Irina; Giovannoni, Gavin; Havrdová, Eva; Hommes, Otto; Kesselring, Jurg; Kobelt, Gisela; Langdon, Dawn; LeLorier, Jacques; Morrow, Sarah A; Oreja-Guevara, Celia; Schippling, Sven; Thalheim, Christoph; Thompson, Heidi; Vermersch, Patrick

2015-05-01

While advances in medicine, technology and healthcare services offer promises of longevity and improved quality of life (QoL), there is also increasing reliance on a patient׳s skills and motivation to optimize all the benefits available. Patient engagement in their own healthcare has been described as the 'blockbuster drug of the century'. In multiple sclerosis (MS), patient engagement is vital if outcomes for the patient, society and healthcare systems are to be optimized. The MS in the 21st Century Steering Group devised a set of themes that require action with regard to patient engagement in MS, namely: 1) setting and facilitating engagement by education and confidence-building; 2) increasing the importance placed on QoL and patient concerns through patient-reported outcomes (PROs); 3) providing credible sources of accurate information; 4) encouraging treatment adherence through engagement; and 5) empowering through a sense of responsibility. Group members independently researched and contributed examples of patient engagement strategies from several countries and examined interventions that have worked well in areas of patient engagement in MS, and other chronic illnesses. The group presents their perspective on these programs, discusses the barriers to achieving patient engagement, and suggests practical strategies for overcoming these barriers. With an understanding of the issues that influence patient engagement in MS, we can start to investigate ways to enhance engagement and subsequent health outcomes. Engaging patients involves a broad, multidisciplinary approach. Copyright © 2015 The Authors. Published by Elsevier B.V. All rights reserved.

Impaired math achievement in patients with acute vestibular neuritis.

PubMed

Moser, Ivan; Vibert, Dominique; Caversaccio, Marco D; Mast, Fred W

2017-12-01

Broad cognitive difficulties have been reported in patients with peripheral vestibular deficit, especially in the domain of spatial cognition. Processing and manipulating numbers relies on the ability to use the inherent spatial features of numbers. It is thus conceivable that patients with acute peripheral vestibular deficit show impaired numerical cognition. Using the number Stroop task and a short math achievement test, we tested 20 patients with acute vestibular neuritis and 20 healthy, age-matched controls. On the one hand, patients showed normal congruency and distance effects in the number Stroop task, which is indicative of normal number magnitude processing. On the other hand, patients scored lower than healthy controls in the math achievement test. We provide evidence that the lower performance cannot be explained by either differences in prior math knowledge (i.e., education) or slower processing speed. Our results suggest that peripheral vestibular deficit negatively affects numerical cognition in terms of the efficient manipulation of numbers. We discuss the role of executive functions in math performance and argue that previously reported executive deficits in patients with peripheral vestibular deficit provide a plausible explanation for the lower math achievement scores. In light of the handicapping effects of impaired numerical cognition in daily living, it is crucial to further investigate the mechanisms that cause mathematical deficits in acute PVD and eventually develop adequate means for cognitive interventions. Copyright © 2017 Elsevier Ltd. All rights reserved.

Optimal ventilation of the anesthetized pediatric patient.

PubMed

Feldman, Jeffrey M

2015-01-01

Mechanical ventilation of the pediatric patient is challenging because small changes in delivered volume can be a significant fraction of the intended tidal volume. Anesthesia ventilators have traditionally been poorly suited to delivering small tidal volumes accurately, and pressure-controlled ventilation has become used commonly when caring for pediatric patients. Modern anesthesia ventilators are designed to deliver small volumes accurately to the patient's airway by compensating for the compliance of the breathing system and delivering tidal volume independent of fresh gas flow. These technology advances provide the opportunity to implement a lung-protective ventilation strategy in the operating room based upon control of tidal volume. This review will describe the capabilities of the modern anesthesia ventilator and the current understanding of lung-protective ventilation. An optimal approach to mechanical ventilation for the pediatric patient is described, emphasizing the importance of using bedside monitors to optimize the ventilation strategy for the individual patient.

Optimizing the function of upstanding activities in adult patients with acquired lesions of the central nervous system by using the Bobath concept approach - A case report.

PubMed

Jelica, Stjepan; Seper, Vesna; Davidović, Erna; Bujisić, Gordana

2011-01-01

Nonspecific medical gymnastic therapy may help patients after stroke achieve certain results in terms of efficiency but not in terms of quality of movement. The goal of treatment by Bobath concept is development of movement (effectiveness) and optimization of movement (efficiency). This article presents the case of a 62-year old patient who had experienced a stroke and has difficulties with standing up activities. It underscores the importance of not only recovery of function but also optimization of the function in such patients.

Analysis of effectiveness, safety and optimization of tocilizumab in a cohort of patients with rheumatoid arthritis in clinical practice.

PubMed

Mena-Vázquez, Natalia; Manrique-Arija, Sara; Rojas-Giménez, Marta; Ureña-Garnica, Inmaculada; Jiménez-Núñez, Francisco G; Fernández-Nebro, Antonio

2017-07-01

To evaluate the effectiveness and safety of tocilizumab (TCZ) in patients with rheumatoid arthritis (RA) in clinical practice, establishing the optimized regimen and switching from intravenous (IV) to subcutaneous (SC) therapy. Retrospective observational study. We included 53 RA patients treated with TCZ. The main outcome was TCZ effectiveness at week 24. Secondary outcome variables included effectiveness at week 52, therapeutic maintenance, physical function and safety. The effectiveness of optimization and the switch from IV to SC was evaluated at 3 and 6 months. The efficacy was measured with the Disease Activity Score. Paired t-tests or Wilcoxon were used to evaluate effectiveness and survival time using Kaplan-Meier. The proportion of patients who achieved remission or low disease activity at weeks 24 and 52 was 75.5% and 87.3%, respectively. The mean retention time (95% confidence interval [95% CI] was 81.7 months [76.6-86.7]). Twenty-one of 53 patients (39.6%) optimized the TCZ dose and 35 patients switched from IV TCZ to SC, with no changes in effectiveness. The adverse event rate was 13.6 events/100 patient-years. Tocilizumab appears to be effective and safe in RA in clinical practice. The optimized regimen appears to be effective in most patients in remission, even when they change from IV to SC. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Reumatología y Colegio Mexicano de Reumatología. All rights reserved.

Knowledge Visualizations: A Tool to Achieve Optimized Operational Decision Making and Data Integration

DTIC Science & Technology

2015-06-01

Hadoop Distributed File System (HDFS) without any integration with Accumulo-based Knowledge Stores based on OWL/RDF. 4. Cloud Based The Apache Software...BTW, 7(12), pp. 227–241. Godin, A. & Akins, D. (2014). Extending DCGS-N naval tactical clouds from in-storage to in-memory for the integrated fires...VISUALIZATIONS: A TOOL TO ACHIEVE OPTIMIZED OPERATIONAL DECISION MAKING AND DATA INTEGRATION by Paul C. Hudson Jeffrey A. Rzasa June 2015 Thesis

Patient-provider communication and low-income adults: age, race, literacy, and optimism predict communication satisfaction.

PubMed

Jensen, Jakob D; King, Andy J; Guntzviller, Lisa M; Davis, LaShara A

2010-04-01

To assess whether literacy, numeracy, and optimism are related to low-income adults' satisfaction with their healthcare provider's communication skills. Low-income adults (N=131) were recruited from seven counties in Indiana through University extension programs. To achieve research triangulation, participants were surveyed and interviewed about their communication satisfaction with health providers. Survey data revealed that four variables significantly predicted satisfaction: age, race, literacy, and optimism. Low-income adults in the current study were more critical of their healthcare provider's communication skills if they were younger, White, functionally literate, and pessimistic. Follow-up interviews confirmed this pattern and suggested it was a byproduct of patient activism. In low-income populations, communication satisfaction may be lower for groups that are traditionally active in doctor-patient interactions (e.g., younger patients, patients with higher literacy skills). Healthcare providers should be aware that older, non-White, optimistic, and literacy deficient patients report greater communication satisfaction than their younger, White, pessimistic, and functionally literate peers. Both groups may be coping with their situation, the former by withdrawing and the latter by actively pushing for a higher standard of care. Healthcare providers should continue to seek out ways to facilitate dialogue with these underserved groups. 2009 Elsevier Ireland Ltd. All rights reserved.

Breaking down patient and physician barriers to optimize glycemic control in type 2 diabetes.

PubMed

Ross, Stuart A

2013-09-01

Approximately half of patients with type 2 diabetes (T2D) do not achieve globally recognized blood glucose targets, despite the availability of a wide range of effective glucose-lowering therapies. Failure to maintain good glycemic control increases the risk of diabetes-related complications and long-term health care costs. Patients must be brought under glycemic control to improve treatment outcomes, but existing barriers to optimizing glycemic control must first be overcome, including patient nonadherence to treatment, the failure of physicians to intensify therapy in a timely manner, and inadequacies in the health care system itself. The reasons for such barriers include treatment side effects, complex treatment regimens, needle anxiety, poor patient education, and the absence of an adequate patient care plan; however, newer therapies and devices, combined with comprehensive care plans involving adequate patient education, can help to minimize barriers and improve treatment outcomes. Copyright © 2013 Elsevier Inc. All rights reserved.

Designing patient-specific 3D printed craniofacial implants using a novel topology optimization method.

PubMed

Sutradhar, Alok; Park, Jaejong; Carrau, Diana; Nguyen, Tam H; Miller, Michael J; Paulino, Glaucio H

2016-07-01

Large craniofacial defects require efficient bone replacements which should not only provide good aesthetics but also possess stable structural function. The proposed work uses a novel multiresolution topology optimization method to achieve the task. Using a compliance minimization objective, patient-specific bone replacement shapes can be designed for different clinical cases that ensure revival of efficient load transfer mechanisms in the mid-face. In this work, four clinical cases are introduced and their respective patient-specific designs are obtained using the proposed method. The optimized designs are then virtually inserted into the defect to visually inspect the viability of the design . Further, once the design is verified by the reconstructive surgeon, prototypes are fabricated using a 3D printer for validation. The robustness of the designs are mechanically tested by subjecting them to a physiological loading condition which mimics the masticatory activity. The full-field strain result through 3D image correlation and the finite element analysis implies that the solution can survive the maximum mastication of 120 lb. Also, the designs have the potential to restore the buttress system and provide the structural integrity. Using the topology optimization framework in designing the bone replacement shapes would deliver surgeons new alternatives for rather complicated mid-face reconstruction.

VMAT optimization with dynamic collimator rotation.

PubMed

Lyu, Qihui; O'Connor, Daniel; Ruan, Dan; Yu, Victoria; Nguyen, Dan; Sheng, Ke

2018-04-16

Although collimator rotation is an optimization variable that can be exploited for dosimetric advantages, existing Volumetric Modulated Arc Therapy (VMAT) optimization uses a fixed collimator angle in each arc and only rotates the collimator between arcs. In this study, we develop a novel integrated optimization method for VMAT, accounting for dynamic collimator angles during the arc motion. Direct Aperture Optimization (DAO) for Dynamic Collimator in VMAT (DC-VMAT) was achieved by adding to the existing dose fidelity objective an anisotropic total variation term for regulating the fluence smoothness, a binary variable for forming simple apertures, and a group sparsity term for controlling collimator rotation. The optimal collimator angle for each beam angle was selected using the Dijkstra's algorithm, where the node costs depend on the estimated fluence map at the current iteration and the edge costs account for the mechanical constraints of multi-leaf collimator (MLC). An alternating optimization strategy was implemented to solve the DAO and collimator angle selection (CAS). Feasibility of DC-VMAT using one full-arc with dynamic collimator rotation was tested on a phantom with two small spherical targets, a brain, a lung and a prostate cancer patient. The plan was compared against a static collimator VMAT (SC-VMAT) plan using three full arcs with 60 degrees of collimator angle separation in patient studies. With the same target coverage, DC-VMAT achieved 20.3% reduction of R50 in the phantom study, and reduced the average max and mean OAR dose by 4.49% and 2.53% of the prescription dose in patient studies, as compared with SC-VMAT. The collimator rotation co-ordinated with the gantry rotation in DC-VMAT plans for deliverability. There were 13 beam angles in the single-arc DC-VMAT plan in patient studies that requires slower gantry rotation to accommodate multiple collimator angles. The novel DC-VMAT approach utilizes the dynamic collimator rotation during arc

The optimal blood glucose level for critically ill adult patients.

PubMed

Lv, Shaoning; Ross, Paul; Tori, Kathleen

2017-09-01

Glycaemic control is recognized as one of the important aspects in managing critically ill patients. Both hyperglycaemia and hypoglycaemia independently increase the risk of patient mortality. Hence, the identification of optimal glycaemic control is of paramount importance in the management of critically ill patients. The aim of this literature review is to examine the current status of glycaemic control in critically ill adult patients. This literature review will focus on randomized controlled trials comparing intensive insulin therapy to conventional insulin therapy, with an objective to identify optimal blood glucose level targets for critically ill adult patients. A literature review was conducted to identify large randomized controlled trials for the optimal targeted blood glucose level for critically ill adult patients published since 2000. A total of eight studies fulfilled the selection criteria of this review. With current human and technology resources, the results of the studies support commencing glycaemic control once the blood glucose level of critically ill patients reaches 10 mmol/L and maintaining this level between 8 mmol/L and 10 mmol/L. This literature review provides a recommendation for targeting the optimal blood glucose level for critically ill patients within moderate blood glucose level target range (8-10 mmol/L). The need for uniformed glucometrics for unbiased reporting and further research for optimal blood glucose target is required, especially in light of new technological advancements in closed-loop insulin delivery and monitoring devices. This literature review has revealed a need to call for consensus in the measurement and reporting of glycaemic control using standardized glucometrics. © 2017 British Association of Critical Care Nurses.

SU-F-I-47: Optimizing Protocols for Image Quality and Dose in Abdominal CT of Large Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

Johnson, L; Yester, M

Purpose: Newer CT scanners are able to use scout views to adjust mA throughout the scan in order to achieve a given noise level. However, given constraints of radiologist preferences for kVp and rotation time, it may not be possible to achieve an acceptable noise level for large patients. A study was initiated to determine for which patients kVp and/or rotation time should be changed in order to achieve acceptable image quality. Methods: Patient scans were reviewed on two new Emergency Department scanners (Philips iCT) to identify patients over a large range of sizes. These iCTs were set with amore » limit of 500 mA to safeguard against a failure that might cause a CT scan to be (incorrectly) obtained at too-high mA. Scout views of these scans were assessed for both AP and LAT patient width and AP and LAT standard deviation in an ROI over the liver. Effective diameter and product of the scout standard deviations over the liver were both studied as possible metrics for identifying patients who would need kVp and/or rotation time changed. The mA used for the liver in the CT was compared to these metrics for those patients whose CT scans showed acceptable image quality. Results: Both effective diameter and product of the scout standard deviations over the liver result in similar predictions for which patients will require the kVp and/or rotation time to be changed to achieve an optimal combination of image quality and dose. Conclusion: Two mechanisms for CT technologists to determine based on scout characteristics what kVp, mA limit, and rotation time to use when DoseRight with our physicians’ preferred kVp and rotation time will not yield adequate image quality are described.« less

MO-DE-204-02: Optimization of the Patient CT Dose in Europe

DOE Office of Scientific and Technical Information (OSTI.GOV)

Tsapaki, V.

2016-06-15

The main topic of the session is to show how dose optimization is being implemented in various regions of the world, including Europe, Australia, North America and other regions. A multi-national study conducted under International Atomic Energy Agency (IAEA) across more than 50 less resourced countries gave insight into patient radiation doses and safety practices in CT, mammography, radiography and interventional procedures, both for children and adults. An important outcome was the capability development on dose assessment and management. An overview of recent European projects related to CT radiation dose and optimization both to adults and children will be presented.more » Existing data on DRLs together with a European methodology proposed on establishing and using DRLs for paediatric radiodiagnostic imaging and interventional radiology practices will be shown. Compared with much of Europe at least, many Australian imaging practices are relatively new to the task of diagnostic imaging dose optimisation. In 2008 the Australian Government prescribed a requirement to periodically compare patient radiation doses with diagnostic reference levels (DRLs), where DRLs have been established. Until recently, Australia had only established DRLs for computed tomography (CT). Regardless, both professional society and individual efforts to improved data collection and develop optimisation strategies across a range of modalities continues. Progress in this field, principally with respect to CT and interventional fluoroscopy will be presented. In the US, dose reduction and optimization efforts for computed tomography have been promoted and mandated by several organizations and accrediting entities. This presentation will cover the general motivation, implementation, and implications of such efforts. Learning Objectives: Understand importance of the dose optimization in Diagnostic Radiology. See how this goal is achieved in different regions of the World. Learn about the

Patient-specific dosimetric endpoints based treatment plan quality control in radiotherapy.

PubMed

Song, Ting; Staub, David; Chen, Mingli; Lu, Weiguo; Tian, Zhen; Jia, Xun; Li, Yongbao; Zhou, Linghong; Jiang, Steve B; Gu, Xuejun

2015-11-07

In intensity modulated radiotherapy (IMRT), the optimal plan for each patient is specific due to unique patient anatomy. To achieve such a plan, patient-specific dosimetric goals reflecting each patient's unique anatomy should be defined and adopted in the treatment planning procedure for plan quality control. This study is to develop such a personalized treatment plan quality control tool by predicting patient-specific dosimetric endpoints (DEs). The incorporation of patient specific DEs is realized by a multi-OAR geometry-dosimetry model, capable of predicting optimal DEs based on the individual patient's geometry. The overall quality of a treatment plan is then judged with a numerical treatment plan quality indicator and characterized as optimal or suboptimal. Taking advantage of clinically available prostate volumetric modulated arc therapy (VMAT) treatment plans, we built and evaluated our proposed plan quality control tool. Using our developed tool, six of twenty evaluated plans were identified as sub-optimal plans. After plan re-optimization, these suboptimal plans achieved better OAR dose sparing without sacrificing the PTV coverage, and the dosimetric endpoints of the re-optimized plans agreed well with the model predicted values, which validate the predictability of the proposed tool. In conclusion, the developed tool is able to accurately predict optimally achievable DEs of multiple OARs, identify suboptimal plans, and guide plan optimization. It is a useful tool for achieving patient-specific treatment plan quality control.

Optimism, social support, and mental health outcomes in patients with advanced cancer.

PubMed

Applebaum, Allison J; Stein, Emma M; Lord-Bessen, Jennifer; Pessin, Hayley; Rosenfeld, Barry; Breitbart, William

2014-03-01

Optimism and social support serve as protective factors against distress in medically ill patients. Very few studies have specifically explored the ways in which these variables interact to impact quality of life (QOL), particularly among patients with advanced cancer. The present study examined the role of optimism as a moderator of the relationship between social support and anxiety, depression, hopelessness, and QOL among patients with advanced cancer. Participants (N = 168) completed self-report assessments of psychosocial, spiritual, and physical well-being, including social support, optimism, hopelessness, depressive and anxious symptoms, and QOL. Hierarchical multiple regression analyses were conducted to determine the extent to which social support and optimism were associated with depressive and anxious symptomatology, hopelessness and QOL, and the potential role of optimism as a moderator of the relationship between social support and these variables. Higher levels of optimism were significantly associated with fewer anxious and depressive symptoms, less hopelessness, and better QOL. Higher levels of perceived social support were also significantly associated with better QOL. Additionally, optimism moderated the relationship between social support and anxiety, such that there was a strong negative association between social support and anxiety for participants with low optimism. This study highlights the importance of optimism and social support in the QOL of patients with advanced cancer. As such, interventions that attend to patients' expectations for positive experiences and the expansion of social support should be the focus of future clinical and research endeavors. Copyright © 2013 John Wiley & Sons, Ltd.

Dispositional optimism and coping strategies in patients with a kidney transplant.

PubMed

Costa-Requena, Gemma; Cantarell-Aixendri, M Carmen; Parramon-Puig, Gemma; Serón-Micas, Daniel

2014-01-01

 Dispositional optimism is a personal resource that determines the coping style and adaptive response to chronic diseases. The aim of this study was to assess the correlations between dispositional optimism and coping strategies in patients with recent kidney transplantation and evaluate the differences in the use of coping strategies in accordance with the level of dispositional optimism.  Patients who were hospitalised in the nephrology department were selected consecutively after kidney transplantation was performed. The evaluation instruments were the Life Orientation Test-Revised, and the Coping Strategies Inventory. The data were analysed with central tendency measures, correlation analyses and means were compared using Student’s t-test.   66 patients with a kidney transplant participated in the study. The coping styles that characterised patients with a recent kidney transplantation were Social withdrawal and Problem avoidance. Correlations between dispositional optimism and coping strategies were significant in a positive direction in Problem-solving (p<.05) and Cognitive restructuring (p<.01), and inversely with Self-criticism (p<.05). Differences in dispositional optimism created significant differences in the Self-Criticism dimension (t=2.58; p<.01).  Dispositional optimism scores provide differences in coping responses after kidney transplantation. Moreover, coping strategies may influence the patient’s perception of emotional wellbeing after kidney transplantation.

Recommendations for optimizing methotrexate treatment for patients with rheumatoid arthritis

PubMed Central

Bello, Alfonso E; Perkins, Elizabeth L; Jay, Randy; Efthimiou, Petros

2017-01-01

Methotrexate (MTX) remains the cornerstone therapy for patients with rheumatoid arthritis (RA), with well-established safety and efficacy profiles and support in international guidelines. Clinical and radiologic results indicate benefits of MTX monotherapy and combination with other agents, yet patients may not receive optimal dosing, duration, or route of administration to maximize their response to this drug. This review highlights best practices for MTX use in RA patients. First, to improve the response to oral MTX, a high initial dose should be administered followed by rapid titration. Importantly, this approach does not appear to compromise safety or tolerability for patients. Treatment with oral MTX, with appropriate dose titration, then should be continued for at least 6 months (as long as the patient experiences some response to treatment within 3 months) to achieve an accurate assessment of treatment efficacy. If oral MTX treatment fails due to intolerability or inadequate response, the patient may be “rescued” by switching to subcutaneous delivery of MTX. Consideration should also be given to starting with subcutaneous MTX given its favorable bioavailability and pharmacodynamic profile over oral delivery. Either initiation of subcutaneous MTX therapy or switching from oral to subcutaneous administration improves persistence with treatment. Upon transition from oral to subcutaneous delivery, MTX dosage should be maintained, rather than increased, and titration should be performed as needed. Similarly, if another RA treatment is necessary to control the disease, the MTX dosage and route of administration should be maintained, with titration as needed. PMID:28435338

Preoperative Nutritional Optimization for Crohn's Disease Patients Can Improve Surgical Outcome.

PubMed

Dreznik, Yael; Horesh, Nir; Gutman, Mordechai; Gravetz, Aviad; Amiel, Imri; Jacobi, Harel; Zmora, Oded; Rosin, Danny

2017-11-01

Preoperative preparation of patients with Crohn's disease is challenging and there are no specific guidelines regarding nutritional support. The aim of this study was to assess whether preoperative nutritional support influenced the postoperative outcome. A retrospective, cohort study including all Crohn's disease patients who underwent abdominal surgery between 2008 and 2014 was conducted. Patients' characteristics and clinical and surgical data were recorded and analyzed. Eighty-seven patients were included in the study. Thirty-seven patients (42.5%) received preoperative nutritional support (mean albumin level 3.14 vs. 3.5 mg/dL in the non-optimized group; p < 0.02) to optimize their nutritional status prior to surgery. Preoperative albumin level, after adequate nutritional preparation, was similar between the 2 groups. The 2 groups differ neither in demographic and surgical data, overall post-op complication (p = 0.85), Clavien-Dindo score (p = 0.42), and length of stay (p = 0.1). Readmission rate was higher in the non-optimized group (p = 0.047). Nutritional support can minimize postoperative complications in patients with low albumin levels. Nutritional status should be optimized in order to avoid hazardous complications. © 2017 S. Karger AG, Basel.

Variation in Patient Profiles and Outcomes in US and Non-US Subgroups of the Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition (CHAMPION) PHOENIX Trial

PubMed Central

Vaduganathan, Muthiah; Harrington, Robert A.; Stone, Gregg W.; Steg, Ph. Gabriel; Gibson, C. Michael; Hamm, Christian W.; Price, Matthew J.; Prats, Jayne; Deliargyris, Efthymios N.; Mahaffey, Kenneth W.; White, Harvey D.

2016-01-01

Background— The Cangrelor Versus Standard Therapy to Achieve Optimal Management of Platelet Inhibition (CHAMPION) PHOENIX trial demonstrated superiority of cangrelor in reducing ischemic events at 48 hours in patients undergoing percutaneous coronary intervention compared with clopidogrel. Methods and Results— We analyzed all patients included in the modified intention-to-treat analysis in US (n=4097; 37.4%) and non-US subgroups (n=6845; 62.6%). The US cohort was older, had a higher burden of cardiovascular risk factors, and had more frequently undergone prior cardiovascular procedures. US patients more frequently underwent percutaneous coronary intervention for stable angina (77.9% versus 46.2%). Almost all US patients (99.1%) received clopidogrel loading doses of 600 mg, whereas 40.5% of non-US patients received 300 mg. Bivalirudin was more frequently used in US patients (56.7% versus 2.9%). At 48 hours, rates of the primary composite end point were comparable in the US and non-US cohorts (5.5% versus 5.2%; P=0.53). Cangrelor reduced rates of the primary composite end point compared with clopidogrel in US (4.5% versus 6.4%; odds ratio 0.70 [95% confidence interval 0.53–0.92]) and in non-US patients (4.8% versus 5.6%; odds ratio 0.85 [95% confidence interval 0.69–1.05]; interaction P=0.26). Similarly, rates of the key secondary end point, stent thrombosis, were reduced by cangrelor in both regions. Rates of Global Use of Strategies to Open Occluded Arteries (GUSTO)–defined severe bleeding were low and not significantly increased by cangrelor in either region. Conclusions— Despite broad differences in clinical profiles and indications for percutaneous coronary intervention by region in a large global cardiovascular clinical trial, cangrelor consistently reduced rates of ischemic end points compared with clopidogrel without an excess in severe bleeding in both the US and non-US subgroups. Clinical Trial Registration— URL: http

The Relationship Between Heart Rate Reserve and Oxygen Uptake Reserve in Heart Failure Patients on Optimized and Non-Optimized Beta-Blocker Therapy

PubMed Central

Carvalho, Vitor Oliveira; Guimarães, Guilherme Veiga; Bocchi, Edimar Alcides

2008-01-01

BACKGROUND The relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in heart failure patients either on non-optimized or off beta-blocker therapy is known to be unreliable. The aim of this study was to evaluate the relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in heart failure patients receiving optimized and non-optimized beta-blocker treatment during a treadmill cardiopulmonary exercise test. METHODS A total of 27 sedentary heart failure patients (86% male, 50±12 years) on optimized beta-blocker therapy with a left ventricle ejection fraction of 33±8% and 35 sedentary non-optimized heart failure patients (75% male, 47±10 years) with a left ventricle ejection fraction of 30±10% underwent the treadmill cardiopulmonary exercise test (Naughton protocol). Resting and peak effort values of both the percentage of oxygen consumption reserve and percentage of heart rate reserve were, by definition, 0 and 100, respectively. RESULTS The heart rate slope for the non-optimized group was derived from the points 0.949±0.088 (0 intercept) and 1.055±0.128 (1 intercept), p<0.0001. The heart rate slope for the optimized group was derived from the points 1.026±0.108 (0 intercept) and 1.012±0.108 (1 intercept), p=0.47. Regression linear plots for the heart rate slope for each patient in the non-optimized and optimized groups revealed a slope of 0.986 (almost perfect) for the optimized group, but the regression analysis for the non-optimized group was 0.030 (far from perfect, which occurs at 1). CONCLUSION The relationship between the percentage of oxygen consumption reserve and percentage of heart rate reserve in patients on optimized beta-blocker therapy was reliable, but this relationship was unreliable in non-optimized heart failure patients. PMID:19060991

[Optimization of radiological scoliosis assessment].

PubMed

Enríquez, Goya; Piqueras, Joaquim; Catalá, Ana; Oliva, Glòria; Ruiz, Agustí; Ribas, Montserrat; Duran, Carmina; Rodrigo, Carlos; Rodríguez, Eugenia; Garriga, Victoria; Maristany, Teresa; García-Fontecha, César; Baños, Joan; Muchart, Jordi; Alava, Fernando

2014-07-01

Most scoliosis are idiopathic (80%) and occur more frequently in adolescent girls. Plain radiography is the imaging method of choice, both for the initial study and follow-up studies but has the disadvantage of using ionizing radiation. The breasts are exposed to x-ray along these repeated examinations. The authors present a range of recommendations in order to optimize radiographic exam technique for both conventional and digital x-ray settings to prevent unnecessary patients' radiation exposure and to reduce the risk of breast cancer in patients with scoliosis. With analogue systems, leaded breast protectors should always be used, and with any radiographic equipment, analog or digital radiography, the examination should be performed in postero-anterior projection and optimized low-dose techniques. The ALARA (as low as reasonable achievable) rule should always be followed to achieve diagnostic quality images with the lowest feasible dose. Copyright © 2014. Published by Elsevier Espana.

Optimal formulations of local foods to achieve nutritional adequacy for 6–23-month-old rural Tanzanian children

PubMed Central

Raymond, Jofrey; Kassim, Neema; Rose, Jerman W.; Agaba, Morris

2017-01-01

ABSTRACT Background: Achieving nutritional goals of infants and young children while maintaining the intake of local and culture-specific foods can be a daunting task. Diet optimisation using linear goal programming (LP) can effectively generate optimal formulations incorporating local and culturally acceptable foods. Objective: The primary objective of this study was to determine whether a realistic and affordable diet that achieves dietary recommended intakes (DRIs) for 22 selected nutrients can be formulated for rural 6–23-month-old children in Tanzania. Design: Dietary intakes of 400 children aged 6–23 months were assessed using a weighed dietary record (WDR), 24-hour dietary recalls and a 7-days food record. A market survey was also carried out to estimate the cost per 100 g of edible portion of foods that are commonly consumed in the study area. Dietary and market survey data were then used to define LP model parameters for diet optimisation. All LP analyses were done using linear program solver (LiPS) version 1.9.4 to generate optimal food formulations. Results: Optimal formulations that achieved DRIs for 20 nutrients for children aged 6–11 months and all selected nutrients for children aged 12–23 months were successfully developed at a twofold cost of the observed food purchase across age groups. Optimal formulations contained a mixture of ingredients such as wholegrain cereals, Irish potatoes, pulses and seeds, fish and poultry meat as well as fruits and vegetables that can be sourced locally. Conclusions: Our findings revealed that given the available food choices, it is possible to develop optimal formulations that can improve dietary adequacy for rural 6–23-month-old children if food budget for the child’s diets is doubled. These findings suggest the need for setting alternative interventions which can help households increase access to nutrient-dense foods that can fill the identified nutrient gaps. PMID:28814951

Optimal Colostomy Placement in Spinal Cord Injury Patients.

PubMed

Xu, Jiashou; Dharmarajan, Sekhar; Johnson, Frank E

2016-03-01

Barring unusual circumstances, sigmoid colostomy is the optimal technique for management of defecation in spinal cord injury (SCI) patients. We sought to provide evidence that a sigmoid colostomy is not difficult to perform in SCI patients and has better long-term results. The St. Louis Department of Veterans Affairs has a Commission on Accreditation of Rehabilitation Facilities (CARF)-approved SCI Unit. We reviewed the operative notes on all SCI patients who received a colostomy for fecal management by three ASCRS-certified colorectal surgeons at the St. Louis Department of Veterans Affairs from January 1, 2007 to November 26, 2012. There were 27 operations for which the recorded indication for surgery suggested that the primary disorder was SCI. Fourteen had traumatic SCI of the thoracic and/or lumbar spine and were evaluable. Of these 14 patients, 12 had laparoscopic sigmoid colostomy and two had open sigmoid colostomy. We encountered one evaluable patient with a remarkably large amount of retroperitoneal bony debris who successfully underwent laparoscopic sigmoid colostomy. In conclusion, sigmoid colostomy is the consensus optimal procedure for fecal management in SCI patients. Laparoscopic procedures are preferred. Care providers should specify sigmoid colostomy when contacting a surgeon.

Characteristics of psychiatric patients for whom financial considerations affect optimal treatment provision.

PubMed

West, Joyce C; Pingitore, David; Zarin, Deborah A

2002-12-01

This study assessed characteristics of psychiatric patients for whom financial considerations affected the provision of "optimal" treatment. Psychiatrists reported that for 33.8 percent of 1,228 patients from a national sample, financial considerations such as managed care limitations, the patient's personal finances, and limitations inherent in the public care system adversely affected the provision of optimal treatment. Patients were more likely to have their treatment adversely affected by financial considerations if they were more severely ill, had more than one behavioral health disorder or a psychosocial problem, or were receiving treatment under managed care arrangements. Patients for whom financial considerations affect the provision of optimal treatment represent a population for whom access to treatment may be particularly important.

Optimal in vitro fertilization in 2020 should reduce treatment burden and enhance care delivery for patients and staff.

PubMed

Gameiro, Sofia; Boivin, Jacky; Domar, Alice

2013-08-01

This review argues that optimal in vitro fertilization in 2020 should include a way of enhancing the delivery of treatment for patients and staff by the minimization of patient, treatment, and clinic sources of burden. Two specific sources of burden are addressed. First, patient vulnerability can be tackled by implementation of pretreatment evidence-based screening for psychological distress, appropriate referral for support, elimination of barriers to acceptance of psychosocial support, and implementation of a routine care flowchart that identifies the specific stages of treatment when psychosocial support should be provided. Second, negative patient-staff interactions can be avoided by training staff in communication/interaction skills, promoting shared decision making, prioritizing psychological interventions that address aspects of care equally problematic for patients and staff, and monitoring the impact of change on patient, staff, and clinic outcomes. In addition, optimal in vitro fertilization should ensure now that the future generations of young adults know what "achieving parenthood" actually entails in the context of the many desired goals of adulthood, greater variety of reproductive techniques available, later age of first births, and, consequently, longer exposure to risk factors (e.g., smoking) that affect fertility. Copyright © 2013 American Society for Reproductive Medicine. Published by Elsevier Inc. All rights reserved.

Optimism, Social Support, and Mental Health Outcomes in Patients with Advanced Cancer

PubMed Central

Applebaum, Allison J.; Stein, Emma M.; Lord-Bessen, Jennifer; Pessin, Hayley; Rosenfeld, Barry; Breitbart, William

2014-01-01

Objective Optimism and social support serve as protective factors against distress in medically ill patients. Very few studies have specifically explored the ways in which these variables interact to impact quality of life (QOL), particularly among patients with advanced cancer. The present study examined the role of optimism as a moderator of the relationship between social support and anxiety, depression, hopelessness, and QOL among patients with advanced cancer. Methods Participants (N = 168) completed self-report assessments of psychosocial, spiritual, and physical well-being, including social support, optimism, hopelessness, depressive and anxious symptoms, and QOL. Hierarchical multiple regression analyses were conducted to determine the extent to which social support and optimism were associated with depressive and anxious symptomatology, hopelessness and QOL, and the potential role of optimism as a moderator of the relationship between social support and these variables. Results Higher levels of optimism were significantly associated with fewer anxious and depressive symptoms, less hopelessness and better QOL. Higher levels of perceived social support were also significantly associated with better QOL. Additionally, optimism moderated the relationship between social support and anxiety, such that there was a strong negative association between social support and anxiety for participants with low optimism. Conclusions This study highlights the importance of optimism and social support in the QOL of patients with advanced cancer. As such, interventions that attend to patients’ expectations for positive experiences and the expansion of social support should be the focus of future clinical and research endeavors. PMID:24123339

Optimizing Oxygenation in the Mechanically Ventilated Patient: Nursing Practice Implications.

PubMed

Barton, Glenn; Vanderspank-Wright, Brandi; Shea, Jacqueline

2016-12-01

Critical care nurses constitute front-line care provision for patients in the intensive care unit (ICU). Hypoxemic respiratory compromise/failure is a primary reason that patients require ICU admission and mechanical ventilation. Critical care nurses must possess advanced knowledge, skill, and judgment when caring for these patients to ensure that interventions aimed at optimizing oxygenation are both effective and safe. This article discusses fundamental aspects of respiratory physiology and clinical indices used to describe oxygenation status. Key nursing interventions including patient assessment, positioning, pharmacology, and managing hemodynamic parameters are discussed, emphasizing their effects toward mitigating ventilation-perfusion mismatch and optimizing oxygenation. Copyright © 2016 Elsevier Inc. All rights reserved.

Optimism on quality of life in Portuguese chronic patients: moderator/mediator?

PubMed

Vilhena, Estela; Pais-Ribeiro, José; Silva, Isabel; Pedro, Luísa; Meneses, Rute F; Cardoso, Helena; Silva, António Martins da; Mendonça, Denisa

2014-07-01

optimism is an important variable that has consistently been shown to affect adjustment to quality of life in chronic diseases. This study aims to clarify if dispositional optimism exerts a moderating or a mediating influence on the personality traits-quality of life association, in Portuguese chronic patients. multiple regression models were used to test the moderation and mediation effects of dispositional optimism in quality of life. A sample of 729 patients was recruited in Portugal's main hospitals and completed self-reported questionnaires assessing socio-demographic and clinical variables, personality, dispositional optimism, quality of life (QoL) and subjective well-being (SWB). the results of the regression models showed that dispositional optimism did not moderate the relationships between personality traits and quality of life. After controlling for gender, age, education level and severity of disease perception, the effects of personality traits on QoL and in SWB were mediated by dispositional optimism (partially and completely), except for the links between neuroticism/openness to experience and physical health. dispositional optimism is more likely to play a mediating, rather than a moderating role in personality traits-quality of life pathway in Portuguese chronic patients, suggesting that "the expectation that good things will happen" contributes to a better quality of life and subjective well-being.

Factors associated with difficulty achieving initial control with crotalidae polyvalent immune fab antivenom in snakebite patients.

PubMed

Yin, Shan; Kokko, Jamie; Lavonas, Eric; Mlynarchek, Sara; Bogdan, Greg; Schaeffer, Tammi

2011-01-01

The prescribing information for Crotalidae Fab antivenom (FabAV) instructs clinicians to administer FabAV until initial control of the envenomation syndrome is achieved. Risk factors for difficulty achieving initial control are not known. The study aim was to identify factors present before administration of antivenom associated with difficulty achieving initial control. The authors conducted a retrospective study of all patients presenting to any one of 17 centers and receiving FabAV from 2002 to 2004. Demographic and historical information, as well as data about nine specific venom effects, were collected prior to the administration of antivenom. An expert panel used standard criteria to determine if initial control was achieved. The patient group that had difficulty achieving initial control was compared to the group that achieved initial control, and adjusted odds ratios were calculated using stepwise logistic regression. A total of 247 patients were included in the final analysis. The majority of patients were envenomated on the upper extremity and were young males. A total of 203 patients (82.2%) achieved initial control. In univariate analysis, thrombocytopenia, bleeding, neurologic effects, and a severe bite were significantly associated with difficulty achieving initial control. After logistic regression, the presence of neurologic effects and thrombocytopenia remained significantly associated with difficulty achieving initial control. When both factors were present, the patient was 13.8 times more likely to have difficulty achieving initial control. A number of factors were present before the administration of FabAV that were independently associated with difficulty achieving initial control of the envenomation syndrome. Predicting which patients will have difficulty achieving initial control has important ramifications for patient disposition and may provide insight into the mechanisms for lack of antivenom efficacy. © 2010 by the Society for Academic

Long-term pain relief with optimized medical treatment including antioxidants and step-up interventional therapy in patients with chronic pancreatitis.

PubMed

Shalimar; Midha, Shallu; Hasan, Ajmal; Dhingra, Rajan; Garg, Pramod Kumar

2017-01-01

Abdominal pain is difficult to treat in patients with chronic pancreatitis (CP). Medical therapy including antioxidants has been shown to relieve pain of CP in the short-term. Our aim was to study the long-term results of optimized medical and interventional therapy for pain relief in patients with CP with a step-up approach. All consecutive patients with CP were included prospectively in the study. They were treated medically with a well-balanced diet, pancreatic enzymes, and antioxidants (9000 IU beta-carotene, 0.54 g vitamin C, 270 IU vitamin E, 600 µg organic selenium, and 2 g methionine). Endoscopic therapy and/or surgery were offered if medical therapy failed. Pain relief was the primary outcome measure. A total of 313 patients (mean age 26.16 ± 12.17; 244 males) with CP were included; 288 (92%) patients had abdominal pain. The etiology of CP was idiopathic in 224 (71.6%) and alcohol in 82 (26.2%). At 1-year follow-up, significant pain relief was achieved in 84.7% of patients: 52.1% with medical therapy, 16.7% with endoscopic therapy, 7.6% with surgery, and 8.3% spontaneously. The mean pain score decreased from 6.36 ± 1.92 to 1.62 ± 2.10 (P < 0.001). Of the 288 patients, 261, 218, 112, and 51 patients were followed up for 3, 5, 10, and 15 years, respectively; 54.0%, 57.3%, 60.7%, and 68.8% of them became pain free at those follow-up periods. Significant pain relief is achieved in the majority of patients with optimized medical and interventional treatment. © 2016 Journal of Gastroenterology and Hepatology Foundation and John Wiley & Sons Australia, Ltd.

Cross-Sectional Assessment of Achievement of Therapeutic Goals in a Canadian Multidisciplinary Clinic for Patients With Advanced Chronic Kidney Disease.

PubMed

Rinfret, Félix; Lambert, France; Youmbissi, Joseph Tchetagni; Arcand, Jean-François; Turcot, Richard; Bessette, Maral Alimardani; Bourque, Solange; Moreau, Vincent; Tousignant, Karine; Deschênes, Diane; Cloutier, Lyne

2018-01-01

The implementation of advanced chronic kidney disease (CKD) multidisciplinary clinics has now demonstrated their effectiveness in delaying and even avoiding dialysis for patients with CKD. However, very little has been documented on the management and achievement of targets for a number of parameters in this context. Our goal was to assess our multidisciplinary clinic therapy performance in relation to the targets for hypertension, anemia, and calcium phosphate assessment. A cross-sectional descriptive study was conducted with a cohort including all patients followed up in our multidisciplinary clinic in July 2014. Comorbidity, laboratory, and clinical data were collected and compared with the recommendations of scientific organizations. The cohort included 128 patients, 37.5% of whom were women. Mean follow-up time was 26.6 ± 25.1 months and mean estimated glomerular filtration rate (eGFR) was 14.0 ± 4.7 mL/min/1.73 m 2 . A total of 24.2% of patients with diabetes achieved blood pressure targets of <130/80 mm Hg, while 56.5% of patients without diabetes achieved targets of <140/90 mm Hg. Hemoglobin of patients treated with erythropoiesis-stimulating agents was 100 to 110 g/L in 36.2% of the patients, below 100 for 39.7% of them, and above 110 for 24.1%, whereas 67.2% were within the acceptable limits of 95 to 115 g/L. In addition, 63.4% of patients had a serum phosphate of <1.5 mmol/L, and 90.9% of patients had total serum calcium <2.5 mmol/L. Our study is a single center study with the majority of our patients being Caucasian. This limits the generalizability of our findings. The control rates of various parameters were satisfactory given the difficult clinical context, but could be optimized. We publish these data in the hope that they are helpful to others engaged in quality improvement in their own programs or more generally.

Randomized, Multicenter Study of Gefitinib Dose-escalation in Advanced Non-small-cell Lung Cancer Patients Achieved Stable Disease after One-month Gefitinib Treatment

PubMed Central

Xue, Cong; Hong, Shaodong; Li, Ning; Feng, Weineng; Jia, Jun; Peng, Jiewen; Lin, Daren; Cao, Xiaolong; Wang, Siyang; Zhang, Weimin; Zhang, Hongyu; Dong, Wei; Zhang, Li

2015-01-01

There is no consensus on the optimal treatment for patients with advanced non-small-cell lung cancer (NSCLC) and stable disease (SD) after gefitinib therapy. This randomized, open-label, multicenter study aimed to explore whether dose-escalation of gefitinib would improve response and survival in NSCLC patients who achieved SD after one-month of standard gefitinib dosage. Between May 2009 and January 2012, 466 patients were enrolled and 100 eligible patients were randomized (1:1) to receive either a higher dose (500 mg/d; H group) or to continue standard dose (250 mg/d; S group) of gefitinib. Objective response rate (ORR) was similar between the two groups (12.5% vs 12.5%, p = 1.000). There were no significant differences regarding progression-free survival (PFS) and overall survival (OS) between both arms (H group vs S group: median PFS, 5.30 months vs 6.23 months, p = 0.167; median OS, 13.70 months vs 18.87 months, p = 0.156). Therefore, dose-escalation of gefitinib does not confer a response or survival advantage in patients who achieve SD with one month of standard-dose gefitinib treatment. PMID:26216071

Green Infrastructure Simulation and Optimization to Achieve Combined Sewer Overflow Reductions in Philadelphia's Mill Creek Sewershed

NASA Astrophysics Data System (ADS)

Cohen, J. S.; McGarity, A. E.

2017-12-01

The ability for mass deployment of green stormwater infrastructure (GSI) to intercept significant amounts of urban runoff has the potential to reduce the frequency of a city's combined sewer overflows (CSOs). This study was performed to aid in the Overbrook Environmental Education Center's vision of applying this concept to create a Green Commercial Corridor in Philadelphia's Overbrook Neighborhood, which lies in the Mill Creek Sewershed. In an attempt to further implement physical and social reality into previous work using simulation-optimization techniques to produce GSI deployment strategies (McGarity, et al., 2016), this study's models incorporated land use types and a specific neighborhood in the sewershed. The low impact development (LID) feature in EPA's Storm Water Management Model (SWMM) was used to simulate various geographic configurations of GSI in Overbrook. The results from these simulations were used to obtain formulas describing the annual CSO reduction in the sewershed based on the deployed GSI practices. These non-linear hydrologic response formulas were then implemented into the Storm Water Investment Strategy Evaluation (StormWISE) model (McGarity, 2012), a constrained optimization model used to develop optimal stormwater management practices on the watershed scale. By saturating the avenue with GSI, not only will CSOs from the sewershed into the Schuylkill River be reduced, but ancillary social and economic benefits of GSI will also be achieved. The effectiveness of these ancillary benefits changes based on the type of GSI practice and the type of land use in which the GSI is implemented. Thus, the simulation and optimization processes were repeated while delimiting GSI deployment by land use (residential, commercial, industrial, and transportation). The results give a GSI deployment strategy that achieves desired annual CSO reductions at a minimum cost based on the locations of tree trenches, rain gardens, and rain barrels in specified land

Achieving symptomatic remission in out-patients with schizophrenia--a naturalistic study with quetiapine.

PubMed

Wobrock, T; Köhler, J; Klein, P; Falkai, P

2009-08-01

Symptomatic remission was defined as a score of mild or less on each of eight key schizophrenia symptoms on the Positive and Negative Syndrome Scale (PANSS-8). To evaluate the symptomatic remission criterion in clinical practice and to determine predictors for achieving symptomatic remission, a 12-week non-interventional study (NIS) with quetiapine was conducted in Germany. For the comparison of patients with and without symptomatic remission, sociodemographic and clinical variables of 693 patients were analyzed by logistic regression for their predictive value to achieve remission. Four hundred and four patients (58.3%) achieved symptomatic remission after 12 weeks' treatment with quetiapine. Remission was significantly predicted by a low degree of PANSS-8 total score, PANSS single items blunted affect (N1), social withdrawal (N4), lack of spontaneity (N6), mannerism and posturing (G5), and low disease severity (CGI-S) at baseline. Predictors of non-remission were older age, diagnosis of schizophrenic residuum, multiple previous episodes, longer duration of current episode, presence of concomitant diseases, and alcohol abuse. This study demonstrated that the majority of schizophrenia out-patients achieved symptomatic remission after 12 weeks treatment and confirms the importance of managing negative symptoms in order to achieve disease remission.

Patient-derived multicellular tumor spheroids towards optimized treatment for patients with hepatocellular carcinoma.

PubMed

Song, Yeonhwa; Kim, Jin-Sun; Kim, Se-Hyuk; Park, Yoon Kyung; Yu, Eunsil; Kim, Ki-Hun; Seo, Eul-Ju; Oh, Heung-Bum; Lee, Han Chu; Kim, Kang Mo; Seo, Haeng Ran

2018-05-25

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide and has poor prognosis. Specially, patients with HCC usually have poor tolerance of systemic chemotherapy, because HCCs develop from chronically damaged tissue that contains considerable inflammation, fibrosis, and cirrhosis. Since HCC exhibits highly heterogeneous molecular characteristics, a proper in vitro system is required for the study of HCC pathogenesis. To this end, we have established two new hepatitis B virus (HBV) DNA-secreting HCC cell lines from infected patients. Based on these two new HCC cell lines, we have developed chemosensitivity assays for patient-derived multicellular tumor spheroids (MCTSs) in order to select optimized anti-cancer drugs to provide more informative data for clinical drug application. To monitor the effect of the interaction of cancer cells and stromal cells in MCTS, we used a 3D co-culture model with patient-derived HCC cells and stromal cells from human hepatic stellate cells, human fibroblasts, and human umbilical vein endothelial cells to facilitate screening for optimized cancer therapy. To validate our system, we performed a comparison of chemosensitivity of the three culture systems, which are monolayer culture system, tumor spheroids, and MCTSs of patient-derived cells, to sorafenib, 5-fluorouracil, and cisplatin, as these compounds are typically standard therapy for advanced HCC in South Korea. In summary, these findings suggest that the MCTS culture system is the best methodology for screening for optimized treatment for each patients with HCC, because tumor spheroids not only mirror the 3D cellular context of the tumors but also exhibit therapeutically relevant pathophysiological gradients and heterogeneity of in vivo tumors.

Genetic evolutionary taboo search for optimal marker placement in infrared patient setup

NASA Astrophysics Data System (ADS)

Riboldi, M.; Baroni, G.; Spadea, M. F.; Tagaste, B.; Garibaldi, C.; Cambria, R.; Orecchia, R.; Pedotti, A.

2007-09-01

In infrared patient setup adequate selection of the external fiducial configuration is required for compensating inner target displacements (target registration error, TRE). Genetic algorithms (GA) and taboo search (TS) were applied in a newly designed approach to optimal marker placement: the genetic evolutionary taboo search (GETS) algorithm. In the GETS paradigm, multiple solutions are simultaneously tested in a stochastic evolutionary scheme, where taboo-based decision making and adaptive memory guide the optimization process. The GETS algorithm was tested on a group of ten prostate patients, to be compared to standard optimization and to randomly selected configurations. The changes in the optimal marker configuration, when TRE is minimized for OARs, were specifically examined. Optimal GETS configurations ensured a 26.5% mean decrease in the TRE value, versus 19.4% for conventional quasi-Newton optimization. Common features in GETS marker configurations were highlighted in the dataset of ten patients, even when multiple runs of the stochastic algorithm were performed. Including OARs in TRE minimization did not considerably affect the spatial distribution of GETS marker configurations. In conclusion, the GETS algorithm proved to be highly effective in solving the optimal marker placement problem. Further work is needed to embed site-specific deformation models in the optimization process.

Optimal scan timing and intravenous route for contrast-enhanced computed tomography in patients after Fontan operation.

PubMed

Park, Eun-Ah; Lee, Whal; Chung, Se-Young; Yin, Yong Hu; Chung, Jin Wook; Park, Jae Hyung

2010-01-01

To determine the optimal scan timing and adequate intravenous route for patients having undergone the Fontan operation. A total of 88 computed tomographic images in 49 consecutive patients who underwent the Fontan operation were retrospectively evaluated and divided into 7 groups: group 1, bolus-tracking method with either intravenous route (n = 20); group 2, 1-minute-delay scan with single antecubital route (n = 36); group 3, 1-minute-delay scan with both antecubital routes (n = 2); group 4, 1-minute-delay scan with foot vein route (n = 3); group 5, 1-minute-delay scan with simultaneous infusion via both antecubital and foot vein routes (n = 2); group 6, 3-minute-delay scan with single antecubital route (n = 22); and group 7, 3-minute-delay scan with foot vein route (n = 3). The presence of beam-hardening artifact, uniform enhancement, and optimal enhancement was evaluated at the right pulmonary artery (RPA), left pulmonary artery (LPA), and Fontan tract. Optimal enhancement was determined when evaluation of thrombus was possible. Standard deviation was measured at the RPA, LPA, and Fontan tract. Beam-hardening artifacts of the RPA, LPA, and Fontan tract were frequently present in groups 1, 4, and 5. The success rate of uniform and optimal enhancement was highest (100%) in groups 6 and 7, followed by group 2 (75%). An SD of less than 30 Hounsfield unit for the pulmonary artery and Fontan tract was found in groups 3, 6, and 7. The optimal enhancement of the pulmonary arteries and Fontan tract can be achieved by a 3-minute-delay scan irrespective of the intravenous route location.

Accelerating IMRT optimization by voxel sampling

NASA Astrophysics Data System (ADS)

Martin, Benjamin C.; Bortfeld, Thomas R.; Castañon, David A.

2007-12-01

This paper presents a new method for accelerating intensity-modulated radiation therapy (IMRT) optimization using voxel sampling. Rather than calculating the dose to the entire patient at each step in the optimization, the dose is only calculated for some randomly selected voxels. Those voxels are then used to calculate estimates of the objective and gradient which are used in a randomized version of a steepest descent algorithm. By selecting different voxels on each step, we are able to find an optimal solution to the full problem. We also present an algorithm to automatically choose the best sampling rate for each structure within the patient during the optimization. Seeking further improvements, we experimented with several other gradient-based optimization algorithms and found that the delta-bar-delta algorithm performs well despite the randomness. Overall, we were able to achieve approximately an order of magnitude speedup on our test case as compared to steepest descent.

Treatment of chronic myeloid leukemia: assessing risk, monitoring response, and optimizing outcome.

PubMed

Shanmuganathan, Naranie; Hiwase, Devendra Keshaorao; Ross, David Morrall

2017-12-01

Over the past two decades, tyrosine kinase inhibitors have become the foundation of chronic myeloid leukemia (CML) treatment. The choice between imatinib and newer tyrosine kinase inhibitors (TKIs) needs to be balanced against the known toxicity and efficacy data for each drug, the therapeutic goal being to maximize molecular response assessed by BCR-ABL RQ-PCR assay. There is accumulating evidence that the early achievement of molecular targets is a strong predictor of superior long-term outcomes. Early response assessment provides the opportunity to intervene early with the aim of ensuring an optimal response. Failure to achieve milestones or loss of response can have diverse causes. We describe how clinical and laboratory monitoring can be used to ensure that each patient is achieving an optimal response and, in patients who do not reach optimal response milestones, how the monitoring results can be used to detect resistance and understand its origins.

Women are less likely than men to achieve optimal glycemic control after 1 year of treatment: A multi-level analysis of a Korean primary care cohort.

PubMed

Choe, Seung-Ah; Kim, Joo Yeong; Ro, Young Sun; Cho, Sung-Il

2018-01-01

We investigated differences in the achievement of glycemic control among newly diagnosed type-2 diabetes patients according to gender using a multi-clinic retrospective cohort study. Optimal glycemic control was defined as hemoglobin A1c (HbA1c) of less than 6.5% after 1 year of diabetes management. A generalized linear mixed model, which controlled for the fixed effects of baseline characteristics and prescribed oral hypoglycemic agent (OHA), was used to calculate the probability of achieving the target HbA1c. The study included 2,253 newly diagnosed type-2 diabetes patients who completed 1 year of diabetic management, including OHA, in the 36 participating primary clinics. Within the study population, the women had an older average age, were less likely to smoke or drink alcohol, and showed lower levels of fasting blood glucose and HbA1c at the time of diagnosis. There were no significant differences by sex in prescribed OHA or median number of visits. After 1 year of diabetes management, 38.9% of women and 40.6% of men achieved the target HbA1c-a small but significant difference. This suggests that type-2 diabetes is managed less well in women than in men.

Optimization of personalized therapies for anticancer treatment.

PubMed

Vazquez, Alexei

2013-04-12

As today, there are hundreds of targeted therapies for the treatment of cancer, many of which have companion biomarkers that are in use to inform treatment decisions. If we would consider this whole arsenal of targeted therapies as a treatment option for every patient, very soon we will reach a scenario where each patient is positive for several markers suggesting their treatment with several targeted therapies. Given the documented side effects of anticancer drugs, it is clear that such a strategy is unfeasible. Here, we propose a strategy that optimizes the design of combinatorial therapies to achieve the best response rates with the minimal toxicity. In this methodology markers are assigned to drugs such that we achieve a high overall response rate while using personalized combinations of minimal size. We tested this methodology in an in silico cancer patient cohort, constructed from in vitro data for 714 cell lines and 138 drugs reported by the Sanger Institute. Our analysis indicates that, even in the context of personalized medicine, combinations of three or more drugs are required to achieve high response rates. Furthermore, patient-to-patient variations in pharmacokinetics have a significant impact in the overall response rate. A 10 fold increase in the pharmacokinetics variations resulted in a significant drop the overall response rate. The design of optimal combinatorial therapy for anticancer treatment requires a transition from the one-drug/one-biomarker approach to global strategies that simultaneously assign makers to a catalog of drugs. The methodology reported here provides a framework to achieve this transition.

Optimizing the patient transport function at Mayo Clinic.

PubMed

Kuchera, Dustin; Rohleder, Thomas R

2011-01-01

In this article, we report on the implementation of a computerized scheduling tool to optimize staffing for patient transport at the Mayo Clinic. The tool was developed and implemented in Microsoft Excel and Visual Basic for Applications and includes an easy-to-use interface. The tool allows transport management to consider the trade-offs between patient waiting time and staffing levels. While improved staffing efficiency was a desire of the project, it was important that patient service quality was also maintained. The results show that staffing could be reduced while maintaining historical patient service levels.

Development and innovation of system resources to optimize patient care.

PubMed

Johnson, Thomas J; Brownlee, Michael J

2018-04-01

Various incremental and disruptive healthcare innovations that are occurring or may occur are discussed, with insights on how multihospital health systems can prepare for the future and optimize the continuity of patient care provided. Innovation in patient care is occurring at an ever-increasing rate, and this is especially true relative to the transition of patients through the care continuum. Health systems must leverage their ability to standardize and develop electronic health record (EHR) systems and other infrastructure necessary to support patient care and optimize outcomes; examples include 3D printing of patient-specific medication dosage forms to enhance precision medicine, the use of drones for medication delivery, and the expansion of telehealth capabilities to improve patient access to the services of pharmacists and other healthcare team members. Disruptive innovations in pharmacy services and delivery will alter how medications are prescribed and delivered to patients now and in the future. Further, technology may also fundamentally alter how and where pharmacists and pharmacy technicians care for patients. This article explores the various innovations that are occurring and that will likely occur in the future, particularly as they apply to multihospital health systems and patient continuity of care. Pharmacy departments that anticipate and are prepared to adapt to incremental and disruptive innovations can demonstrate value in the multihospital health system through strategies such as optimizing the EHR, identifying telehealth opportunities, supporting infrastructure, and integrating services. Copyright © 2018 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

A Pilot Study Assessing ECG versus ECHO Ventriculoventricular Optimization in Pediatric Resynchronization Patients.

PubMed

Punn, Rajesh; Hanisch, Debra; Motonaga, Kara S; Rosenthal, David N; Ceresnak, Scott R; Dubin, Anne M

2016-02-01

Cardiac resynchronization therapy indications and management are well described in adults. Echocardiography (ECHO) has been used to optimize mechanical synchrony in these patients; however, there are issues with reproducibility and time intensity. Pediatric patients add challenges, with diverse substrates and limited capacity for cooperation. Electrocardiographic (ECG) methods to assess electrical synchrony are expeditious but have not been extensively studied in children. We sought to compare ECHO and ECG CRT optimization in children. Prospective, pediatric, single-center cross-over trial comparing ECHO and ECG optimization with CRT. Patients were assigned to undergo either ECHO or ECG optimization, followed for 6 months, and crossed-over to the other assignment for another 6 months. ECHO pulsed-wave tissue Doppler and 12-lead ECG were obtained for 5 VV delays. ECG optimization was defined as the shortest QRSD and ECHO optimization as the lowest dyssynchrony index. ECHOs/ECGs were interpreted by readers blinded to optimization technique. After each 6 month period, these data were collected: ejection fraction, velocimetry-derived cardiac index, quality of life, ECHO-derived stroke distance, M-mode dyssynchrony, study cost, and time. Outcomes for each optimization method were compared. From June 2012 to December 2013, 19 patients enrolled. Mean age was 9.1 ± 4.3 years; 14 (74%) had structural heart disease. The mean time for optimization was shorter using ECG than ECHO (9 ± 1 min vs. 68 ± 13 min, P < 0.01). Mean cost for charges was $4,400 ± 700 less for ECG. No other outcome differed between groups. ECHO optimization of synchrony was not superior to ECG optimization in this pilot study. ECG optimization required less time and cost than ECHO optimization. © 2015 Wiley Periodicals, Inc.

A Study of the Relationships between Distributed Leadership, Teacher Academic Optimism and Student Achievement in Taiwanese Elementary Schools

ERIC Educational Resources Information Center

Chang, I-Hua

2011-01-01

The purpose of this study was to explore the relationships between distributed leadership, teachers' academic optimism and student achievement in learning. The study targeted public elementary schools in Taiwan and adopted stratified random sampling to investigate 1500 teachers. Teachers' perceptions were collected by a self-report scale. In…

Nutrition and fluid optimization for patients with short bowel syndrome.

PubMed

Matarese, Laura E

2013-03-01

Short bowel syndrome (SBS) is characterized by nutrient malabsorption and occurs following surgical resection, congenital defect, or disease of the bowel. The severity of SBS depends on the length and anatomy of the bowel resected and the health of the remaining tissue. During the 2 years following resection, the remnant bowel undergoes an adaptation process that increases its absorptive capacity. Oral diet and enteral nutrition (EN) enhance intestinal adaptation; although patients require parenteral nutrition (PN) and/or intravenous (IV) fluids in the immediate postresection period, diet and EN should be reintroduced as soon as possible. The SBS diet should include complex carbohydrates; simple sugars should be avoided. Optimal fat intake varies based on patient anatomy; patients with end-jejunostomies can tolerate a higher proportion of calories from dietary fat than patients with a remnant colon. Patients with SBS are prone to deficiencies in vitamins, minerals, and essential fatty acids; serum levels should be periodically monitored and supplements provided as needed. Prebiotic or probiotic therapy may be beneficial for patients with SBS, although further research is needed to determine optimal protocols. Patients with SBS, particularly those without a colon, are at high risk of dehydration; oral rehydration solutions sipped throughout the day can help maintain hydration. One of the primary goals of SBS therapy is to reduce or eliminate dependence on PN/IV; optimization of EN and hydration substantially increases the probability of successful PN/IV weaning.

Dasatinib rapidly induces deep molecular response in chronic-phase chronic myeloid leukemia patients who achieved major molecular response with detectable levels of BCR-ABL1 transcripts by imatinib therapy.

PubMed

Shiseki, Masayuki; Yoshida, Chikashi; Takezako, Naoki; Ohwada, Akira; Kumagai, Takashi; Nishiwaki, Kaichi; Horikoshi, Akira; Fukuda, Tetsuya; Takano, Hina; Kouzai, Yasuji; Tanaka, Junji; Morita, Satoshi; Sakamoto, Junichi; Sakamaki, Hisashi; Inokuchi, Koiti

2017-10-01

With the introduction of imatinib, a first-generation tyrosine kinase inhibitor (TKI) to inhibit BCR-ABL1 kinase, the outcome of chronic-phase chronic myeloid leukemia (CP-CML) has improved dramatically. However, only a small proportion of CP-CML patients subsequently achieve a deep molecular response (DMR) with imatinib. Dasatinib, a second-generation TKI, is more potent than imatinib in the inhibition of BCR-ABL1 tyrosine kinase in vitro and more effective in CP-CML patients who do not achieve an optimal response with imatinib treatment. In the present study, we attempted to investigate whether switching the treatment from imatinib to dasatinib can induce DMR in 16 CP-CML patients treated with imatinib for at least two years who achieved a major molecular response (MMR) with detectable levels of BCR-ABL1 transcripts. The rates of achievement of DMR at 1, 3, 6 and 12 months after switching to dasatinib treatment in the 16 patients were 44% (7/16), 56% (9/16), 63% (10/16) and 75% (12/16), respectively. The cumulative rate of achieving DMR at 12 months from initiation of dasatinib therapy was 93.8% (15/16). The proportion of natural killer cells and cytotoxic T cells in peripheral lymphocytes increased after switching to dasatinib. In contrast, the proportion of regulatory T cells decreased during treatment. The safety profile of dasatinib was consistent with previous studies. Switching to dasatinib would be a therapeutic option for CP-CML patients who achieved MMR but not DMR by imatinib, especially for patients who wish to discontinue TKI therapy.

Achievement of therapeutic targets in Mexican patients with diabetes mellitus.

PubMed

Lavalle-González, Fernando J; Chiquete, Erwin; de la Luz, Julieta; Ochoa-Guzmán, Ana; Sánchez-Orozco, Laura V; Godínez-Gutiérrez, Sergio A

2012-12-01

Complications of diabetes comprise the leading cause of death in Mexico. We aimed to describe the characteristics of management and achievement of therapeutic targets in Mexican patients with diabetes mellitus. We analyzed data from 2642 Mexican patients with type 1 (T1D, n=203, 7.7%) and type 2 diabetes (T2D, n=2439, 92.3%) included in the third wave of the International Diabetes Management Practices Study. Of T2D patients, 63% were on oral glucose-lowering drugs (OGLD) exclusively (mostly metformin), 11% on insulin, 22% on OGLD plus insulin, and 4% on diet and exercise exclusively. T2D patients on insulin were more likely to be trained on diabetes, but they were older, had worse control, longer disease duration and more chronic complications than patients on OGLD only. Glycated hemoglobin (HbA1c) <7% was achieved by 21% and 37% of T1D and T2D patients, respectively. Only 5% of T1D and 3% of T2D attained the composite target of HbA1c <7%, blood pressure <130/80 mmHg and low-density lipoprotein cholesterol <100 mg/dl. T1D patients had less macrovascular but more microvascular complications, compared with T2D patients. Late complications increased with disease duration, so that about 80% of patients after 20 years of diagnosis have at least one late complication. Reaching the target HbA1c <7% was associated with a reduced number of microvascular but not with less macrovascular complications. A great proportion of these Mexican patients with diabetes did not reach therapeutic targets. Insulin was used mostly in complicated cases with advanced disease. Copyright © 2011 SEEN. Published by Elsevier Espana. All rights reserved.

A system dynamics optimization framework to achieve population desired of average weight target

NASA Astrophysics Data System (ADS)

Abidin, Norhaslinda Zainal; Zulkepli, Jafri Haji; Zaibidi, Nerda Zura

2017-11-01

Obesity is becoming a serious problem in Malaysia as it has been rated as the highest among Asian countries. The aim of the paper is to propose a system dynamics (SD) optimization framework to achieve population desired weight target based on the changes in physical activity behavior and its association to weight and obesity. The system dynamics approach of stocks and flows diagram was used to quantitatively model the impact of both behavior on the population's weight and obesity trends. This work seems to bring this idea together and highlighting the interdependence of the various aspects of eating and physical activity behavior on the complex of human weight regulation system. The model was used as an experimentation vehicle to investigate the impacts of changes in physical activity on weight and prevalence of obesity implications. This framework paper provides evidence on the usefulness of SD optimization as a strategic decision making approach to assist in decision making related to obesity prevention. SD applied in this research is relatively new in Malaysia and has a high potential to apply to any feedback models that address the behavior cause to obesity.

The Relationship of Mental Pressure with Optimism and Academic Achievement Motivation among Second Grade Male High School Students

ERIC Educational Resources Information Center

Sarouni, Ali Sedigh; Jenaabadi, Hossein; Pourghaz, Abdulwahab

2016-01-01

The present study aimed to examine the relationship of mental pressure with optimism and academic achievement motivation among second grade second period male high school students. This study followed a descriptive-correlational method. The sample included 200 second grade second period male high school students in Sooran. Data collection tools in…

Periodic Application of Stochastic Cost Optimization Methodology to Achieve Remediation Objectives with Minimized Life Cycle Cost

NASA Astrophysics Data System (ADS)

Kim, U.; Parker, J.

2016-12-01

Many dense non-aqueous phase liquid (DNAPL) contaminated sites in the U.S. are reported as "remediation in progress" (RIP). However, the cost to complete (CTC) remediation at these sites is highly uncertain and in many cases, the current remediation plan may need to be modified or replaced to achieve remediation objectives. This study evaluates the effectiveness of iterative stochastic cost optimization that incorporates new field data for periodic parameter recalibration to incrementally reduce prediction uncertainty and implement remediation design modifications as needed to minimize the life cycle cost (i.e., CTC). This systematic approach, using the Stochastic Cost Optimization Toolkit (SCOToolkit), enables early identification and correction of problems to stay on track for completion while minimizing the expected (i.e., probability-weighted average) CTC. This study considers a hypothetical site involving multiple DNAPL sources in an unconfined aquifer using thermal treatment for source reduction and electron donor injection for dissolved plume control. The initial design is based on stochastic optimization using model parameters and their joint uncertainty based on calibration to site characterization data. The model is periodically recalibrated using new monitoring data and performance data for the operating remediation systems. Projected future performance using the current remediation plan is assessed and reoptimization of operational variables for the current system or consideration of alternative designs are considered depending on the assessment results. We compare remediation duration and cost for the stepwise re-optimization approach with single stage optimization as well as with a non-optimized design based on typical engineering practice.

Optimizing outcome after cardiac arrest.

PubMed

Nolan, Jerry P

2011-10-01

To discuss recent data relating to survival rates after cardiac arrest and interventions that can be used to optimize outcome. A recent analysis of 70 studies indicates that following out-of-hospital cardiac arrest (OHCA), 7.6% of patients will survive to hospital discharge (95% confidence interval 6.7-8.4). Following in-hospital cardiac arrest, 18% of patients will survive to hospital discharge. Survival may be optimized by increasing the rate of bystander cardiopulmonary resuscitation (CPR), which can be achieved by improving recognition of cardiac arrest, simplifying CPR and training more of the community. Feedback systems improve the quality of CPR but this has yet to be translated into improved outcome. One study has shown improved survival following OHCA with active compression-decompression CPR combined with an impedance-threshold device. In those who have no obvious extracardiac cause of OHCA, 70% have at least one significant coronary lesion demonstrable by coronary angiography. Although generally reserved for those with ST-elevation myocardial infarction, primary percutaneous coronary intervention may also benefit OHCA survivors with ECG patterns other than ST elevation. The term 'mild therapeutic hypothermia' has been replaced by the term 'targeted temperature management'; its role in optimizing outcome after cardiac arrest continues to be defined. In several centres, survival rates following OHCA are increasing. All links in the chain of survival must be optimized if a good-quality neurological outcome is to be achieved.

Protocol adherence and the ability to achieve target haemoglobin levels in haemodialysis patients.

PubMed

Chan, Kevin; Moran, John; Hlatky, Mark; Lafayette, Richard

2009-06-01

Anemia management remains complicated in patients with endstage renal disease on hemodialysis. We wished to evaluate the effect of protocol adherence to EPO and intravenous iron dosing on achieving the desired range of hemoglobin levels. A cohort of hemodialysis patients was studied to evaluate the rate of adherence to EPO and iron dosing protocols over a 5 month period. A database was completed to evaluate all known comorbidities, demographic factors, and facility issues that might affect hemoglobin levels. A logistic regression model was employed to evaluate the effect of adherence to the anemia protocols on the probability of achieving a hemoglobin level below, within or above the targeted range of 11-12.5 g/dl. Among 2114 patients, we found that adherence to both the EPO and iron dosing protocol resulted in the greatest probability of achieving the target hemoglobin range (56 +/- 5% in anemia protocol adherent patients versus 42 +/- 7% in non adherent patients). This was predominantly due to a lowered risk of having above target hemoglobin levels rather than below. The use of the anemia protocols was associated with lower rates of hospitalization (9 +/- 0.7 visits/100 months in adherent group vs 15 +/- 2 in non adherent group) and lower utilization of both EPO and intravenous iron. Furthermore, patients in the adherent groups had less variability of their hemoglobin levels month by month, at least as judged by standard deviation. Adherence to anemia protocols, as practiced in the dialysis units included in this cohort, may improve hemodialysis patients' ability to achieve target hemoglobin levels, and by avoiding above target hemoglobin values, lower drug utilization and reduce variability of hemoglobin levels.

Optimizing the management of elderly colorectal surgery patients.

PubMed

Tan, Kok-Yang; Konishi, Fumio; Tan, Lawrence; Chin, Wui-Kin; Ong, Hean-Yee; Tan, Phyllis

2010-11-01

With the ever increasing number of geriatric surgical patients, there is a need to develop efficient processes that address all of the potential issues faced by patients during the perioperative period. This article explores the physiological changes in elderly surgical patients and the outcomes achieved after major abdominal surgery. Perioperative management strategies for elderly surgical patients in line with the practices of the Geriatric Surgical Team of Alexandra Health, Singapore, are also presented. A coordinated transdisciplinary approach best tackles the complexities encountered in these patients.

Evaluation and Optimization of Therapeutic Footwear for Neuropathic Diabetic Foot Patients Using In-Shoe Plantar Pressure Analysis

PubMed Central

Bus, Sicco A.; Haspels, Rob; Busch-Westbroek, Tessa E.

2011-01-01

OBJECTIVE Therapeutic footwear for diabetic foot patients aims to reduce the risk of ulceration by relieving mechanical pressure on the foot. However, footwear efficacy is generally not assessed in clinical practice. The purpose of this study was to assess the value of in-shoe plantar pressure analysis to evaluate and optimize the pressure-reducing effects of diabetic therapeutic footwear. RESEARCH DESIGN AND METHODS Dynamic in-shoe plantar pressure distribution was measured in 23 neuropathic diabetic foot patients wearing fully customized footwear. Regions of interest (with peak pressure >200 kPa) were selected and targeted for pressure optimization by modifying the shoe or insole. After each of a maximum of three rounds of modifications, the effect on in-shoe plantar pressure was measured. Successful optimization was achieved with a peak pressure reduction of >25% (criterion A) or below an absolute level of 200 kPa (criterion B). RESULTS In 35 defined regions, mean peak pressure was significantly reduced from 303 (SD 77) to 208 (46) kPa after an average 1.6 rounds of footwear modifications (P < 0.001). This result constitutes a 30.2% pressure relief (range 18–50% across regions). All regions were successfully optimized: 16 according to criterion A, 7 to criterion B, and 12 to criterion A and B. Footwear optimization lasted on average 53 min. CONCLUSIONS These findings suggest that in-shoe plantar pressure analysis is an effective and efficient tool to evaluate and guide footwear modifications that significantly reduce pressure in the neuropathic diabetic foot. This result provides an objective approach to instantly improve footwear quality, which should reduce the risk for pressure-related plantar foot ulcers. PMID:21610125

A D-Optimal designed population pharmacokinetic study of oral itraconazole in adult cystic fibrosis patients

PubMed Central

Hennig, Stefanie; Waterhouse, Timothy H; Bell, Scott C; France, Megan; Wainwright, Claire E; Miller, Hugh; Charles, Bruce G; Duffull, Stephen B

2007-01-01

What is already known about this subject • Itraconazole is a triazole antifungal used in the treatment of allergic bronchopulmonary aspergillosis in patients with cystic fibrosis (CF). • The pharmacokinetic (PK) properties of this drug and its active metabolite have been described before, mostly in healthy volunteers. • However, only sparse information from case reports were available of the PK properties of this drug in CF patients at the start of our study. What this study adds • This study reports for the first time the population pharmacokinetic properties of itraconazole and a known active metabolite, hydroxy-itraconazole in adult patients with CF. • As a result, this study offers new dosing approaches and their pharmacoeconomic impact as well as a PK model for therapeutic drug monitoring of this drug in this patient group. • Furthermore, it is an example of a successful d-optimal design application in a clinical setting. Aim The primary objective of the study was to estimate the population pharmacokinetic parameters for itraconazole and hydroxy-itraconazole, in particular, the relative oral bioavailability of the capsule compared with solution in adult cystic fibrosis patients, in order to develop new dosing guidelines. A secondary objective was to evaluate the performance of a population optimal design. Methods The blood sampling times for the population study were optimized previously using POPT v.2.0. The design was based on the administration of solution and capsules to 30 patients in a cross-over study. Prior information suggested that itraconazole is generally well described by a two-compartment disposition model with either linear or saturable elimination. The pharmacokinetics of itraconazole and the metabolite were modelled simultaneously using NONMEM. Dosing schedules were simulated to assess their ability to achieve a trough target concentration of 0.5 mg ml−1. Results Out of 241 blood samples, 94% were taken within the defined optimal

Effect of perceived social support and dispositional optimism on the depression of burn patients.

PubMed

He, Fei; Zhou, Qin; Zhao, Zhijing; Zhang, Yuan; Guan, Hao

2016-06-01

Burn wounds have a significant impact on the mental health of patients. This study aimed to investigate the impact of perceived social support and dispositional optimism on depression of burn patients. A total of 246 burn patients accomplished the Multidimensional Scale of Perceived Social Support, the Revised Life Orientation Test, and Depression Scale. The results revealed that both perceived social support and optimism were significantly correlated with depression. Structural equation modeling indicated that optimism partially mediated the relationship between perceived social support and depression. Implications for prevention of depression in burn patients were discussed. © The Author(s) 2014.

Promising Practices for Achieving Patient-centered Hospital Care: A National Study of High-performing US Hospitals.

PubMed

Aboumatar, Hanan J; Chang, Bickey H; Al Danaf, Jad; Shaear, Mohammad; Namuyinga, Ruth; Elumalai, Sathyanarayanan; Marsteller, Jill A; Pronovost, Peter J

2015-09-01

Patient-centered care is integral to health care quality, yet little is known regarding how to achieve patient-centeredness in the hospital setting. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey measures patients' reports on clinician behaviors deemed by patients as key to a high-quality hospitalization experience. We conducted a national study of hospitals that achieved the highest performance on HCAHPS to identify promising practices for improving patient-centeredness, common challenges met, and how those were addressed. We identified hospitals that achieved the top ranks or remarkable recent improvements on HCAHPS and surveyed key informants at these hospitals. Using quantitative and qualitative methods, we described the interventions used at these hospitals and developed an explanatory model for achieving patient-centeredness in hospital care. Fifty-two hospitals participated in this study. Hospitals used similar interventions that focused on improving responsiveness to patient needs, the discharge experience, and patient-clinician interactions. To improve responsiveness, hospitals used proactive nursing rounds (reported at 83% of hospitals) and executive/leader rounds (62%); for the discharge experience, multidisciplinary rounds (56%), postdischarge calls (54%), and discharge folders (52%) were utilized; for clinician-patient interactions, hospitals promoted specific desired behaviors (65%) and set behavioral standards (60%) for which employees were held accountable. Similar strategies were also used to achieve successful intervention implementation including HCAHPS data feedback, and employee and leader engagement and accountability. High-performing hospitals used a set of patient-centered care processes that involved both leaders and clinicians in ensuring that patient needs and preferences are addressed.

Optimal allocation of land and water resources to achieve Water, Energy and Food Security in the upper Blue Nile basin

NASA Astrophysics Data System (ADS)

Allam, M.; Eltahir, E. A. B.

2017-12-01

Rapid population growth, hunger problems, increasing energy demands, persistent conflicts between the Nile basin riparian countries and the potential impacts of climate change highlight the urgent need for the conscious stewardship of the upper Blue Nile (UBN) basin resources. This study develops a framework for the optimal allocation of land and water resources to agriculture and hydropower production in the UBN basin. The framework consists of three optimization models that aim to: (a) provide accurate estimates of the basin water budget, (b) allocate land and water resources optimally to agriculture, and (c) allocate water to agriculture and hydropower production, and investigate trade-offs between them. First, a data assimilation procedure for data-scarce basins is proposed to deal with data limitations and produce estimates of the hydrologic components that are consistent with the principles of mass and energy conservation. Second, the most representative topography and soil properties datasets are objectively identified and used to delineate the agricultural potential in the basin. The agricultural potential is incorporated into a land-water allocation model that maximizes the net economic benefits from rain-fed agriculture while allowing for enhancing the soils from one suitability class to another to increase agricultural productivity in return for an investment in soil inputs. The optimal agricultural expansion is expected to reduce the basin flow by 7.6 cubic kilometres, impacting downstream countries. The optimization framework is expanded to include hydropower production. This study finds that allocating water to grow rain-fed teff in the basin is more profitable than allocating water for hydropower production. Optimal operation rules for the Grand Ethiopian Renaissance dam (GERD) are identified to maximize annual hydropower generation while achieving a relatively uniform monthly production rate. Trade-offs between agricultural expansion and hydropower

Preload assessment and optimization in critically ill patients.

PubMed

Voga, Gorazd

2010-01-01

Preload assessment and optimization is the basic hemodynamic intervention in critically ill. Beside clinical assessment, non-invasive or invasive assessment by measurement of various pressure or volume hemodynamic variables, are helpful for estimation of preload and fluid responsiveness. The use of dynamic variables is useful in particular subgroup of critically ill patients. In patients with inadequate preload, fluid responsiveness and inadequate flow, treatment with crystalloids or colloids is mandatory. When rapid hemodynamic response is necessary colloids are preferred.

Optimizing care for the obese patient in interventional radiology

PubMed Central

Aberle, Dwight; Charles, Hearns; Hodak, Steven; O’Neill, Daniel; Oklu, Rahmi; Deipolyi, Amy R.

2017-01-01

With the rising epidemic of obesity, interventional radiologists are treating increasing numbers of obese patients, as comorbidities associated with obesity preclude more invasive treatments. These patients are at heightened risk of vascular and oncologic disease, both of which often require interventional radiology care. Obese patients pose unique challenges in imaging, technical feasibility, and periprocedural monitoring. This review describes the technical and clinical challenges posed by this population, with proposed methods to mitigate these challenges and optimize care. PMID:28082253

Successful Optimization of Adalimumab Therapy in Refractory Uveitis Due to Behçet's Disease.

PubMed

Martín-Varillas, José Luis; Calvo-Río, Vanesa; Beltrán, Emma; Sánchez-Bursón, Juan; Mesquida, Marina; Adán, Alfredo; Hernandez, María Victoria; Garfella, Marisa Hernández; Pascual, Elia Valls; Martínez-Costa, Lucía; Sellas-Fernández, Agustí; Cordero-Coma, Miguel; Díaz-Llopis, Manuel; Gallego, Roberto; Salom, David; Ortego, Norberto; García-Serrano, José L; Callejas-Rubio, José-Luis; Herreras, José M; García-Aparicio, Ángel; Maíz, Olga; Blanco, Ana; Torre, Ignacio; Díaz-Valle, David; Pato, Esperanza; Aurrecoechea, Elena; Caracuel, Miguel A; Gamero, Fernando; Minguez, Enrique; Carrasco-Cubero, Carmen; Olive, Alejandro; Vázquez, Julio; Ruiz-Moreno, Oscar; Manero, Javier; Muñoz-Fernández, Santiago; Martinez, Myriam Gandía; Rubio-Romero, Esteban; Toyos-Sáenz de Miera, F Javier; López Longo, Francisco Javier; Nolla, Joan M; Revenga, Marcelino; González-Vela, Carmen; Loricera, Javier; Atienza-Mateo, Belén; Demetrio-Pablo, Rosalía; Hernández, José Luis; González-Gay, Miguel A; Blanco, Ricardo

2018-03-27

To assess efficacy, safety, and cost-effectiveness of adalimumab (ADA) therapy optimization in a large series of patients with uveitis due to Behçet disease (BD) who achieved remission after the use of this biologic agent. Open-label multicenter study of ADA-treated patients with BD uveitis refractory to conventional immunosuppressants. Sixty-five of 74 patients with uveitis due to BD, who achieved remission after a median ADA duration of 6 (range, 3-12) months. ADA was optimized in 23 (35.4%) of them. This biologic agent was maintained at a dose of 40 mg/subcutaneously/2 weeks in the remaining 42 patients. After remission, based on a shared decision between the patient and the treating physician, ADA was optimized. When agreement between patient and physician was reached, optimization was performed by prolonging the ADA dosing interval progressively. Comparison between optimized and nonoptimized patients was performed. Efficacy, safety, and cost-effectiveness in optimized and nonoptimized groups. To determine efficacy, intraocular inflammation (anterior chamber cells, vitritis, and retinal vasculitis), macular thickness, visual acuity, and the sparing effect of glucocorticoids were assessed. No demographic or ocular differences were found at the time of ADA onset between the optimized and the nonoptimized groups. Most ocular outcomes were similar after a mean ± standard deviation follow-up of 34.7±13.3 and 26±21.3 months in the optimized and nonoptimized groups, respectively. However, relevant adverse effects were only seen in the nonoptimized group (lymphoma, pneumonia, severe local reaction at the injection site, and bacteremia by Escherichia coli, 1 each). Moreover, the mean ADA treatment costs were lower in the optimized group than in the nonoptimized group (6101.25 euros/patient/year vs. 12 339.48; P < 0.01). ADA optimization in BD uveitis refractory to conventional therapy is effective, safe, and cost-effective. Copyright © 2018 American Academy of

Comprehensive disease control (CDC): what does achieving CDC mean for patients with rheumatoid arthritis?

PubMed

Emery, Paul; Kavanaugh, Arthur; Bao, Yanjun; Ganguli, Arijit; Mulani, Parvez

2015-12-01

This study assessed the impact of simultaneous achievement of clinical, functional and structural efficacy, herein referred to as comprehensive disease control (CDC), on short-term and long-term work-related outcomes, health-related quality of life (HRQoL), pain and fatigue. Data were pooled from three randomised trials of adalimumab plus methotrexate for treatment of early-stage or late-stage rheumatoid arthritis (RA). CDC was defined as 28-joint Disease Activity Score using C reactive protein <2.6, Health Assessment Questionnaire <0.5 and change from baseline in modified Total Sharp Score ≤0.5. Changes in scores at weeks 26 and 52 for work-related outcomes, Short Form 36 (SF-36) physical (PCS) and mental component scores (MCS), a Visual Analogue Scale measuring pain (VAS-Pain) and Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) were compared between patient groups defined by achievement of CDC at week 26 using linear regression with adjustment for baseline scores. Patients with RA who achieved CDC at week 26 (n=200) had significantly greater improvements in VAS-Pain (46.9 vs 26.9; p<0.0001), FACIT-F (13.3 vs 7.5; p<0.0001), SF-36 PCS (19.7 vs 8.9; p<0.0001) and SF-36 MCS (8.1 vs 5.0; p=0.0004) than those who did not (n=1267). Results were consistent at week 52 and among methotrexate-naive patients with early RA, methotrexate-experienced patients with late-stage RA and patients with inadequate response to methotrexate. Patients with RA who achieved CDC at week 26 had improved short-term and long-term HRQoL, pain, fatigue and work-related outcomes compared with patients who do not. These results demonstrate that the joint achievement of all CDC components provides meaningful benefits to patients. DE019: NCT00195702, PREMIER: NCT00195702, OPTIMA: NCT00195702. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Patients' empowerment, physicians' perceptions, and achievement of therapeutic goals in patients with type 1 and type 2 diabetes mellitus in Mexico.

PubMed

Lavalle-González, Fernando J; Chiquete, Erwin

2016-01-01

Physicians' perception may not parallel objective measures of therapeutic targets in patients with diabetes. This is an issue rarely addressed in the medical literature. We aimed to analyze physicians' perception and characteristics of adequate control of patients with diabetes. We studied information on physicians and their patients who participated in the third wave of the International Diabetes Management Practices Study registry in Mexico. This analysis was performed on 2,642 patients, 203 with type 1 diabetes mellitus (T1DM) and 2,439 with type 2 diabetes mellitus (T2DM), treated by 200 physicians. The patients perceived at target had lower hemoglobin A1c (HbA1c) and fasting blood glucose than those considered not at target. However, overestimation of the frequency of patients with HbA1c <7% was 41.5% in patients with T1DM and 31.7% in patients with T2DM (underestimation: 2.8% and 8.0%, respectively). The agreement between the physicians' perception and the class of HbA1c was suboptimal (κ: 0.612). Diabetologists and endocrinologists tested HbA1c more frequently than primary care practitioners, internists, or cardiologists; however, no differences were observed in mean HbA1c, for both T1DM (8.4% vs 7.2%, P=0.42) and T2DM (8.03% vs 8.01%, P=0.87) patients. Nevertheless, insulin users perceived at target, who practiced self-monitoring and self-adjustment of insulin, had a lower mean HbA1c than patients without these characteristics (mean HbA1c in T1DM: 6.8% vs 9.6%, respectively; mean HbA1c in T2DM: 7.0% vs 10.1%, respectively). Although there is a significant physicians' overestimation about the optimal glycemic control, this global impression and characteristics of patients' empowerment, such as self-monitoring and self-adjustment of insulin, are associated with the achievement of targets.

Patient specific optimization-based treatment planning for catheter-based ultrasound hyperthermia and thermal ablation

NASA Astrophysics Data System (ADS)

Prakash, Punit; Chen, Xin; Wootton, Jeffery; Pouliot, Jean; Hsu, I.-Chow; Diederich, Chris J.

2009-02-01

A 3D optimization-based thermal treatment planning platform has been developed for the application of catheter-based ultrasound hyperthermia in conjunction with high dose rate (HDR) brachytherapy for treating advanced pelvic tumors. Optimal selection of applied power levels to each independently controlled transducer segment can be used to conform and maximize therapeutic heating and thermal dose coverage to the target region, providing significant advantages over current hyperthermia technology and improving treatment response. Critical anatomic structures, clinical target outlines, and implant/applicator geometries were acquired from sequential multi-slice 2D images obtained from HDR treatment planning and used to reconstruct patient specific 3D biothermal models. A constrained optimization algorithm was devised and integrated within a finite element thermal solver to determine a priori the optimal applied power levels and the resulting 3D temperature distributions such that therapeutic heating is maximized within the target, while placing constraints on maximum tissue temperature and thermal exposure of surrounding non-targeted tissue. This optimizationbased treatment planning and modeling system was applied on representative cases of clinical implants for HDR treatment of cervix and prostate to evaluate the utility of this planning approach. The planning provided significant improvement in achievable temperature distributions for all cases, with substantial increase in T90 and thermal dose (CEM43T90) coverage to the hyperthermia target volume while decreasing maximum treatment temperature and reducing thermal dose exposure to surrounding non-targeted tissues and thermally sensitive rectum and bladder. This optimization based treatment planning platform with catheter-based ultrasound applicators is a useful tool that has potential to significantly improve the delivery of hyperthermia in conjunction with HDR brachytherapy. The planning platform has been extended

Stochastic optimization of intensity modulated radiotherapy to account for uncertainties in patient sensitivity

NASA Astrophysics Data System (ADS)

Kåver, Gereon; Lind, Bengt K.; Löf, Johan; Liander, Anders; Brahme, Anders

1999-12-01

The aim of the present work is to better account for the known uncertainties in radiobiological response parameters when optimizing radiation therapy. The radiation sensitivity of a specific patient is usually unknown beyond the expectation value and possibly the standard deviation that may be derived from studies on groups of patients. Instead of trying to find the treatment with the highest possible probability of a desirable outcome for a patient of average sensitivity, it is more desirable to maximize the expectation value of the probability for the desirable outcome over the possible range of variation of the radiation sensitivity of the patient. Such a stochastic optimization will also have to consider the distribution function of the radiation sensitivity and the larger steepness of the response for the individual patient. The results of stochastic optimization are also compared with simpler methods such as using biological response `margins' to account for the range of sensitivity variation. By using stochastic optimization, the absolute gain will typically be of the order of a few per cent and the relative improvement compared with non-stochastic optimization is generally less than about 10 per cent. The extent of this gain varies with the level of interpatient variability as well as with the difficulty and complexity of the case studied. Although the dose changes are rather small (<5 Gy) there is a strong desire to make treatment plans more robust, and tolerant of the likely range of variation of the radiation sensitivity of each individual patient. When more accurate predictive assays of the radiation sensitivity for each patient become available, the need to consider the range of variations can be reduced considerably.

Optimizing value utilizing Toyota Kata methodology in a multidisciplinary clinic.

PubMed

Merguerian, Paul A; Grady, Richard; Waldhausen, John; Libby, Arlene; Murphy, Whitney; Melzer, Lilah; Avansino, Jeffrey

2015-08-01

Value in healthcare is measured in terms of patient outcomes achieved per dollar expended. Outcomes and cost must be measured at the patient level to optimize value. Multidisciplinary clinics have been shown to be effective in providing coordinated and comprehensive care with improved outcomes, yet tend to have higher cost than typical clinics. We sought to lower individual patient cost and optimize value in a pediatric multidisciplinary reconstructive pelvic medicine (RPM) clinic. The RPM clinic is a multidisciplinary clinic that takes care of patients with anomalies of the pelvic organs. The specialties involved include Urology, General Surgery, Gynecology, and Gastroenterology/Motility. From May 2012 to November 2014 we performed time-driven activity-based costing (TDABC) analysis by measuring provider time for each step in the patient flow. Using observed time and the estimated hourly cost of each of the providers we calculated the final cost at the individual patient level, targeting clinic preparation. We utilized Toyota Kata methodology to enhance operational efficiency in an effort to optimize value. Variables measured included cost, time to perform a task, number of patients seen in clinic, percent value-added time (VAT) to patients (face to face time) and family experience scores (FES). At the beginning of the study period, clinic costs were $619 per patient. We reduced conference time from 6 min/patient to 1 min per patient, physician preparation time from 8 min to 6 min and increased Medical Assistant (MA) preparation time from 9.5 min to 20 min, achieving a cost reduction of 41% to $366 per patient. Continued improvements further reduced the MA preparation time to 14 min and the MD preparation time to 5 min with a further cost reduction to $194 (69%) (Figure). During this study period, we increased the number of appointments per clinic. We demonstrated sustained improvement in FES with regards to the families overall experience with their providers

Improving Emergency Department flow through optimized bed utilization

PubMed Central

Chartier, Lucas Brien; Simoes, Licinia; Kuipers, Meredith; McGovern, Barb

2016-01-01

Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flow-interrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the post-intervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements. PMID:27752312

Improving Emergency Department flow through optimized bed utilization.

PubMed

Chartier, Lucas Brien; Simoes, Licinia; Kuipers, Meredith; McGovern, Barb

2016-01-01

Over the last decade, patient volumes in the emergency department (ED) have grown disproportionately compared to the increase in staffing and resources at the Toronto Western Hospital, an academic tertiary care centre in Toronto, Canada. The resultant congestion has spilled over to the ED waiting room, where medically undifferentiated and potentially unstable patients must wait until a bed becomes available. The aim of this quality improvement project was to decrease the 90th percentile of wait time between triage and bed assignment (time-to-bed) by half, from 120 to 60 minutes, for our highest acuity patients. We engaged key stakeholders to identify barriers and potential strategies to achieve optimal flow of patients into the ED. We first identified multiple flow-interrupting challenges, including operational bottlenecks and cultural issues. We then generated change ideas to address two main underlying causes of ED congestion: unnecessary patient utilization of ED beds and communication breakdown causing bed turnaround delays. We subsequently performed seven tests of change through sequential plan-do-study-act (PDSA) cycles. The most significant gains were made by improving communication strategies: small gains were achieved through the optimization of in-house digital information management systems, while significant improvements were achieved through the implementation of a low-tech direct contact mechanism (a two-way radio or walkie-talkie). In the post-intervention phase, time-to-bed for the 90th percentile of high-acuity patients decreased from 120 minutes to 66 minutes, with special cause variation showing a significant shift in the weekly measurements.

Emerging Techniques for Dose Optimization in Abdominal CT

PubMed Central

Platt, Joel F.; Goodsitt, Mitchell M.; Al-Hawary, Mahmoud M.; Maturen, Katherine E.; Wasnik, Ashish P.; Pandya, Amit

2014-01-01

Recent advances in computed tomographic (CT) scanning technique such as automated tube current modulation (ATCM), optimized x-ray tube voltage, and better use of iterative image reconstruction have allowed maintenance of good CT image quality with reduced radiation dose. ATCM varies the tube current during scanning to account for differences in patient attenuation, ensuring a more homogeneous image quality, although selection of the appropriate image quality parameter is essential for achieving optimal dose reduction. Reducing the x-ray tube voltage is best suited for evaluating iodinated structures, since the effective energy of the x-ray beam will be closer to the k-edge of iodine, resulting in a higher attenuation for the iodine. The optimal kilovoltage for a CT study should be chosen on the basis of imaging task and patient habitus. The aim of iterative image reconstruction is to identify factors that contribute to noise on CT images with use of statistical models of noise (statistical iterative reconstruction) and selective removal of noise to improve image quality. The degree of noise suppression achieved with statistical iterative reconstruction can be customized to minimize the effect of altered image quality on CT images. Unlike with statistical iterative reconstruction, model-based iterative reconstruction algorithms model both the statistical noise and the physical acquisition process, allowing CT to be performed with further reduction in radiation dose without an increase in image noise or loss of spatial resolution. Understanding these recently developed scanning techniques is essential for optimization of imaging protocols designed to achieve the desired image quality with a reduced dose. © RSNA, 2014 PMID:24428277

Dyadic influence of hope and optimism on patient marital satisfaction among couples with advanced breast cancer.

PubMed

Rock, Emily E; Steiner, Jennifer L; Rand, Kevin L; Bigatti, Silvia M

2014-09-01

An estimated 10-40 % of breast cancer (BC) patients report negative changes to their partnered relationships. Literature suggests that for these patients, marital satisfaction is related to depression and other quality of life factors which are associated with survivorship and treatment response. However, existing literature does not provide a clear explanation of the factors that strengthen vs. create strain in couples facing cancer. Given the benefits of a satisfying relationship to patient quality of life, it is important to better understand factors that put patients at greater risk for marital difficulties. This study examined the differential and combined roles of hope and optimism among BC patients and their partners on patient marital satisfaction. Fifty-six breast cancer patient-partner dyads completed study questionnaires as part of a larger study. Regression analyses were used to examine the main and interaction effects of patient and partner hope and optimism on patient marital satisfaction. Higher patient and partner hope predicted greater patient marital satisfaction, whereas optimism did not. These results are divergent from the literature on optimism and well-being, which shows the importance of studying these two traits concurrently. Interaction effects suggest certain combinations of patient and partner hope and optimism are more beneficial than others for patient marital satisfaction and suggest a dyadic approach is important for investigation of well-being in breast cancer.

Dyadic Influence of Hope and Optimism on Patient Marital Satisfaction among Couples with Advanced Breast Cancer

PubMed Central

Rock, Emily E.; Steiner, Jennifer L.; Rand, Kevin L.; Bigatti, Silvia M.

2014-01-01

PURPOSE An estimated 10–40% of breast cancer (BC) patients report negative changes to their partnered relationships. Literature suggests that for these patients, marital satisfaction is related to depression and other quality of life factors which are associated with survivorship and treatment response. However, existing literature does not provide a clear explanation of the factors that strengthen vs. create strain in couples facing cancer. Given the benefits of a satisfying relationship to patient quality of life, it is important to better understand factors that put patients at greater risk for marital difficulties. This study examined the differential and combined roles of hope and optimism among BC patients and their partners on patient marital satisfaction. METHOD Fifty-six breast cancer patient-partner dyads completed study questionnaires as part of a larger study. Regression analyses were used to examine the main and interaction effects of patient and partner hope and optimism on patient marital satisfaction. RESULTS AND CONCLUSION Higher patient and partner hope predicted greater patient marital satisfaction, whereas optimism did not. These results are divergent from the literature on optimism and well-being, which shows the importance of studying these two traits concurrently. Interaction effects suggest certain combinations of patient and partner hope and optimism are more beneficial than others for patient marital satisfaction and suggest a dyadic approach is important for investigation of well-being in breast cancer. PMID:24687536

Population Pharmacokinetics and Optimal Sampling Strategy for Model-Based Precision Dosing of Melphalan in Patients Undergoing Hematopoietic Stem Cell Transplantation.

PubMed

Mizuno, Kana; Dong, Min; Fukuda, Tsuyoshi; Chandra, Sharat; Mehta, Parinda A; McConnell, Scott; Anaissie, Elias J; Vinks, Alexander A

2018-05-01

High-dose melphalan is an important component of conditioning regimens for patients undergoing hematopoietic stem cell transplantation. The current dosing strategy based on body surface area results in a high incidence of oral mucositis and gastrointestinal and liver toxicity. Pharmacokinetically guided dosing will individualize exposure and help minimize overexposure-related toxicity. The purpose of this study was to develop a population pharmacokinetic model and optimal sampling strategy. A population pharmacokinetic model was developed with NONMEM using 98 observations collected from 15 adult patients given the standard dose of 140 or 200 mg/m 2 by intravenous infusion. The determinant-optimal sampling strategy was explored with PopED software. Individual area under the curve estimates were generated by Bayesian estimation using full and the proposed sparse sampling data. The predictive performance of the optimal sampling strategy was evaluated based on bias and precision estimates. The feasibility of the optimal sampling strategy was tested using pharmacokinetic data from five pediatric patients. A two-compartment model best described the data. The final model included body weight and creatinine clearance as predictors of clearance. The determinant-optimal sampling strategies (and windows) were identified at 0.08 (0.08-0.19), 0.61 (0.33-0.90), 2.0 (1.3-2.7), and 4.0 (3.6-4.0) h post-infusion. An excellent correlation was observed between area under the curve estimates obtained with the full and the proposed four-sample strategy (R 2  = 0.98; p < 0.01) with a mean bias of -2.2% and precision of 9.4%. A similar relationship was observed in children (R 2  = 0.99; p < 0.01). The developed pharmacokinetic model-based sparse sampling strategy promises to achieve the target area under the curve as part of precision dosing.

Strategies to optimize lithium-ion supercapacitors achieving high-performance: Cathode configurations, lithium loadings on anode, and types of separator

NASA Astrophysics Data System (ADS)

Cao, Wanjun; Li, Yangxing; Fitch, Brian; Shih, Jonathan; Doung, Tien; Zheng, Jim

2014-12-01

The Li-ion capacitor (LIC) is composed of a lithium-doped carbon anode and an activated carbon cathode, which is a half Li-ion battery (LIB) and a half electrochemical double-layer capacitor (EDLC). LICs can achieve much more energy density than EDLC without sacrificing the high power performance advantage of capacitors over batteries. LIC pouch cells were assembled using activated carbon (AC) cathode and hard carbon (HC) + stabilized lithium metal power (SLMP®) anode. Different cathode configurations, various SLMP loadings on HC anode, and two types of separators were investigated to achieve the optimal electrochemical performance of the LIC. Firstly, the cathode binders study suggests that the PTFE binder offers improved energy and power performances for LIC in comparison to PVDF. Secondly, the mass ratio of SLMP to HC is at 1:7 to obtain the optimized electrochemical performance for LIC among all the various studied mass ratios between lithium loading amounts and active anode material. Finally, compared to the separator Celgard PP 3501, cellulose based TF40-30 is proven to be a preferred separator for LIC.

Coaching patients On Achieving Cardiovascular Health (COACH): a multicenter randomized trial in patients with coronary heart disease.

PubMed

Vale, Margarite J; Jelinek, Michael V; Best, James D; Dart, Anthony M; Grigg, Leeanne E; Hare, David L; Ho, Betty P; Newman, Robert W; McNeil, John J

Disease management programs in which drugs are prescribed by dietitians or nurses have been shown to improve the coronary risk factor profile in patients with coronary heart disease. However, those disease management programs in which drugs are not prescribed by allied health professionals have not improved coronary risk factor status. The objective of the Coaching patients On Achieving Cardiovascular Health (COACH) study was to determine whether dietitians or nurses who did not prescribe medications could coach patients with coronary heart disease to work with their physicians to achieve the target levels for their total cholesterol (TC) and other risk factors. Multicenter randomized controlled trial in which 792 patients from 6 university teaching hospitals underwent a stratified randomization by cardiac diagnosis within each hospital: 398 were assigned to usual care plus The COACH Program and 394 to usual care alone. Patients in The COACH Program group received regular personal coaching via telephone and mailings to achieve the target levels for their particular coronary risk factors. There was one coach per hospital. The primary outcome was the change in TC (DeltaTC) from baseline (in hospital) to 6 months after randomization. Secondary outcomes included measurement of a wide range of physical, nutritional, and psychological factors. The analysis was performed by intention to treat. The COACH Program achieved a significantly greater DeltaTC than usual care alone: the mean DeltaTC was 21 mg/dL (0.54 mmol/L) (95% confidence interval [CI], 16-25 mg/dL [0.42-0.65 mmol/L]) in The COACH Program vs 7 mg/dL (0.18 mmol/L) (95% CI, 3-11 mg/dL [0.07-0.29 mmol/L]) in the usual care group (P<.0001). Thus, the reduction in TC from baseline to 6 months after randomization was 14 mg/dL (0.36 mmol/L) (95% CI, 8-20 mg/dL [0.20-0.52 mmol/L]) greater in The COACH Program group than in the usual care group. Coaching produced substantial improvements in most of the other coronary

Enablers and barriers for women with gestational diabetes mellitus to achieve optimal glycaemic control - a qualitative study using the theoretical domains framework.

PubMed

Martis, Ruth; Brown, Julie; McAra-Couper, Judith; Crowther, Caroline A

2018-04-11

Glycaemic target recommendations vary widely between international professional organisations for women with gestational diabetes mellitus (GDM). Some studies have reported women's experiences of having GDM, but little is known how this relates to their glycaemic targets. The aim of this study was to identify enablers and barriers for women with GDM to achieve optimal glycaemic control. Women with GDM were recruited from two large, geographically different, hospitals in New Zealand to participate in a semi-structured interview to explore their views and experiences focusing on enablers and barriers to achieving optimal glycaemic control. Final thematic analysis was performed using the Theoretical Domains Framework. Sixty women participated in the study. Women reported a shift from their initial negative response to accepting their diagnosis but disliked the constant focus on numbers. Enablers and barriers were categorised into ten domains across the three study questions. Enablers included: the ability to attend group teaching sessions with family and hear from women who have had GDM; easy access to a diabetes dietitian with diet recommendations tailored to a woman's context including ethnic food and financial considerations; free capillary blood glucose (CBG) monitoring equipment, health shuttles to take women to appointments; child care when attending clinic appointments; and being taught CBG testing by a community pharmacist. Barriers included: lack of health information, teaching sessions, consultations, and food diaries in a woman's first language; long waiting times at clinic appointments; seeing a different health professional every clinic visit; inconsistent advice; no tailored physical activities assessments; not knowing where to access appropriate information on the internet; unsupportive partners, families, and workplaces; and unavailability of social media or support groups for women with GDM. Perceived judgement by others led some women only to share

Should Schools Be Optimistic? An Investigation of the Association between Academic Optimism of Schools and Student Achievement in Primary Education

ERIC Educational Resources Information Center

Boonen, Tinneke; Pinxten, Maarten; Van Damme, Jan; Onghena, Patrick

2014-01-01

Academic emphasis, collective efficacy, and faculty trust in students and parents (3 school characteristics positively associated with student achievement) are assumed to form a higher order latent construct, "academic optimism" (Hoy, Tarter, & Woolfolk Hoy, 2006a, 2006b). The aim of the present study is to corroborate the latent…

Long-term lamivudine treatment achieves regression of advanced liver fibrosis/cirrhosis in patients with chronic hepatitis B.

PubMed

Xu, Bei; Lin, Lanyi; Xu, Guoguang; Zhuang, Yan; Guo, Qing; Liu, Yunye; Wang, Hui; Zhou, Xiaqiu; Wu, Shanming; Bao, Shisan; Cai, Wei; Xie, Qing

2015-02-01

Antiviral therapy is important in advanced liver fibrosis/cirrhosis with chronic hepatitis B (AdLF-CHB) patients, but complete regression of cirrhosis remains to be the challenge. We aimed to investigate whether up to 10 years lamivudine treatment achieves liver fibrosis/cirrhosis regression in AdLF-CHB patients. Improvement of hepatic fibrosis/cirrhosis, virological response and disease progression were evaluated in 28 AdLF-CHB patients with up to 10 years lamivudine treatment. Liver biopsy was performed in all of the 28 patients at baseline, but only 19 patients had second biopsy at year 10. There were 24 hepatitis B e antigen (HBeAg)-positive and 4 HBeAg-negative patients within the original 28 AdLF-CHB patients. At the end of 10 years lamivudine treatment, 20 of the 24 HBeAg-positive patients had HBeAg loss. HBeAg seroconversion was detected in 10 of these 20 HBeAg loss patients. HBsAg loss was observed in 4 of the original 28 patients. Among these four HBsAg loss patients, three had HBsAg seroconversion. All patients achieved hepatitis B virus DNA (HBV DNA) undetectable. Histopathology was evaluated between paired original and final liver biopsies among 19 patients as follows: 4/19 achieved complete liver fibrosis/cirrhosis regression; 9/19 improved in Ishak fibrosis score; whereas 6/19 showed no fibrosis improvement. About 75% patients achieved inflammatory/fibrotic improvement. No significant disease progression was observed in 24/28 patients. Furthermore, no significant difference in histopathology improvement, cirrhosis regression, disease progression between non-resistance and rescue for resistance was observed. Long-term lamivudine therapy achieves regression of fibrosis/cirrhosis and improvement of histological and disease progression in AdLF-CHB patients. © 2014 Journal of Gastroenterology and Hepatology Foundation and Wiley Publishing Asia Pty Ltd.

Perspectives on optimizing care of patients in multidisciplinary chronic kidney disease clinics.

PubMed

Collister, David; Russell, Randall; Verdon, Josee; Beaulieu, Monica; Levin, Adeera

2016-01-01

To summarize a jointly held symposium by the Canadian Society of Nephrology (CSN), the Canadian Association of Nephrology Administrators (CANA), and the Canadian Kidney Knowledge Translation and Generation Network (CANN-NET) entitled "Perspectives on Optimizing Care of Patients in Multidisciplinary Chronic Kidney Disease (CKD) Clinics" that was held on April 24, 2015, in Montreal, Quebec. The panel consisted of a variety of members from across Canada including a multidisciplinary CKD clinic patient (Randall Russell), nephrology fellow (Dr. David Collister), geriatrician (Dr. Josee Verdon), and nephrologists (Dr. Monica Beaulieu, Dr. Adeera Levin). The objectives of the symposium were (1) to gain an understanding of the goals of care for CKD patients, (2) to gain an appreciation of different perspectives regarding optimal care for patients with CKD, (3) to examine the components required for optimal care including education strategies, structures, and tools, and (4) to describe a framework and metrics for CKD care which respect patient and system needs. This article summarizes the key concepts discussed at the symposium from a patient and physician perspectives. Key messages include (1) understanding patient values and preferences is important as it provides a framework as to what to prioritize in multidisciplinary CKD clinic and provincial renal program models, (2) barriers to effective communication and education are common in the elderly, and adaptive strategies to limit their influence are critical to improve adherence and facilitate shared decision-making, (3) the use of standardized operating procedures (SOPs) improves efficiency and minimizes practice variability among health care practitioners, and (4) CKD scorecards with standardized system processes are useful in approaching variability as well as measuring and improving patient outcomes. The perspectives provided may not be applicable across centers given the differences in patient populations including

Physiological geroscience: targeting function to increase healthspan and achieve optimal longevity

PubMed Central

Justice, Jamie N.; LaRocca, Thomas J.

2015-01-01

Abstract Most nations of the world are undergoing rapid and dramatic population ageing, which presents great socio‐economic challenges, as well as opportunities, for individuals, families, governments and societies. The prevailing biomedical strategy for reducing the healthcare impact of population ageing has been ‘compression of morbidity’ and, more recently, to increase healthspan, both of which seek to extend the healthy period of life and delay the development of chronic diseases and disability until a brief period at the end of life. Indeed, a recently established field within biological ageing research, ‘geroscience’, is focused on healthspan extension. Superimposed on this background are new attitudes and demand for ‘optimal longevity’ – living long, but with good health and quality of life. A key obstacle to achieving optimal longevity is the progressive decline in physiological function that occurs with ageing, which causes functional limitations (e.g. reduced mobility) and increases the risk of chronic diseases, disability and mortality. Current efforts to increase healthspan centre on slowing the fundamental biological processes of ageing such as inflammation/oxidative stress, increased senescence, mitochondrial dysfunction, impaired proteostasis and reduced stress resistance. We propose that optimization of physiological function throughout the lifespan should be a major emphasis of any contemporary biomedical policy addressing global ageing. Effective strategies should delay, reduce in magnitude or abolish reductions in function with ageing (primary prevention) and/or improve function or slow further declines in older adults with already impaired function (secondary prevention). Healthy lifestyle practices featuring regular physical activity and ideal energy intake/diet composition represent first‐line function‐preserving strategies, with pharmacological agents, including existing and new pharmaceuticals and novel �

Physiological geroscience: targeting function to increase healthspan and achieve optimal longevity.

PubMed

Seals, Douglas R; Justice, Jamie N; LaRocca, Thomas J

2016-04-15

Most nations of the world are undergoing rapid and dramatic population ageing, which presents great socio-economic challenges, as well as opportunities, for individuals, families, governments and societies. The prevailing biomedical strategy for reducing the healthcare impact of population ageing has been 'compression of morbidity' and, more recently, to increase healthspan, both of which seek to extend the healthy period of life and delay the development of chronic diseases and disability until a brief period at the end of life. Indeed, a recently established field within biological ageing research, 'geroscience', is focused on healthspan extension. Superimposed on this background are new attitudes and demand for 'optimal longevity' - living long, but with good health and quality of life. A key obstacle to achieving optimal longevity is the progressive decline in physiological function that occurs with ageing, which causes functional limitations (e.g. reduced mobility) and increases the risk of chronic diseases, disability and mortality. Current efforts to increase healthspan centre on slowing the fundamental biological processes of ageing such as inflammation/oxidative stress, increased senescence, mitochondrial dysfunction, impaired proteostasis and reduced stress resistance. We propose that optimization of physiological function throughout the lifespan should be a major emphasis of any contemporary biomedical policy addressing global ageing. Effective strategies should delay, reduce in magnitude or abolish reductions in function with ageing (primary prevention) and/or improve function or slow further declines in older adults with already impaired function (secondary prevention). Healthy lifestyle practices featuring regular physical activity and ideal energy intake/diet composition represent first-line function-preserving strategies, with pharmacological agents, including existing and new pharmaceuticals and novel 'nutraceutical' compounds, serving as potential

Predictors for achieving adequate protein and energy intake in nursing home rehabilitation patients.

PubMed

van Zwienen-Pot, J I; Visser, M; Kruizenga, H M

2018-07-01

Adequate energy and protein intake could be essential for contributing significantly to the rehabilitations process. Data on the actual nutritional intake of older nursing home rehabilitation patients have not yet been investigated. To investigate the nutritional intake and predictors for achieving protein and energy requirements on the 14th day of admission in nursing home rehabilitation patients. Fifty-nine patients aged 65+ years newly admitted to nursing home rehabilitation wards were included. Data on potential variables were collected on admission. On the fourteenth day nutritional intake was assessed. Intake was considered 'adequate' if patients had achieved ≥ 1.2 g of protein/kg bodyweight and ≥ 85% of their energy needs according to Harris and Benedict + 30%. Multiple logistic regression analyses were performed to select predictors for adequate intake. Protein and energy intake was assessed in 79 patients [67% female, mean age 82 ± (SD) 8 years, BMI 25 ± 6 kg/m 2 ]. Mean energy intake was 1677 kcal (± 433) and mean protein intake was 68 g (± 20). Fourteen patients (18%) achieved an adequate protein and energy intake. Predictors for adequate intake were use of sip/tube feeding (OR = 7.7; 95% CI = 1.35-44.21), BMI (0.68; 0.53-0.87) and nausea (8.59; 1.42-52.01). Only 18% of older nursing home rehabilitation patients had an adequate protein and energy intake at 14 days after admission. Patients with higher BMI were less likely, while those using sip/tube feeding or feeling nauseous were more likely to achieve an adequate protein and energy intake.

The association between achieving low-density lipoprotein cholesterol (LDL-C) goal and statin treatment in an employee population.

PubMed

Burton, Wayne N; Chen, Chin-Yu; Schultz, Alyssa B; Edington, Dee W

2010-02-01

Statin medications are recommended for patients who have not achieved low-density lipoprotein cholesterol (LDL-C) goals through lifestyle modifications. The objective of this retrospective observational study was to examine statin medication usage patterns and the relationship with LDL-C goal levels (according to Adult Treatment Panel III guidelines) among a cohort of employees of a major financial services corporation. From 1995 to 2004, a total of 1607 executives participated in a periodic health examination program. An index date was assigned for each study participant (date of their exam) and statin medication usage was determined from the pharmacy claims database for 365 days before the index date. Patients were identified as adherent to statins if the medication possession ratio was > or =80%. In all, 150 (9.3%) executives filled at least 1 statin prescription in the 365 days prior to their exam. A total of 102 statin users (68%) were adherent to statin medication. Among all executives who received statin treatment, 70% (odds ratio [OR] = 2.30, 95% confidence interval [CI] = 1.82, 2.90) achieved near-optimal (<130 mg/dL) and 30% (OR = 1.78, 95% CI = 1.15, 2.76) achieved optimal (<100 mg/dL) LDL-C goals, which is significantly higher than the rates among statin nonusers (55% and 21%). Adherent statin users were more likely to achieve recommended near-optimal LDL-C goals compared to statin nonusers (overall P = 0.002; adherent: OR = 2.75, 95% CI = 1.662, 4.550), while nonadherent statin users were more likely to achieve the optimal goal compared to statin nonusers (OR = 2.223; CI = 1.145, 4.313). Statin usage was associated with improvements in LDL-C goal attainment among executives who participated in a periodic health examination. Appropriate statin medication adherence should be encouraged in working populations in order to achieve LDL-C goals.

Navy Strategy for Achieving Information Dominance, 2013-2017. Optimizing Navy’s Primacy in the Maritime and Information Domains

DTIC Science & Technology

2013-01-01

and resources to optimize decision making and maximize warfighting effects, Navy Information Dominance has become a leading Service priority. In 2009...This Strategy for Achieving Information Dominance provides the framework through which the Navy s information capabilities will be mainstreamed into...the Navy s culture as a distinct warfighting discipline. The strategy focuses on the three fundamental Information Dominance capabilities of Assured

Clinical importance of achieving biochemical control with medical therapy in adult patients with acromegaly

PubMed Central

Christofides, Elena A

2016-01-01

In acromegaly, achieving biochemical control (growth hormone [GH] level <1.0 ng/mL and age- and sex-normalized levels of insulin-like growth factor 1 [IGF-1]) through timely diagnosis and appropriate treatment provides an opportunity to improve patient outcomes. Diagnosis of acromegaly is challenging because it is rooted in observing subtle clinical manifestations, and it is typical for acromegaly to evolve for up to 10 years before it is recognized. This results in chronic exposure to elevated levels of GH and IGF-1 and delay in patients receiving appropriate treatment, which consequently increases mortality risk. In this review, the clinical impact of elevated GH and IGF-1 levels, the effectiveness of current therapies, and the potential role of novel treatments for acromegaly will be discussed. Clinical burden of acromegaly and benefits associated with management of GH and IGF-1 levels will be reviewed. Major treatment paradigms in acromegaly include surgery, medical therapy, and radiotherapy. With medical therapies, such as somatostatin analogs, dopamine agonists, and GH receptor antagonists, a substantial proportion of patients achieve reduced GH and normalized IGF-1 levels. In addition, signs and symptoms, quality of life, and comorbidities have also been reported to improve to varying degrees in patients who achieve biochemical control. Currently, there are several innovative therapies in development to improve patient outcomes, patient use, and access. Timely biochemical control of acromegaly ensures that the patient can ultimately improve morbidity and mortality from this disease and its extensive consequences. PMID:27471378

Improvement of in-hospital telemetry monitoring in coronary care units: an intervention study for achieving optimal electrode placement and attachment, hygiene and delivery of critical information to patients.

PubMed

Pettersen, Trond R; Fålun, Nina; Norekvål, Tone M

2014-12-01

In-hospital telemetry monitoring is important for diagnosis and treatment of patients at risk of developing life-threatening arrhythmias. It is widely used in critical and non-critical care wards. Nurses are responsible for correct electrode placement, thus ensuring optimal quality of the monitoring. The aims of this study were to determine whether a complex educational intervention improves (a) optimal electrode placement, (b) hygiene, and (c) delivery of critical information to patients (reason for monitoring, limitations in cellular phone use, and not to leave the ward without informing a member of staff). A prospective interventional study design was used, with data collection occurring over two six-week periods: before implementation of the intervention (n=201) and after the intervention (n=165). Standard abstraction forms were used to obtain data on patients' clinical characteristics, and 10 variables related to electrode placement and attachment, hygiene and delivery of critical information. At pre-intervention registration, 26% of the electrodes were misplaced. Twelve per cent of the patients received information about limiting their cellular phone use while monitored, 70% were informed of the purpose of monitoring, and 71% used a protective cover for their unit. Post-intervention, outcome measures for the three variables improved significantly: use of protective cover (p<0.001), information about the purpose of monitoring (p=0.005) and information about limitations in cellular phone use (p=0.003). Nonetheless, 23% of the electrodes were still misplaced. The study highlights the need for better, continued education for in-hospital telemetry monitoring in coronary care units, and other units that monitor patients with telemetry. © The European Society of Cardiology 2013.

Moving Beyond Maximum Tolerated Dose for Targeted Oncology Drugs: Use of Clinical Utility Index to Optimize Venetoclax Dosage in Multiple Myeloma Patients.

PubMed

Freise, K J; Jones, A K; Verdugo, M E; Menon, R M; Maciag, P C; Salem, A H

2017-12-01

Exposure-response analyses of venetoclax in combination with bortezomib and dexamethasone in previously treated patients with multiple myeloma (MM) were performed on a phase Ib venetoclax dose-ranging study. Logistic regression models were utilized to determine relationships, identify subpopulations with different responses, and optimize the venetoclax dosage that balanced both efficacy and safety. Bortezomib refractory status and number of prior treatments were identified to impact the efficacy response to venetoclax treatment. Higher venetoclax exposures were estimated to increase the probability of achieving a very good partial response (VGPR) or better through venetoclax doses of 1,200 mg. However, the probability of neutropenia (grade ≥3) was estimated to increase at doses >800 mg. Using a clinical utility index, a venetoclax dosage of 800 mg daily was selected to optimally balance the VGPR or better rates and neutropenia rates in MM patients administered 1-3 prior lines of therapy and nonrefractory to bortezomib. © 2017 American Society for Clinical Pharmacology and Therapeutics.

Estimation of optimal nasotracheal tube depth in adult patients.

PubMed

Ji, Sung-Mi

2017-12-01

The aim of this study was to estimate the optimal depth of nasotracheal tube placement. We enrolled 110 patients scheduled to undergo oral and maxillofacial surgery, requiring nasotracheal intubation. After intubation, the depth of tube insertion was measured. The neck circumference and distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch were measured. To estimate optimal tube depth, correlation and regression analyses were performed using clinical and anthropometric parameters. The mean tube depth was 28.9 ± 1.3 cm in men (n = 62), and 26.6 ± 1.5 cm in women (n = 48). Tube depth significantly correlated with height (r = 0.735, P < 0.001). Distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch correlated with depth of the endotracheal tube (r = 0.363, r = 0.362, and r = 0.546, P < 0.05). The tube depth also correlated with the sum of these distances (r = 0.646, P < 0.001). We devised the following formula for estimating tube depth: 19.856 + 0.267 × sum of the three distances (R 2 = 0.432, P < 0.001). The optimal tube depth for nasotracheally intubated adult patients correlated with height and sum of the distances from nares to tragus, tragus to angle of the mandible, and angle of the mandible to sternal notch. The proposed equation would be a useful guide to determine optimal nasotracheal tube placement.

Robust Airfoil Optimization to Achieve Consistent Drag Reduction Over a Mach Range

NASA Technical Reports Server (NTRS)

Li, Wu; Huyse, Luc; Padula, Sharon; Bushnell, Dennis M. (Technical Monitor)

2001-01-01

We prove mathematically that in order to avoid point-optimization at the sampled design points for multipoint airfoil optimization, the number of design points must be greater than the number of free-design variables. To overcome point-optimization at the sampled design points, a robust airfoil optimization method (called the profile optimization method) is developed and analyzed. This optimization method aims at a consistent drag reduction over a given Mach range and has three advantages: (a) it prevents severe degradation in the off-design performance by using a smart descent direction in each optimization iteration, (b) there is no random airfoil shape distortion for any iterate it generates, and (c) it allows a designer to make a trade-off between a truly optimized airfoil and the amount of computing time consumed. For illustration purposes, we use the profile optimization method to solve a lift-constrained drag minimization problem for 2-D airfoil in Euler flow with 20 free-design variables. A comparison with other airfoil optimization methods is also included.

Is patient size important in dose determination and optimization in cardiology?

NASA Astrophysics Data System (ADS)

Reay, J.; Chapple, C. L.; Kotre, C. J.

2003-12-01

Patient dose determination and optimization have become more topical in recent years with the implementation of the Medical Exposures Directive into national legislation, the Ionising Radiation (Medical Exposure) Regulations. This legislation incorporates a requirement for new equipment to provide a means of displaying a measure of patient exposure and introduces the concept of diagnostic reference levels. It is normally assumed that patient dose is governed largely by patient size; however, in cardiology, where procedures are often very complex, the significance of patient size is less well understood. This study considers over 9000 cardiology procedures, undertaken throughout the north of England, and investigates the relationship between patient size and dose. It uses simple linear regression to calculate both correlation coefficients and significance levels for data sorted by both room and individual clinician for the four most common examinations, left ventrical and/or coronary angiography, single vessel stent insertion and single vessel angioplasty. This paper concludes that the correlation between patient size and dose is weak for the procedures considered. It also illustrates the use of an existing method for removing the effect of patient size from dose survey data. This allows typical doses and, therefore, reference levels to be defined for the purposes of dose optimization.

Optimizing the patient for surgical treatment of the wound.

PubMed

Myers, Wesley T; Leong, Mimi; Phillips, Linda G

2007-10-01

Plastic surgeons are consulted often to close wounds that fail or are difficult to heal. Optimizing the patient's medical condition before surgical closure of a wound can mean the difference between a successful outcome and an undesirable one. It is imperative that plastic surgeons have an extensive knowledge of the modifiable risk factors affecting the wound-healing process and their subsequent complications. This knowledge allows the surgeon to tailor the treatment options and intervene when appropriate to optimize outcomes for successful surgical closure of a wound. Whether the impairments to wound healing and closure are local or systemic, they must be addressed appropriately.

A free gingival impression for achieving optimal interdental papilla height: a case report.

PubMed

Nozawa, Takeshi; Kitami, Norikazu; Tsurumaki, Shunzo; Enomoto, Hiroaki; Ito, Koichi

2011-02-01

Failure to tend to inadequate crown contours in the crown trial can cause long-term disharmony of the free gingival form. This case report describes a novel technique for free gingival impression from a final provisional restoration to a zirconia crown. Two die casts were manufactured from a silicone impression. The first die cast was for the zirconia crown; the second die cast was for the final provisional restoration and the provisionalized transfer coping. A free gingival impression was taken using a provisionalized transfer coping, and a soft gingival model was manufactured. The proximal contact position was managed using the predicted convex curve of the interdental papillae. One year after zirconia crown placement, no inflammation was observed around the pyramidal interdental papillae, and symmetric interdental papilla heights were evident. A free gingival impression using a two die-cast technique appears to be useful for achieving optimal interdental papilla height.

Full body photography in the massive weight loss population: an inquiry to optimize patient-centered care.

PubMed

Wasicek, Philip; Kaswan, Sumesh; Messing, Susan; Gusenoff, Jeffrey A

2013-11-01

Medical photography of body contouring patients often requires complete nudity, placing patients in a vulnerable situation. We investigated patient perspectives on full body photography in an effort to better protect the patients and enhance comfort with the photography process. Sixty-five massive weight loss patients were identified who underwent body contouring surgery with full body photography. Photographs were taken at the time of initial consult, time of marking, and postoperatively. A retrospective chart review was performed to assess body mass indices and comorbidities, and a telephone survey inquired about several aspects of the photographic process. Fifty-six (86%) patients participated. Patients were more comfortable at the time of markings (P = 0.0004) and at the postoperative session (P = 0.0009). Patients' perception of positive body image increased after body contouring surgery (P < 0.0001). Patients who reported being comfortable at their initial session had a higher body mass index (P = 0.0027). Professionalism of the staff was rated as the most important aspect of the photographic process. Patients preferring a chaperone of the same sex tended to be less comfortable with the process (P = 0.015). Most patients preferred the surgeon as the photographer (P = 0.03). Patient comfort with full body photography improves quickly as they move through the surgical process. Maintaining professionalism is the most important factor in achieving patient trust and comfort. Limiting the number of observers in the room, providing explicit details of the photography process, and having at least 1 person of the same sex in the room can optimize patient safety and comfort.

An intelligent algorithm for optimizing emergency department job and patient satisfaction.

PubMed

Azadeh, Ali; Yazdanparast, Reza; Abdolhossein Zadeh, Saeed; Keramati, Abbas

2018-06-11

Purpose Resilience engineering, job satisfaction and patient satisfaction were evaluated and analyzed in one Tehran emergency department (ED) to determine ED strengths, weaknesses and opportunities to improve safety, performance, staff and patient satisfaction. The paper aims to discuss these issues. Design/methodology/approach The algorithm included data envelopment analysis (DEA), two artificial neural networks: multilayer perceptron and radial basis function. Data were based on integrated resilience engineering (IRE) and satisfaction indicators. IRE indicators are considered inputs and job and patient satisfaction indicators are considered output variables. Methods were based on mean absolute percentage error analysis. Subsequently, the algorithm was employed for measuring staff and patient satisfaction separately. Each indicator is also identified through sensitivity analysis. Findings The results showed that salary, wage, patient admission and discharge are the crucial factors influencing job and patient satisfaction. The results obtained by the algorithm were validated by comparing them with DEA. Practical implications The approach is a decision-making tool that helps health managers to assess and improve performance and take corrective action. Originality/value This study presents an IRE and intelligent algorithm for analyzing ED job and patient satisfaction - the first study to present an integrated IRE, neural network and mathematical programming approach for optimizing job and patient satisfaction, which simultaneously optimizes job and patient satisfaction, and IRE. The results are validated by DEA through statistical methods.

SU-F-J-11: Radiobiologically Optimized Patient Localization During Prostate External Beam Localization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Huang, Y; Gardner, S; Liu, C

2016-06-15

Purpose: To present a novel positioning strategy which optimizes radiation delivery with radiobiological response knowledge, and to evaluate its application during prostate external beam radiotherapy. Methods: Ten patients with low or intermediate risk prostate cancer were evaluated retrospectively in this IRB-approved study. For each patient, a VMAT plan was generated on the planning CT (PCT) to deliver 78 Gy in 39 fractions with PTV = prostate + 7 mm margin, except for 5mm in the posterior direction. Five representative pretreatment CBCT images were selected for each patient, and prostate, rectum, and bladder were delineated on all CBCT images. Each CBCTmore » was auto-registered to the corresponding PCT. Starting from this auto-matched position (AM-position), a search for optimal treatment position was performed utilizing a score function based on radiobiological and dosimetric indices (D98-DTV, NTCP-rectum, and NTCP-bladder) for the daily target volume (DTV), rectum, and bladder. DTV was defined as prostate + 4 mm margin to account for intra-fraction motion as well as contouring variability on CBCT. We termed the optimal treatment position the radiobiologically optimized couch shift position (ROCS-position). Results: The indices, averaged over the 10 patients’ treatment plans, were (mean±SD): 77.7±0.2 Gy (D98-PTV), 12.3±2.7% (NTCP-rectum), and 53.2±11.2% (NTCP-bladder). The corresponding values calculated on all 50 CBCT images at the AM-positions were 72.9±11.3 Gy (D98-DTV), 15.8±6.4% (NTCP-rectum), and 53.0±21.1% (NTCP-bladder), respectively. In comparison, calculated on CBCT at the ROCS-positions, the indices were 77.0±2.1 Gy (D98-DTV), 12.1±5.7% (NTCP-rectum), and 60.7±16.4% (NTCP-bladder). Compared to autoregistration, ROCS-optimization recovered dose coverage to target volume and lowered the risk to rectum. Moreover, NTCPrectum for one patient remained high after ROCS-optimization and therefore could potentially benefit from adaptive planning

Dose-mass inverse optimization for minimally moving thoracic lesions

NASA Astrophysics Data System (ADS)

Mihaylov, I. B.; Moros, E. G.

2015-05-01

In the past decade, several different radiotherapy treatment plan evaluation and optimization schemes have been proposed as viable approaches, aiming for dose escalation or an increase of healthy tissue sparing. In particular, it has been argued that dose-mass plan evaluation and treatment plan optimization might be viable alternatives to the standard of care, which is realized through dose-volume evaluation and optimization. The purpose of this investigation is to apply dose-mass optimization to a cohort of lung cancer patients and compare the achievable healthy tissue sparing to that one achievable through dose-volume optimization. Fourteen non-small cell lung cancer (NSCLC) patient plans were studied retrospectively. The range of tumor motion was less than 0.5 cm and motion management in the treatment planning process was not considered. For each case, dose-volume (DV)-based and dose-mass (DM)-based optimization was performed. Nine-field step-and-shoot IMRT was used, with all of the optimization parameters kept the same between DV and DM optimizations. Commonly used dosimetric indices (DIs) such as dose to 1% the spinal cord volume, dose to 50% of the esophageal volume, and doses to 20 and 30% of healthy lung volumes were used for cross-comparison. Similarly, mass-based indices (MIs), such as doses to 20 and 30% of healthy lung masses, 1% of spinal cord mass, and 33% of heart mass, were also tallied. Statistical equivalence tests were performed to quantify the findings for the entire patient cohort. Both DV and DM plans for each case were normalized such that 95% of the planning target volume received the prescribed dose. DM optimization resulted in more organs at risk (OAR) sparing than DV optimization. The average sparing of cord, heart, and esophagus was 23, 4, and 6%, respectively. For the majority of the DIs, DM optimization resulted in lower lung doses. On average, the doses to 20 and 30% of healthy lung were lower by approximately 3 and 4%, whereas lung

Living donor liver transplantation for hepatocellular carcinoma achieves better outcomes.

PubMed

Lin, Chih-Che; Chen, Chao-Long

2016-10-01

Liver transplantation (LT) for hepatocellular carcinoma (HCC) at Kaohsiung Chang Gung Memorial Hospital mainly relies on live donor LT (LDLT). Owing to taking the risk of LD, we are obligated to adopt strict selection criteria for HCC patients and optimize the pre-transplant conditions to ensure a high disease-free survival similar to those without HCC, even better than deceased donor LT (DDLT). Better outcomes are attributed to excellent surgical results and optimal patient selection. The hospital mortality of primary and salvage LDLT are lower than 2% in our center. Although Taiwan Health Insurance Policy extended the Milan to University of California, San Francisco (UCSF) criteria in 2006, selection criteria will not be consolidated to take into account only by the morphologic size/number of tumors but also by their biology. The criteria are divided into modifiable image morphology, alpha fetoprotein (AFP), and positron emission tomography (PET) scan with standard uptake value (SUV) and unmodifiable unfavorable pathology such as HCC combined with cholangiocarcinoma (CC), sarcomatoid type, and poor differentiation. Downstaging therapy is necessary for HCC patients beyond criteria to fit all modifiable standards. The upper limit of downstaging treatment seems to be extended by more effective drug eluting transarterial chemoembolization in cases without absolute contraindications. In contrast, the pitfall of unmodifiable tumor pathology should be excluded by the findings of pretransplant core biopsy/resection if possible. More recently, achieving complete tumor necrosis in explanted liver could almost predict no recurrence after transplant. Necrotizing therapy is advised if possible before transplant even the tumor status within criteria to minimize the possibility of tumor recurrence. LDLT with low surgical mortality in experienced centers provides the opportunities of optimizing the pre-transplant tumor conditions and timing of transplant to achieve better

Calculation of the Target Lumbar Lordosis Angle for Restoring an Optimal Pelvic Tilt in Elderly Patients With Adult Spinal Deformity.

PubMed

Yamato, Yu; Hasegawa, Tomohiko; Kobayashi, Sho; Yasuda, Tatsuya; Togawa, Daisuke; Arima, Hideyuki; Oe, Shin; Iida, Takahiro; Matsumura, Akira; Hosogane, Naobumi; Matsumoto, Morio; Matsuyama, Yukihiro

2016-02-01

This investigation consisted of a cross-sectional study and a retrospective multicenter case series. This investigation sought to identify the ideal lumbar lordosis (LL) angle for restoring an optimal pelvic tilt (PT) in patients with adult spinal deformity (ASD). To achieve successful corrective fusion in ASD patients with sagittal imbalance, it is essential to correct the sagittal spinal alignment and obtain a suitable pelvic inclination. We determined the LL angle that would restore the optimal PT following ASD surgery. The cross-sectional study included 184 elderly volunteers (mean age 64 years) with an Oswestry Disability Index score less than 20%. The relationship between PT or LL and the pelvic incidence (PI) in normal individuals was investigated. The second study included 116 ASD patients (mean age 66 years) who underwent thoracolumbar corrective fusion at 1 of 4 spine centers. The postoperative PT values were calculated using the parameters measured. On the basis of these studies, an ideal LL angle was determined. In the cross-sectional study, the linear regression equation for the optimal PT as a function of PI was "optimal PT = 0.47 × PI - 7.5." In the second study, the postoperative PT was determined as a function of PI and corrected LL, using the equation "postoperative PT = 0.7 × PI - 0.5 × corrected LL + 8.1." The target LL angle was determined by mathematically equalizing the PTs of these 2 equations: "target LL = 0.45 × PI + 31.8." The ideal LL angle can be determined using the equation "LL = 0.45 × PI + 31.8," which can be used as a reference during surgical planning in ASD cases. 4.

Population pharmacokinetics of phenytoin after intravenous administration of fosphenytoin sodium in pediatric patients, adult patients, and healthy volunteers.

PubMed

Tanaka, Jun; Kasai, Hidefumi; Shimizu, Kenji; Shimasaki, Shigeki; Kumagai, Yuji

2013-03-01

We performed a population pharmacokinetic analysis of phenytoin after intravenous administration of fosphenytoin sodium in healthy, neurosurgical, and epileptic subjects, including pediatric patients, and determined the optimal dose and infusion rate for achieving the therapeutic range. We used pooled data obtained from two phase I studies and one phase III study performed in Japan. The population pharmacokinetic analysis was performed using NONMEM software. The optimal dose and infusion rate were determined using simulation results obtained using the final model. The therapeutic range for total plasma phenytoin concentration is 10-20 μg/mL. We used a linear two-compartment model with conversion of fosphenytoin to phenytoin. Pharmacokinetic parameters of phenytoin, such as total clearance and central and peripheral volume of distribution were influenced by body weight. The dose simulations are as follows. In adult patients, the optimal dose and infusion rate of phenytoin for achieving the therapeutic range was 22.5 mg/kg and 3 mg/kg/min respectively. In pediatric patients, the total plasma concentration of phenytoin was within the therapeutic range for a shorter duration than that in adult patients at 22.5 mg/kg (3 mg/kg/min). However, many pediatric patients showed phenytoin concentration within the toxic range after administration of a dose of 30 mg/kg. The pharmacokinetics of phenytoin after intravenous administration of fosphenytoin sodium could be described using a linear two-compartment model. The administration of fosphenytoin sodium 22.5 mg/kg at an infusion rate of 3 mg/kg/min was optimal for achieving the desired plasma phenytoin concentration.

Optimization of PSA screening policies: a comparison of the patient and societal perspectives.

PubMed

Zhang, Jingyu; Denton, Brian T; Balasubramanian, Hari; Shah, Nilay D; Inman, Brant A

2012-01-01

To estimate the benefit of PSA-based screening for prostate cancer from the patient and societal perspectives. A partially observable Markov decision process model was used to optimize PSA screening decisions. Age-specific prostate cancer incidence rates and the mortality rates from prostate cancer and competing causes were considered. The model trades off the potential benefit of early detection with the cost of screening and loss of patient quality of life due to screening and treatment. PSA testing and biopsy decisions are made based on the patient's probability of having prostate cancer. Probabilities are inferred based on the patient's complete PSA history using Bayesian updating. The results of all PSA tests and biopsies done in Olmsted County, Minnesota, from 1993 to 2005 (11,872 men and 50,589 PSA test results). Patients' perspective: to maximize expected quality-adjusted life years (QALYs); societal perspective: to maximize the expected monetary value based on societal willingness to pay for QALYs and the cost of PSA testing, prostate biopsies, and treatment. From the patient perspective, the optimal policy recommends stopping PSA testing and biopsy at age 76. From the societal perspective, the stopping age is 71. The expected incremental benefit of optimal screening over the traditional guideline of annual PSA screening with threshold 4.0 ng/mL for biopsy is estimated to be 0.165 QALYs per person from the patient perspective and 0.161 QALYs per person from the societal perspective. PSA screening based on traditional guidelines is found to be worse than no screening at all. PSA testing done with traditional guidelines underperforms and therefore underestimates the potential benefit of screening. Optimal screening guidelines differ significantly depending on the perspective of the decision maker.

Towards reducing thrombogenicity of LVAD therapy: optimizing surgical and patient management strategies

NASA Astrophysics Data System (ADS)

Chivukula, Venkat Keshav; Lafzi, Ali; Mokadam, Nahush; Beckman, Jennifer; Mahr, Claudius; Aliseda, Alberto

2017-11-01

Unfavourable hemodynamics in heart failure patients implanted with left ventricular assist devices (LVAD), due to non-optimal surgical configurations and patient management, strongly influence thrombogenicity. This is consistent with the increase in devastating thromboembolic complications (specifically thrombosis and stroke) in patients, even as the risk of thrombosis inside the device decreases with modern designs. Inflow cannula and outflow graft surgical configurations have been optimized via patient-specific modeling that computes the thrombogenic potential with a combination of Eulerian (endothelial) wall shear stress and Lagrangian (platelet shear history) tracking. Using this view of hemodynamics, the benefits of intermittent aortic valve opening (promoting washout and reducing stagnant flow in the aortic valve region) have been assessed in managing the patient's residual native cardiac output. The use of this methodology to understand the contribution of the hemodynamics in the flow surrounding the LVAD itself to thrombogenesis show promise in developing holistic patient-specific management strategies to minimize stroke risk and enhance efficacy of LVAD therapy. Funded in part by an AHA postdoctoral fellowship 16POST30520004.

Type of dyslipidemia and achievement of the LDL-cholesterol goal in chronic kidney disease patients at the University Hospital.

PubMed

Sangsawang, Tamon; Sriwijitkamol, Apiradee

2015-01-01

Chronic kidney disease (CKD) has been defined as a coronary artery disease risk equivalent. Therefore, the current guideline has been recommended for CKD patients to reach and maintain a low-density lipoprotein-cholesterol (LDL-C) goal of less than 100 mg/dL. However, the data regarding the achievement of LDL-C goal in these patients is lacking. This study was conducted to evaluate the types of dyslipidemia affecting patients with CKD stages 3 and 4 and to determine whether these patients achieved LDL-C goal. We performed a retrospective chart review of patients with CKD stage 3 or 4 and dyslipidemia who were followed-up at Siriraj Hospital between October 2011 and September 2012. In total, 150 patients with CKD stage 3 or 4 and dyslipidemia were recruited. The mean age was 72±10 years, and the body mass index was 25.6±4 kg/m(2); 60% had CKD stage 3 with an estimated glomerular filtration rate of 34±12 mL/min/1.73 m(2), and 54% had type 2 diabetes. The percentage of patients with hypercholesterolemia was 78%, hypertriglyceridemia 54%, and low high-density lipoprotein-C 36%. Of these, 52% had mixed hyperlipidemia. Statin treatment was prescribed to 87% of the patients, of which only 31.3% achieved the LDL-C goal according to the National Cholesterol Education Program and the European Society of Cardiology/European Atherosclerosis Society recommendations. Patients who did not achieve the LDL-C goal had a higher cholesterol level at diagnosis and higher prevalence of type 2 diabetes and stroke than those who achieved it. Two-thirds of CKD patients with hyperlipidemia had mixed hyperlipidemia. Despite the high frequency of statin treatment, only one-third of patients with CKD achieved the LDL-C goal. Thus, a developmental plan for the management of dyslipidemia in patients with CKD should be implemented to increase their achievement of the LDL-C goal.

Optimizing quality of life in patients with idiopathic pulmonary fibrosis

PubMed Central

van Manen, Mirjam J. G.; Geelhoed, J. J. Miranda.; Tak, Nelleke C.; Wijsenbeek, Marlies S.

2017-01-01

Idiopathic pulmonary fibrosis (IPF) is a devastating, progressive and ultimately fatal lung disease. The combination of poor prognosis, uncertainty of disease course and severe symptom burden heavily impacts patients’ and their families’ quality of life. Though new antifibrotic drugs have been shown to decrease disease progression, the effect on health-related quality of life (HRQOL) has not been convincingly demonstrated. In a relentless disease such as IPF, striving to optimize HRQOL should complement the endeavour to prolong life. Unfortunately, there is a paucity of interventions improving symptoms and functionality for patients with IPF, and research focusing on symptom improvement, and assessing and optimizing HRQOL, is limited. This review summarizes the most recent insights into measuring and improving quality of life for patients with IPF, and discusses challenges in the management of this devastating disease. Moreover, we postulate a new model for continuous care in IPF – ‘the ABCDE of IPF care’: Assessing patients’ needs; Backing patients by giving information and support; delivering Comfort care by focusing on treating symptoms and taking into account Comorbidities; striving to prolong life by Disease modification; helping and preparing patients and their caregivers for the eventual End-of-life events that are likely to occur. PMID:28134007

Optimal Scoring Methods of Hand-Strength Tests in Patients with Stroke

ERIC Educational Resources Information Center

Huang, Sheau-Ling; Hsieh, Ching-Lin; Lin, Jau-Hong; Chen, Hui-Mei

2011-01-01

The purpose of this study was to determine the optimal scoring methods for measuring strength of the more-affected hand in patients with stroke by examining the effect of reducing measurement errors. Three hand-strength tests of grip, palmar pinch, and lateral pinch were administered at two sessions in 56 patients with stroke. Five scoring methods…

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients.

PubMed

Xu, Chang; Song, Hua-Yu; Han, Shao-Liang; Ni, Shi-Chang; Zhang, Hu-Xiang; Xing, Chun-Gen

2017-08-21

To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer. A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated. All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors.

Teachers' Autonomy Support, Autonomy Suppression and Conditional Negative Regard as Predictors of Optimal Learning Experience among High-Achieving Bedouin Students

ERIC Educational Resources Information Center

Kaplan, Haya

2018-01-01

The study is based on self-determination theory and focuses on the motivation of high-achieving Bedouin students who belong to a hierarchical-collectivist society. The study focuses on the question: What are the relations between teachers' autonomy support and control and an optimal learning experience among students? The study is unique in its…

Achieving Conservation when Opportunity Costs Are High: Optimizing Reserve Design in Alberta's Oil Sands Region

PubMed Central

Schneider, Richard R.; Hauer, Grant; Farr, Dan; Adamowicz, W. L.; Boutin, Stan

2011-01-01

Recent studies have shown that conservation gains can be achieved when the spatial distributions of biological benefits and economic costs are incorporated in the conservation planning process. Using Alberta, Canada, as a case study we apply these techniques in the context of coarse-filter reserve design. Because targets for ecosystem representation and other coarse-filter design elements are difficult to define objectively we use a trade-off analysis to systematically explore the relationship between conservation targets and economic opportunity costs. We use the Marxan conservation planning software to generate reserve designs at each level of conservation target to ensure that our quantification of conservation and economic outcomes represents the optimal allocation of resources in each case. Opportunity cost is most affected by the ecological representation target and this relationship is nonlinear. Although petroleum resources are present throughout most of Alberta, and include highly valuable oil sands deposits, our analysis indicates that over 30% of public lands could be protected while maintaining access to more than 97% of the value of the region's resources. Our case study demonstrates that optimal resource allocation can be usefully employed to support strategic decision making in the context of land-use planning, even when conservation targets are not well defined. PMID:21858046

Number of Blades-up Runs Using JetStream XC Atherectomy for Optimal Tissue Debulking in Patients with Femoropopliteal Artery In-Stent Restenosis.

PubMed

Shammas, Nicolas W; Shammas, Gail A; Aasen, Nicole; Jarvis, Gary

2015-12-01

Rotational atherectomy with the use of the JetStream XC device is indicated for treatment of infrainguinal arterial obstructive disease. The number of blades-up (BU) runs needed for optimal tissue debulking in femoropopliteal in-stent restenosis (ISR) is unknown. In the present series, 6 patients (15 lesions) were treated for femoropopliteal ISR with the JetStream XC device. Minimal luminal diameter or percent stenosis improved significantly from baseline after 2 BU runs, but no further gain was seen between 2 and 4 BU runs (P > .05). However, adjunctive balloon angioplasty reduced percent stenosis significantly following BU runs. In conclusion, the JetStream XC device achieved optimal acute angiographic results in treating femoropopliteal ISR following 2 BU runs and adjunctive balloon angioplasty. Copyright © 2015 SIR. Published by Elsevier Inc. All rights reserved.

Improved motor performance in patients with acute stroke using the optimal individual attentional strategy

PubMed Central

Sakurada, Takeshi; Nakajima, Takeshi; Morita, Mitsuya; Hirai, Masahiro; Watanabe, Eiju

2017-01-01

It is believed that motor performance improves when individuals direct attention to movement outcome (external focus, EF) rather than to body movement itself (internal focus, IF). However, our previous study found that an optimal individual attentional strategy depended on motor imagery ability. We explored whether the individual motor imagery ability in stroke patients also affected the optimal attentional strategy for motor control. Individual motor imagery ability was determined as either kinesthetic- or visual-dominant by a questionnaire in 28 patients and 28 healthy-controls. Participants then performed a visuomotor task that required tracing a trajectory under three attentional conditions: no instruction (NI), attention to hand movement (IF), or attention to cursor movement (EF). Movement error in the stroke group strongly depended on individual modality dominance of motor imagery. Patients with kinesthetic dominance showed higher motor accuracy under the IF condition but with concomitantly lower velocity. Alternatively, patients with visual dominance showed improvements in both speed and accuracy under the EF condition. These results suggest that the optimal attentional strategy for improving motor accuracy in stroke rehabilitation differs according to the individual dominance of motor imagery. Our findings may contribute to the development of tailor-made pre-assessment and rehabilitation programs optimized for individual cognitive abilities. PMID:28094320

Developing Optimized Treatment Plans for Patients with Dyslipidemia in the Era of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitor Therapeutics.

PubMed

Underberg, James A; Blaha, Michael J; Jackson, Elizabeth J; Jones, Peter H

2017-10-01

This educational content was derived from a live satellite symposium at the American College of Physicians Internal Medicine Meeting 2017 in San Diego, California (online at http://courses.elseviercme.com/acp/702e). This activity will focus on optimized treatment plans for patients with dyslipidemia in the era of proprotein convertase subtilisin/kexin type 9 inhibitor therapeutics. Low-density lipoprotein cholesterol has been identified as an important therapeutic target to prevent the progression of atherosclerotic disease; however, only 1 of every 3 adults with high low-density lipoprotein cholesterol has the condition under control. Expert faculty on this panel will discuss the science of proprotein convertase subtilisin/kexin type 9 inhibitors and aid physicians in the best practices to achieve low-density lipoprotein cholesterol target in their patients. Copyright © 2017. Published by Elsevier Inc.

Learning optimal embedded cascades.

PubMed

Saberian, Mohammad Javad; Vasconcelos, Nuno

2012-10-01

The problem of automatic and optimal design of embedded object detector cascades is considered. Two main challenges are identified: optimization of the cascade configuration and optimization of individual cascade stages, so as to achieve the best tradeoff between classification accuracy and speed, under a detection rate constraint. Two novel boosting algorithms are proposed to address these problems. The first, RCBoost, formulates boosting as a constrained optimization problem which is solved with a barrier penalty method. The constraint is the target detection rate, which is met at all iterations of the boosting process. This enables the design of embedded cascades of known configuration without extensive cross validation or heuristics. The second, ECBoost, searches over cascade configurations to achieve the optimal tradeoff between classification risk and speed. The two algorithms are combined into an overall boosting procedure, RCECBoost, which optimizes both the cascade configuration and its stages under a detection rate constraint, in a fully automated manner. Extensive experiments in face, car, pedestrian, and panda detection show that the resulting detectors achieve an accuracy versus speed tradeoff superior to those of previous methods.

Simple instruments facilitating achievement of transanal total mesorectal excision in male patients

PubMed Central

Xu, Chang; Song, Hua-Yu; Han, Shao-Liang; Ni, Shi-Chang; Zhang, Hu-Xiang; Xing, Chun-Gen

2017-01-01

AIM To assess the efficacy of a modified approach with transanal total mesorectal excision (taTME) using simple customized instruments in male patients with low rectal cancer. METHODS A total of 115 male patients with low rectal cancer from December 2006 to August 2015 were retrospectively studied. All patients had a bulky tumor (tumor diameter ≥ 40 mm). Forty-one patients (group A) underwent a classical approach of transabdominal total mesorectal excision (TME) and transanal intersphincteric resection (ISR), and the other 74 patients (group B) underwent a modified approach with transabdominal TME, transanal ISR, and taTME. Some simple instruments including modified retractors and an anal dilator with a papilionaceous fixture were used to perform taTME. The operative time, quality of mesorectal excision, circumferential resection margin, local recurrence, and postoperative survival were evaluated. RESULTS All 115 patients had successful sphincter preservation. The operative time in group B (240 min, range: 160-330 min) was significantly shorter than that in group A (280 min, range: 200-360 min; P = 0.000). Compared with group A, more complete distal mesorectum and total mesorectum were achieved in group B (100% vs 75.6%, P = 0.000; 90.5% vs 70.7%, P = 0.008, respectively). After 46.1 ± 25.6 mo follow-up, group B had a lower local recurrence rate and higher disease-free survival rate compared with group A, but these differences were not statistically significant (5.4% vs 14.6%, P = 0.093; 79.5% vs 65.1%, P = 0.130). CONCLUSION Retrograde taTME with simple customized instruments can achieve high-quality TME, and it might be an effective and economical alternative for male patients with bulky tumors. PMID:28883706

Optimizing Quality of Care and Patient Safety in Malaysia: The Current Global Initiatives, Gaps and Suggested Solutions.

PubMed

Jarrar, Mu'taman; Abdul Rahman, Hamzah; Don, Mohammad Sobri

2015-10-20

Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed. The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme "1 Care for 1 Malaysia" in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors. There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia.

Optimizing Quality of Care and Patient Safety in Malaysia: The Current Global Initiatives, Gaps and Suggested Solutions

PubMed Central

Jarrar, Mu’taman; Rahman, Hamzah Abdul; Don, Mohammad Sobri

2016-01-01

Background and Objective: Demand for health care service has significantly increased, while the quality of healthcare and patient safety has become national and international priorities. This paper aims to identify the gaps and the current initiatives for optimizing the quality of care and patient safety in Malaysia. Design: Review of the current literature. Highly cited articles were used as the basis to retrieve and review the current initiatives for optimizing the quality of care and patient safety. The country health plan of Ministry of Health (MOH) Malaysia and the MOH Malaysia Annual Reports were reviewed. Results: The MOH has set four strategies for optimizing quality and sustaining quality of life. The 10th Malaysia Health Plan promotes the theme “1 Care for 1 Malaysia” in order to sustain the quality of care. Despite of these efforts, the total number of complaints received by the medico-legal section of the MOH Malaysia is increasing. The current global initiatives indicted that quality performance generally belong to three main categories: patient; staffing; and working environment related factors. Conclusions: There is no single intervention for optimizing quality of care to maintain patient safety. Multidimensional efforts and interventions are recommended in order to optimize the quality of care and patient safety in Malaysia. PMID:26755459

Selective robust optimization: A new intensity-modulated proton therapy optimization strategy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Li, Yupeng; Niemela, Perttu; Siljamaki, Sami

2015-08-15

Purpose: To develop a new robust optimization strategy for intensity-modulated proton therapy as an important step in translating robust proton treatment planning from research to clinical applications. Methods: In selective robust optimization, a worst-case-based robust optimization algorithm is extended, and terms of the objective function are selectively computed from either the worst-case dose or the nominal dose. Two lung cancer cases and one head and neck cancer case were used to demonstrate the practical significance of the proposed robust planning strategy. The lung cancer cases had minimal tumor motion less than 5 mm, and, for the demonstration of the methodology,more » are assumed to be static. Results: Selective robust optimization achieved robust clinical target volume (CTV) coverage and at the same time increased nominal planning target volume coverage to 95.8%, compared to the 84.6% coverage achieved with CTV-based robust optimization in one of the lung cases. In the other lung case, the maximum dose in selective robust optimization was lowered from a dose of 131.3% in the CTV-based robust optimization to 113.6%. Selective robust optimization provided robust CTV coverage in the head and neck case, and at the same time improved controls over isodose distribution so that clinical requirements may be readily met. Conclusions: Selective robust optimization may provide the flexibility and capability necessary for meeting various clinical requirements in addition to achieving the required plan robustness in practical proton treatment planning settings.« less

Optimal Diet Planning for Eczema Patient Using Integer Programming

NASA Astrophysics Data System (ADS)

Zhen Sheng, Low; Sufahani, Suliadi

2018-04-01

Human diet planning is conducted by choosing appropriate food items that fulfill the nutritional requirements into the diet formulation. This paper discusses the application of integer programming to build the mathematical model of diet planning for eczema patients. The model developed is used to solve the diet problem of eczema patients from young age group. The integer programming is a scientific approach to select suitable food items, which seeks to minimize the costs, under conditions of meeting desired nutrient quantities, avoiding food allergens and getting certain foods into the diet that brings relief to the eczema conditions. This paper illustrates that the integer programming approach able to produce the optimal and feasible solution to deal with the diet problem of eczema patient.

Achieving Symptom Control in Patients with Moderate Asthma

PubMed Central

Weir, Nargues A.; Levine, Stewart J.

2012-01-01

Disease severity in asthma can be classified as mild, moderate or severe based upon the frequency of symptoms or the severity of airflow obstruction. This review will focus on the treatment of youths greater than 12 years of age and adults with moderate persistent asthma. Moderate asthmatics may have daily symptoms that cause some limitation with normal daily activities and require use of a rescue inhaled short-acting beta2-agonist inhaler or experience nocturnal awakenings secondary to asthma that occur more than once per week. Furthermore, spirometry may reveal airflow obstruction with a reduction in FEV1 to between 60% and 80% of predicted. Although inhaled corticosteroids (ICS) are the primary controller medication used to modify symptoms in moderate asthmatics, additional controller medications, such as inhaled long-acting beta2-agonists (LABA), leukotriene receptor antagonists (LTRA) or theophylline, are often needed to obtain optimal disease control. While the addition of an inhaled LABA to an ICS is very effective at improving disease control in moderate asthma, concerns have arisen over the safety of LABAs, in particular the risk of asthma-related death. Therefore, consideration may be given to initially adding a LTRA, rather than a LABA, to ICS when asthma symptoms are not adequately controlled by ICS alone. Furthermore, individualization of medication regimens, treatment of co-morbid conditions, and patient education are crucial to optimizing compliance with therapy, improving disease control, and reducing the risk of exacerbations. Lastly, the development of new asthma treatments, perhaps based upon personalized medicine, may revolutionize the future treatment of moderate asthma. PMID:22259262

Optimization of the sources in local hyperthermia using a combined finite element-genetic algorithm method.

PubMed

Siauve, N; Nicolas, L; Vollaire, C; Marchal, C

2004-12-01

This article describes an optimization process specially designed for local and regional hyperthermia in order to achieve the desired specific absorption rate in the patient. It is based on a genetic algorithm coupled to a finite element formulation. The optimization method is applied to real human organs meshes assembled from computerized tomography scans. A 3D finite element formulation is used to calculate the electromagnetic field in the patient, achieved by radiofrequency or microwave sources. Space discretization is performed using incomplete first order edge elements. The sparse complex symmetric matrix equation is solved using a conjugate gradient solver with potential projection pre-conditionning. The formulation is validated by comparison of calculated specific absorption rate distributions in a phantom to temperature measurements. A genetic algorithm is used to optimize the specific absorption rate distribution to predict the phases and amplitudes of the sources leading to the best focalization. The objective function is defined as the specific absorption rate ratio in the tumour and healthy tissues. Several constraints, regarding the specific absorption rate in tumour and the total power in the patient, may be prescribed. Results obtained with two types of applicators (waveguides and annular phased array) are presented and show the faculties of the developed optimization process.

Standardization and Optimization of Computed Tomography Protocols to Achieve Low-Dose

PubMed Central

Chin, Cynthia; Cody, Dianna D.; Gupta, Rajiv; Hess, Christopher P.; Kalra, Mannudeep K.; Kofler, James M.; Krishnam, Mayil S.; Einstein, Andrew J.

2014-01-01

The increase in radiation exposure due to CT scans has been of growing concern in recent years. CT scanners differ in their capabilities and various indications require unique protocols, but there remains room for standardization and optimization. In this paper we summarize approaches to reduce dose, as discussed in lectures comprising the first session of the 2013 UCSF Virtual Symposium on Radiation Safety in Computed Tomography. The experience of scanning at low dose in different body regions, for both diagnostic and interventional CT procedures, is addressed. An essential primary step is justifying the medical need for each scan. General guiding principles for reducing dose include tailoring a scan to a patient, minimizing scan length, use of tube current modulation and minimizing tube current, minimizing-tube potential, iterative reconstruction, and periodic review of CT studies. Organized efforts for standardization have been spearheaded by professional societies such as the American Association of Physicists in Medicine. Finally, all team members should demonstrate an awareness of the importance of minimizing dose. PMID:24589403

Optimization of EGFR high positive cell isolation procedure by design of experiments methodology.

PubMed

Levi, Ofer; Tal, Baruch; Hileli, Sagi; Shapira, Assaf; Benhar, Itai; Grabov, Pavel; Eliaz, Noam

2015-01-01

Circulating tumor cells (CTCs) in blood circulation may play a role in monitoring and even in early detection of metastasis patients. Due to the limited presence of CTCs in blood circulation, viable CTCs isolation technology must supply a very high recovery rate. Here, we implement design of experiments (DOE) methodology in order to optimize the Bio-Ferrography (BF) immunomagnetic isolation (IMI) procedure for the EGFR high positive CTCs application. All consequent DOE phases such as screening design, optimization experiments and validation experiments were used. A significant recovery rate of more than 95% was achieved while isolating 100 EGFR high positive CTCs from 1 mL human whole blood. The recovery achievement in this research positions BF technology as one of the most efficient IMI technologies, which is ready to be challenged with patients' blood samples. © 2015 International Clinical Cytometry Society.

Achieving Optimal Privacy in Trust-Aware Social Recommender Systems

NASA Astrophysics Data System (ADS)

Dokoohaki, Nima; Kaleli, Cihan; Polat, Huseyin; Matskin, Mihhail

Collaborative filtering (CF) recommenders are subject to numerous shortcomings such as centralized processing, vulnerability to shilling attacks, and most important of all privacy. To overcome these obstacles, researchers proposed for utilization of interpersonal trust between users, to alleviate many of these crucial shortcomings. Till now, attention has been mainly paid to strong points about trust-aware recommenders such as alleviating profile sparsity or calculation cost efficiency, while least attention has been paid on investigating the notion of privacy surrounding the disclosure of individual ratings and most importantly protection of trust computation across social networks forming the backbone of these systems. To contribute to addressing problem of privacy in trust-aware recommenders, within this paper, first we introduce a framework for enabling privacy-preserving trust-aware recommendation generation. While trust mechanism aims at elevating recommender's accuracy, to preserve privacy, accuracy of the system needs to be decreased. Since within this context, privacy and accuracy are conflicting goals we show that a Pareto set can be found as an optimal setting for both privacy-preserving and trust-enabling mechanisms. We show that this Pareto set, when used as the configuration for measuring the accuracy of base collaborative filtering engine, yields an optimized tradeoff between conflicting goals of privacy and accuracy. We prove this concept along with applicability of our framework by experimenting with accuracy and privacy factors, and we show through experiment how such optimal set can be inferred.

Effective management of patients with acute ischemic stroke based on lean production on thrombolytic flow optimization.

PubMed

Liang, Zhuoyuan; Ren, Lijie; Wang, Ting; Hu, Huoyou; Li, Weiping; Wang, Yaping; Liu, Dehong; Lie, Yi

2016-12-01

The efficacy of thrombolytic therapy for acute ischemic stroke (AIS) decreases when the administration of tissue plasminogen activator (tPA) is delayed. Derived from Toyota Production System, lean production aims to create top-quality products with high-efficiency procedures, a concept that easily applies to emergency medicine. In this study, we aimed to determine whether applying lean principles to flow optimization could hasten the initiation of thrombolysis. A multidisciplinary team (Stroke Team) was organized to implement an ongoing, continuous loop of lean production that contained the following steps: decomposition, recognition, intervention, reengineering and assessment. The door-to-needle time (DNT) and the percentage of patients with DNT ≤ 60 min before and after the adoption of lean principles were used to evaluate the efficiency of our flow optimization. Thirteen patients with AIS in the pre-lean period and 43 patients with AIS in the lean period (23 in lean period I and 20 patients in lean period II) were consecutively enrolled in our study. After flow optimization, we reduced DNT from 90 to 47 min (p < 0.001 ¤ ). In addition, the percentage of patients treated ≤60 min after hospital arrival increased from 38.46 to 75.0 % (p = 0.015 ¤ ). Adjusted analysis of covariance confirmed a significant influence of optimization on delay of tPA administration (p < 0.001). The patients were more likely to have a good prognosis (mRS ≤ 2 at 90 days) after the flow optimization (30.77-75.00 %, p = 0.012 ¤ ). Our study may offer an effective approach for optimizing the thrombolytic flow in the management of AIS.

Optimizing Patient-centered Communication and Multidisciplinary Care Coordination in Emergency Diagnostic Imaging: A Research Agenda.

PubMed

Sabbatini, Amber K; Merck, Lisa H; Froemming, Adam T; Vaughan, William; Brown, Michael D; Hess, Erik P; Applegate, Kimberly E; Comfere, Nneka I

2015-12-01

Patient-centered emergency diagnostic imaging relies on efficient communication and multispecialty care coordination to ensure optimal imaging utilization. The construct of the emergency diagnostic imaging care coordination cycle with three main phases (pretest, test, and posttest) provides a useful framework to evaluate care coordination in patient-centered emergency diagnostic imaging. This article summarizes findings reached during the patient-centered outcomes session of the 2015 Academic Emergency Medicine consensus conference "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." The primary objective was to develop a research agenda focused on 1) defining component parts of the emergency diagnostic imaging care coordination process, 2) identifying gaps in communication that affect emergency diagnostic imaging, and 3) defining optimal methods of communication and multidisciplinary care coordination that ensure patient-centered emergency diagnostic imaging. Prioritized research questions provided the framework to define a research agenda for multidisciplinary care coordination in emergency diagnostic imaging. © 2015 by the Society for Academic Emergency Medicine.

Whole-body computed tomography in trauma patients: optimization of the patient scanning position significantly shortens examination time while maintaining diagnostic image quality.

PubMed

Hickethier, Tilman; Mammadov, Kamal; Baeßler, Bettina; Lichtenstein, Thorsten; Hinkelbein, Jochen; Smith, Lucy; Plum, Patrick Sven; Chon, Seung-Hun; Maintz, David; Chang, De-Hua

2018-01-01

The study was conducted to compare examination time and artifact vulnerability of whole-body computed tomographies (wbCTs) for trauma patients using conventional or optimized patient positioning. Examination time was measured in 100 patients scanned with conventional protocol (Group A: arms positioned alongside the body for head and neck imaging and over the head for trunk imaging) and 100 patients scanned with optimized protocol (Group B: arms flexed on a chest pillow without repositioning). Additionally, influence of two different scanning protocols on image quality in the most relevant body regions was assessed by two blinded readers. Total wbCT duration was about 35% or 3:46 min shorter in B than in A. Artifacts in aorta (27 vs 6%), liver (40 vs 8%) and spleen (27 vs 5%) occurred significantly more often in B than in A. No incident of non-diagnostic image quality was reported, and no significant differences for lungs and spine were found. An optimized wbCT positioning protocol for trauma patients allows a significant reduction of examination time while still maintaining diagnostic image quality.

Optimal Flow.

ERIC Educational Resources Information Center

Norman, Donald A.

1996-01-01

Discusses the educational applications of experimental psychologist Mihaly Csikszentmihalyi's theory of peak experience, or optimal flow. Optimal flow refers to the receptive state people achieve when they are engaged in interesting and challenging activity. Includes an insightful critique of multimedia instruction from this perspective. (MJP)

Achieving Core Indicators for HIV Clinical Care Among New Patients at an Urban HIV Clinic.

PubMed

Greer, Gillian A; Tamhane, Ashutosh; Malhotra, Rakhi; Burkholder, Greer A; Mugavero, Michael J; Raper, James L; Zinski, Anne

2015-09-01

Following the release of the 2010 National HIV/AIDS Strategy for the United States, the Institute of Medicine (IOM) issued core clinical indicators for measuring health outcomes in HIV-positive persons. As early retention in HIV primary care is associated with improved long-term health outcomes, we employed IOM indicators as a guide to examine a cohort of persons initiating HIV outpatient medical care at a university-affiliated HIV clinic in the Southern United States (January 2007-July 2012). Using indicators for visit attendance, CD4 and viral load laboratory testing frequency, and antiretroviral therapy initiation, we evaluated factors associated with achieving IOM core indicators among care- and treatment-naïve patients during the first year of HIV care. Of 448 patients (mean age = 35 years, 35.7% white, 79.0% male, 58.4% education beyond high school, 35.9% monthly income > $1,000 US, 47.3% uninsured), 84.6% achieved at least four of five IOM indicators. In multivariable analyses, persons with monthly income > $1,000 (ORadj. = 3.71; 95% CI: 1.68-8.19; p = 0.001) and depressive symptoms (ORadj. = 2.13; 95% CI: 1.02-4.45; p = 0.04) were significantly more likely to achieve at least four of the five core indicators, while patients with anxiety symptoms were significantly less likely to achieve these indicators (ORadj. = 0.50; 95% CI: 0.26-0.97; p = 0.04). Age, sex, race, education, insurance status, transportation barriers, alcohol use, and HIV status disclosure to family were not associated with achieving core indicators. Evaluating and addressing financial barriers and anxiety symptoms during the first year of HIV outpatient care may improve individual health outcomes and subsequent achievement of the National HIV/AIDS Strategy.

Achieving high convection volumes in postdilution online hemodiafiltration: a prospective multicenter study

PubMed Central

Chapdelaine, Isabelle; Nubé, Menso J; Blankestijn, Peter J; Bots, Michiel L; Konings, Constantijn J A M; Kremer Hovinga, Ton K; Molenaar, Femke M; van der Weerd, Neelke C; Grooteman, Muriel P C

2017-01-01

Abstract Background. Available evidence suggests a reduced mortality risk for patients treated with high-volume postdilution hemodiafiltration (HDF) when compared with hemodialysis (HD) patients. As the magnitude of the convection volume depends on treatment-related factors rather than patient-related characteristics, we prospectively investigated whether a high convection volume (defined as ≥22 L/session) is feasible in the majority of patients (>75%). Methods. A multicenter study was performed in adult prevalent dialysis patients. Nonparticipating eligible patients formed the control group. Using a stepwise protocol, treatment time (up to 4 hours), blood flow rate (up to 400 mL/min) and filtration fraction (up to 33%) were optimized as much as possible. The convection volume was determined at the end of this optimization phase and at 4 and 8 weeks thereafter. Results. Baseline characteristics were comparable in participants (n = 86) and controls (n = 58). At the end of the optimization and 8 weeks thereafter, 71/86 (83%) and 66/83 (80%) of the patients achieved high-volume HDF (mean 25.5 ± 3.6 and 26.0 ± 3.4 L/session, respectively). While treatment time remained unaltered, mean blood flow rate increased by 27% and filtration fraction increased by 23%. Patients with <22 L/session had a higher percentage of central venous catheters (CVCs), a shorter treatment time and lower blood flow rate when compared with patients with ≥22 L/session. Conclusions. High-volume HDF is feasible in a clear majority of dialysis patients. Since none of the patients agreed to increase treatment time, these findings indicate that high-volume HDF is feasible just by increasing blood flow rate and filtration fraction. PMID:29225810

Appraising Reading Achievement.

ERIC Educational Resources Information Center

Ediger, Marlow

To determine quality sequence in pupil progress, evaluation approaches need to be used which guide the teacher to assist learners to attain optimally. Teachers must use a variety of procedures to appraise student achievement in reading, because no one approach is adequate. Appraisal approaches might include: (1) observation and subsequent…

Thyroidectomy as Primary Treatment Optimizes BMI in Patients with Hyperthyroidism

PubMed Central

Schneider, David F.; Nookala, Ratnam; Jaraczewski, Taylor J.; Chen, Herbert; Solorzano, Carmen C.; Sippel, Rebecca S.

2014-01-01

Objective The purpose of this study was to determine how the timing of thyroidectomy influenced postoperative weight change. Methods We conducted a two institution study, identifying patients treated with total thyroidectomy for hyperthyroidism. Patients were classified as “early” if they were referred for surgery as the first treatment option or “delayed” if they were previously treated with radioactive iodine. Groups were compared with the student's t-test or Chi-squared test where appropriate. Results There were 204 patients undergoing thyroidectomy for hyperthyroidsim. 171 patients were classified as early and 33 were delayed. Overall, patients gained 6.0% ± 0.8 of their preoperative body weight at last follow-up. Preoperative BMIs were similar between groups (p= 0.98), and the median follow-up time was 388 days (range 15 – 1,584 days). Both groups gained weight until they achieved a normal TSH postoperatively. After achieving a normal TSH, the early group stabilized or lost weight (-0.2 lbs/day) while the delayed group continued to gain weight (0.02 lbs/day, p = 0.61). At last follow-up, there were significantly more patients in the delayed group who increased their BMI category compared to the early group (42.4% vs. 21.6%, p = 0.01). Twice as many patients in the delayed group moved up or into an unhealthy BMI category (overweight or obese) compared to the early group (39.4% vs. 19.3%, p = 0.01). Conclusions Compared to patients initially treated with radioactive iodine, patients with hyperthyroidism who underwent surgery as the first treatment were less likely to become overweight or obese postoperatively. PMID:24522995

Pilot implementation of a technologically advanced system for the optimization of pre-hospital, trauma patient care.

PubMed

Vagianos, Constantine E; Dimopoulou, Efi; Tsiftsis, Dimitrios; Spyropoulos, Charalambos; Spyrakopoulos, Panagiotis; Vagenas, Konstantinos

2010-07-01

Cooperation between medical informatics, wireless communication and pre-hospital emergency services is essential for the optimal pre-hospital patient treatment. The use of technological innovations improves medical care in the pre-hospital setting with regard to the organization of an integrated center, which coordinates all parties involved for the patient's best interest. A dispatch center was developed in the city of Patras, in southwestern Greece, equipped with a Geographic Information System (GIS), which immediately points out the location of emergency vehicles (EVs) on a digital map depicting the city plan. Additionally, three ambulances of the National Center of Immediate Aid (NCIA) were equipped with a decentralized traffic management system for the vehicle's traffic priority at signaled junctions. The system consisted of a cellular-based (GSM) telemedicine module, a Global Positioning System (GPS) and a web camera system in the vehicle cabin. The aforementioned system provided considerable assistance to the pre-hospital treatment first by selecting the ambulance closest to the accident's location and then by pinpointing the optimum route to the hospital, thus significantly reducing the overall transportation time. The project's objective to coordinate emergency hospital departments involved in the treatment of trauma patients with other emergency services by utilizing high technology was achieved within this interdisciplinary effort.

Patients with myeloid malignancies bearing PDGFRB fusion genes achieve durable long-term remissions with imatinib

PubMed Central

Cheah, Chan Y.; Burbury, Kate; Apperley, Jane F.; Huguet, Francoise; Pitini, Vincenzo; Gardembas, Martine; Ross, David M.; Forrest, Donna; Genet, Philippe; Rousselot, Philippe; Patton, Nigel; Smith, Graeme; Dunbar, Cynthia E.; Ito, Sawa; Aguiar, Ricardo C. T.; Odenike, Olatoyosi; Gimelfarb, Alla; Cross, Nicholas C. P.; Seymour, John F.

2014-01-01

Myeloid neoplasms and eosinophilia with rearrangements of PDGFRB are uncommon Philadelphia-negative myeloproliferative neoplasms. Patients are typically male, with morphologic features of a Philadelphia-negative chronic myeloproliferative syndrome or chronic myelomonocytic leukemia with eosinophilia. Reciprocal translocations involving PDGFRB result in fusion genes with constitutively activated receptor tyrosine kinase sensitive to inhibition with imatinib. We present an updated and expanded analysis of a cohort of 26 such patients treated with imatinib. After a median follow-up of 10.2 years (range, 1.8-17 years), the 10-year overall survival rate was 90% (95% confidence interval, 64%-97%); after median imatinib duration of 6.6 years (range, 0.1-12 years), the 6-year progression-free survival rate was 88% (95% confidence interval, 65%-96%). Of the patients, 96% responded; no patients who achieved a complete cytogenetic (n = 13) or molecular (n = 8) remission lost their response or progressed to blast crisis. Imatinib is well-tolerated and achieves excellent long-term responses in patients with PDGFRB rearrangements. PMID:24687085

Interleaved segment correction achieves higher improvement factors in using genetic algorithm to optimize light focusing through scattering media

NASA Astrophysics Data System (ADS)

Li, Runze; Peng, Tong; Liang, Yansheng; Yang, Yanlong; Yao, Baoli; Yu, Xianghua; Min, Junwei; Lei, Ming; Yan, Shaohui; Zhang, Chunmin; Ye, Tong

2017-10-01

Focusing and imaging through scattering media has been proved possible with high resolution wavefront shaping. A completely scrambled scattering field can be corrected by applying a correction phase mask on a phase only spatial light modulator (SLM) and thereby the focusing quality can be improved. The correction phase is often found by global searching algorithms, among which Genetic Algorithm (GA) stands out for its parallel optimization process and high performance in noisy environment. However, the convergence of GA slows down gradually with the progression of optimization, causing the improvement factor of optimization to reach a plateau eventually. In this report, we propose an interleaved segment correction (ISC) method that can significantly boost the improvement factor with the same number of iterations comparing with the conventional all segment correction method. In the ISC method, all the phase segments are divided into a number of interleaved groups; GA optimization procedures are performed individually and sequentially among each group of segments. The final correction phase mask is formed by applying correction phases of all interleaved groups together on the SLM. The ISC method has been proved significantly useful in practice because of its ability to achieve better improvement factors when noise is present in the system. We have also demonstrated that the imaging quality is improved as better correction phases are found and applied on the SLM. Additionally, the ISC method lowers the demand of dynamic ranges of detection devices. The proposed method holds potential in applications, such as high-resolution imaging in deep tissue.

Achievement of lipid targets with the combination of rosuvastatin and fenofibric Acid in patients with type 2 diabetes mellitus.

PubMed

Rosenson, Robert S; Carlson, Dawn M; Kelly, Maureen T; Setze, Carolyn M; Hirshberg, Boaz; Stolzenbach, James C; Williams, Laura A

2011-02-01

The objective of this study was to assess the proportion of patients with type 2 diabetes mellitus (T2DM) attaining individual and combined targets of low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), non-HDL-C, and apolipoprotein B (ApoB) after treatment with rosuvastatin (R) + fenofibric acid (FA) compared with corresponding-dose R monotherapy. This post hoc analysis evaluated data from the T2DM subset of patients with mixed dyslipidemia (LDL-C ≥130 mg/dL, HDL-C <40/50 mg/dL in men/women, and TG ≥150 mg/dL) from 2 randomized studies. Patients included in the analysis (N = 456) were treated with R (5, 10, or 20 mg), FA 135 mg, or R (5, 10, or 20 mg) + FA 135 mg for 12 weeks. Attainment of LDL-C <100 mg/dL, HDL-C >40/50 mg/dL in men/women, TG <150 mg/dL, non-HDL-C <130 mg/dL, ApoB <90 mg/dL, and the combined targets of these parameters was assessed. Treatment with R + FA resulted in a significantly higher proportion of patients achieving optimal levels of HDL-C (46.8% vs. 20.8%, P = 0.009 for R 10 mg + FA), TG (60.0% vs. 34.0%, P = 0.02 for R 10 mg + FA; 54.0% vs. 26.4%, P = 0.005 for R 20 mg + FA), non-HDL-C (55.1% vs. 36.4%, P = 0.04 for R 5 mg + FA), ApoB (58.0% vs. 36.4%, P = 0.02 for R 5 mg + FA); and the combined targets of LDL-C, HDL-C, and TG (28.3% vs. 8.3%, P = 0.02 for R 10 mg + FA) and all 5 parameters (26.1% vs. 8.3%, P = 0.03 for R 10 mg + FA) than corresponding-dose R monotherapies. A significantly greater proportion of T2DM patients achieved individual and combined lipid targets when treated with the combination of R + FA than corresponding-dose R monotherapies.

Functional Recovery in Major Depressive Disorder: Providing Early Optimal Treatment for the Individual Patient

PubMed Central

Katzman, Martin A; Habert, Jeffrey; McIntosh, Diane; MacQueen, Glenda M; Milev, Roumen V; McIntyre, Roger S; Blier, Pierre

2018-01-01

Abstract Major depressive disorder is an often chronic and recurring illness. Left untreated, major depressive disorder may result in progressive alterations in brain morphometry and circuit function. Recent findings, however, suggest that pharmacotherapy may halt and possibly reverse those effects. These findings, together with evidence that a delay in treatment is associated with poorer clinical outcomes, underscore the urgency of rapidly treating depression to full recovery. Early optimized treatment, using measurement-based care and customizing treatment to the individual patient, may afford the best possible outcomes for each patient. The aim of this article is to present recommendations for using a patient-centered approach to rapidly provide optimal pharmacological treatment to patients with major depressive disorder. Offering major depressive disorder treatment determined by individual patient characteristics (e.g., predominant symptoms, medical history, comorbidities), patient preferences and expectations, and, critically, their own definition of wellness provides the best opportunity for full functional recovery. PMID:29024974

Functional Recovery in Major Depressive Disorder: Providing Early Optimal Treatment for the Individual Patient.

PubMed

Oluboka, Oloruntoba J; Katzman, Martin A; Habert, Jeffrey; McIntosh, Diane; MacQueen, Glenda M; Milev, Roumen V; McIntyre, Roger S; Blier, Pierre

2018-02-01

Major depressive disorder is an often chronic and recurring illness. Left untreated, major depressive disorder may result in progressive alterations in brain morphometry and circuit function. Recent findings, however, suggest that pharmacotherapy may halt and possibly reverse those effects. These findings, together with evidence that a delay in treatment is associated with poorer clinical outcomes, underscore the urgency of rapidly treating depression to full recovery. Early optimized treatment, using measurement-based care and customizing treatment to the individual patient, may afford the best possible outcomes for each patient. The aim of this article is to present recommendations for using a patient-centered approach to rapidly provide optimal pharmacological treatment to patients with major depressive disorder. Offering major depressive disorder treatment determined by individual patient characteristics (e.g., predominant symptoms, medical history, comorbidities), patient preferences and expectations, and, critically, their own definition of wellness provides the best opportunity for full functional recovery. © The Author(s) 2017. Published by Oxford University Press on behalf of CINP.

Optimizing Anti-VEGF Treatment Outcomes for Patients with Neovascular Age-Related Macular Degeneration.

PubMed

Wykoff, Charles C; Clark, W Lloyd; Nielsen, Jared S; Brill, Joel V; Greene, Laurence S; Heggen, Cherilyn L

2018-02-01

The introduction of anti-vascular endothelial growth factor (anti-VEGF) drugs to ophthalmology has revolutionized the treatment of neovascular age-related macular degeneration (nAMD). Despite this significant progress, gaps and challenges persist in the diagnosis of nAMD, initiation of treatment, and management of frequent intravitreal injections. Thus, nAMD remains a leading cause of blindness in the United States. To present current knowledge, evidence, and expert perspectives on anti-VEGF therapies in nAMD to support managed care professionals and providers in decision making and collaborative strategies to overcome barriers to optimize anti-VEGF treatment outcomes among nAMD patients. Three anti-VEGF therapies currently form the mainstay of treatment for nAMD, including 2 therapies approved by the FDA for treatment of nAMD (aflibercept and ranibizumab) and 1 therapy approved by the FDA for oncology indications and used off-label for treatment of nAMD (bevacizumab). In clinical trials, each of the 3 agents maintained visual acuity (VA) in approximately 90% or more of nAMD patients over 2 years. However, in long-term and real-world settings, significant gaps and challenges in diagnosis, treatment, and management pose barriers to achieving optimal outcomes for patients with nAMD. Many considerations, including individual patient characteristics, on-label versus off-label treatment, repackaging, and financial considerations, add to the complexity of nAMD decision making and management. Many factors may contribute to additional challenges leading to suboptimal long-term outcomes among nAMD patients, such as delays in diagnosis and/or treatment approval and initiation, individual patient response to different anti-VEGF therapies, lapses in physician regimentation of anti-VEGF injection and monitoring, and inadequate patient adherence to treatment and monitoring. These latter factors highlight the considerable logistical, emotional, and financial burdens of long

Effect of self-efficacy and physical activity goal achievement on arthritis pain and quality of life in patients with rheumatoid arthritis.

PubMed

Knittle, Keegan P; De Gucht, Véronique; Hurkmans, Emalie J; Vlieland, Thea P M Vliet; Peeters, André J; Ronday, H Karel; Maes, Stan

2011-11-01

To examine physical activity and achievement of physical activity goals in relation to self-reported pain and quality of life among patients with rheumatoid arthritis (RA). At baseline, 271 patients with RA were asked to specify a physical activity goal, and filled in questionnaires assessing physical activity, motivation, and self-efficacy for physical activity, arthritis pain, and quality of life. Six months later, patients indicated to what extent they had achieved their baseline physical activity goal and completed the same set of questionnaires. These data were used to construct multiple mediation models that placed physical activity and physical activity goal achievement as mediators between self-efficacy and motivation on one hand, and arthritis pain and quality of life on the other. A total of 106 patients with RA completed both questionnaires. Self-efficacy at baseline predicted subsequent level of physical activity and achievement of physical activity goals. Goal achievement had a direct effect upon quality of life outcomes. Bootstrapping confidence intervals revealed indirect effects of self-efficacy upon arthritis pain and quality of life through goal achievement, but not through physical activity. Higher levels of self-efficacy for physical activity increase the likelihood that patients will achieve their physical activity goals. Achievement of physical activity goals seems to be related to lower self-reported arthritis pain, and higher levels of quality of life. In practice, clinicians can foster self-efficacy and goal achievement by assisting patients in setting realistic and attainable exercise goals, developing action plans, and by providing feedback on goal progress. Copyright © 2011 by the American College of Rheumatology.

Multidisciplinary optimization for engineering systems - Achievements and potential

NASA Technical Reports Server (NTRS)

Sobieszczanski-Sobieski, Jaroslaw

1989-01-01

The currently common sequential design process for engineering systems is likely to lead to suboptimal designs. Recently developed decomposition methods offer an alternative for coming closer to optimum by breaking the large task of system optimization into smaller, concurrently executed and, yet, coupled tasks, identified with engineering disciplines or subsystems. The hierarchic and non-hierarchic decompositions are discussed and illustrated by examples. An organization of a design process centered on the non-hierarchic decomposition is proposed.

Multidisciplinary optimization for engineering systems: Achievements and potential

NASA Technical Reports Server (NTRS)

Sobieszczanski-Sobieski, Jaroslaw

1989-01-01

The currently common sequential design process for engineering systems is likely to lead to suboptimal designs. Recently developed decomposition methods offer an alternative for coming closer to optimum by breaking the large task of system optimization into smaller, concurrently executed and, yet, coupled tasks, identified with engineering disciplines or subsystems. The hierarchic and non-hierarchic decompositions are discussed and illustrated by examples. An organization of a design process centered on the non-hierarchic decomposition is proposed.

Ant Lion Optimization algorithm for kidney exchanges.

PubMed

Hamouda, Eslam; El-Metwally, Sara; Tarek, Mayada

2018-01-01

The kidney exchange programs bring new insights in the field of organ transplantation. They make the previously not allowed surgery of incompatible patient-donor pairs easier to be performed on a large scale. Mathematically, the kidney exchange is an optimization problem for the number of possible exchanges among the incompatible pairs in a given pool. Also, the optimization modeling should consider the expected quality-adjusted life of transplant candidates and the shortage of computational and operational hospital resources. In this article, we introduce a bio-inspired stochastic-based Ant Lion Optimization, ALO, algorithm to the kidney exchange space to maximize the number of feasible cycles and chains among the pool pairs. Ant Lion Optimizer-based program achieves comparable kidney exchange results to the deterministic-based approaches like integer programming. Also, ALO outperforms other stochastic-based methods such as Genetic Algorithm in terms of the efficient usage of computational resources and the quantity of resulting exchanges. Ant Lion Optimization algorithm can be adopted easily for on-line exchanges and the integration of weights for hard-to-match patients, which will improve the future decisions of kidney exchange programs. A reference implementation for ALO algorithm for kidney exchanges is written in MATLAB and is GPL licensed. It is available as free open-source software from: https://github.com/SaraEl-Metwally/ALO_algorithm_for_Kidney_Exchanges.

MCTP system model based on linear programming optimization of apertures obtained from sequencing patient image data maps.

PubMed

Ureba, A; Salguero, F J; Barbeiro, A R; Jimenez-Ortega, E; Baeza, J A; Miras, H; Linares, R; Perucha, M; Leal, A

2014-08-01

The authors present a hybrid direct multileaf collimator (MLC) aperture optimization model exclusively based on sequencing of patient imaging data to be implemented on a Monte Carlo treatment planning system (MC-TPS) to allow the explicit radiation transport simulation of advanced radiotherapy treatments with optimal results in efficient times for clinical practice. The planning system (called CARMEN) is a full MC-TPS, controlled through aMATLAB interface, which is based on the sequencing of a novel map, called "biophysical" map, which is generated from enhanced image data of patients to achieve a set of segments actually deliverable. In order to reduce the required computation time, the conventional fluence map has been replaced by the biophysical map which is sequenced to provide direct apertures that will later be weighted by means of an optimization algorithm based on linear programming. A ray-casting algorithm throughout the patient CT assembles information about the found structures, the mass thickness crossed, as well as PET values. Data are recorded to generate a biophysical map for each gantry angle. These maps are the input files for a home-made sequencer developed to take into account the interactions of photons and electrons with the MLC. For each linac (Axesse of Elekta and Primus of Siemens) and energy beam studied (6, 9, 12, 15 MeV and 6 MV), phase space files were simulated with the EGSnrc/BEAMnrc code. The dose calculation in patient was carried out with the BEAMDOSE code. This code is a modified version of EGSnrc/DOSXYZnrc able to calculate the beamlet dose in order to combine them with different weights during the optimization process. Three complex radiotherapy treatments were selected to check the reliability of CARMEN in situations where the MC calculation can offer an added value: A head-and-neck case (Case I) with three targets delineated on PET/CT images and a demanding dose-escalation; a partial breast irradiation case (Case II) solved

Using Technology, Clinical Workflow Redesign, and Team Solutions to Achieve the Patient Centered Medical Home

DTIC Science & Technology

2011-01-01

The Quadruple Aim: Working Together, Achieving Success 2011 Military Health System Conference TMA and Services Using Technology, Clinical Workflow...Redesign, and Team Solutions to Achieve the Patient Centered Medical Home LTC Nicole Kerkenbush, MHA, MN Army Medical Department, Office of the...Surgeon General Chief Medical Information Officer 1 Military Health System Conference Report Documentation Page Form ApprovedOMB No. 0704-0188 Public

SU-D-206-01: Employing a Novel Consensus Optimization Strategy to Achieve Iterative Cone Beam CT Reconstruction On a Multi-GPU Platform

DOE Office of Scientific and Technical Information (OSTI.GOV)

Li, B; Southern Medical University, Guangzhou, Guangdong; Tian, Z

Purpose: While compressed sensing-based cone-beam CT (CBCT) iterative reconstruction techniques have demonstrated tremendous capability of reconstructing high-quality images from undersampled noisy data, its long computation time still hinders wide application in routine clinic. The purpose of this study is to develop a reconstruction framework that employs modern consensus optimization techniques to achieve CBCT reconstruction on a multi-GPU platform for improved computational efficiency. Methods: Total projection data were evenly distributed to multiple GPUs. Each GPU performed reconstruction using its own projection data with a conventional total variation regularization approach to ensure image quality. In addition, the solutions from GPUs were subjectmore » to a consistency constraint that they should be identical. We solved the optimization problem with all the constraints considered rigorously using an alternating direction method of multipliers (ADMM) algorithm. The reconstruction framework was implemented using OpenCL on a platform with two Nvidia GTX590 GPU cards, each with two GPUs. We studied the performance of our method and demonstrated its advantages through a simulation case with a NCAT phantom and an experimental case with a Catphan phantom. Result: Compared with the CBCT images reconstructed using conventional FDK method with full projection datasets, our proposed method achieved comparable image quality with about one third projection numbers. The computation time on the multi-GPU platform was ∼55 s and ∼ 35 s in the two cases respectively, achieving a speedup factor of ∼ 3.0 compared with single GPU reconstruction. Conclusion: We have developed a consensus ADMM-based CBCT reconstruction method which enabled performing reconstruction on a multi-GPU platform. The achieved efficiency made this method clinically attractive.« less

Time-optimal control with finite bandwidth

NASA Astrophysics Data System (ADS)

Hirose, M.; Cappellaro, P.

2018-04-01

Time-optimal control theory provides recipes to achieve quantum operations with high fidelity and speed, as required in quantum technologies such as quantum sensing and computation. While technical advances have achieved the ultrastrong driving regime in many physical systems, these capabilities have yet to be fully exploited for the precise control of quantum systems, as other limitations, such as the generation of higher harmonics or the finite response time of the control apparatus, prevent the implementation of theoretical time-optimal control. Here we present a method to achieve time-optimal control of qubit systems that can take advantage of fast driving beyond the rotating wave approximation. We exploit results from time-optimal control theory to design driving protocols that can be implemented with realistic, finite-bandwidth control fields, and we find a relationship between bandwidth limitations and achievable control fidelity.

Impact of Timely Treatment Intensification on Glycemic Goal Achievement in Patients With Type 2 Diabetes Failing Metformin Monotherapy.

PubMed

Mahabaleshwarkar, Rohan; Templin, Megan; Gohs, Frank; Mulder, Holly; DeSantis, Andrea; Ejzykowicz, Flavia; Rajpathak, Swapnil; Wilkins, Nick

2017-10-01

Purpose The purpose of the study was to examine the association between timely treatment intensification (TTI) and glycemic goal achievement in patients with type 2 diabetes (T2D) failing metformin monotherapy (MM). Methods This study was set at a large integrated health care system in the United States. The study cohort included T2D patients aged 18 to 85 years who were on MM between January 2009 and September 2013 and had an uncontrolled glycated hemoglobin (A1C) reading (≥8%) after at least 3 months of MM (corresponding date was index date). Secondary analyses were performed using A1C <7% as T2D control. TTI was defined as receipt of an add-on therapy within 180 days after the index date. Impact of TTI on glycemic goal achievement was determined using multivariate Cox proportional hazards regression. Patients were censored at their last A1C reading or health care visit during 2 years after the index date. Results The study cohort consisted of 996 patients, ~58% male and ~59% Caucasian, with a mean age of ~54 (±12) years. TTI was observed in 50.2% of the patients. The rate of glycemic goal achievement was higher in patients with TTI compared with patients without TTI (hazards ratio = 1.632, 95% confidence interval = 1.328-2.006). The results for the secondary analyses were largely consistent with the primary findings. Conclusions TTI positively affected glycemic goal achievement among T2D patients failing MM and could be a useful strategy to increase the currently low proportion of patients with their T2D controlled in the United States.

Impact of optimal anticoagulation therapy on chronic venous ulcer healing in thrombophilic patients with post-thrombotic syndrome.

PubMed

Hinojosa, C A; Olivares-Cruz, S; Laparra-Escareno, H; Sanchez-Castro, S; Tamayo-Garcia, B; Anaya-Ayala, J E

2016-12-02

Post-thrombotic syndrome (PTS) is the long-term sequelae of deep venous thrombosis (DVT). PTS clinical manifestations include chronic leg pain, oedema, lipodermatosclerosis and ulcers. The objective of this study is to determine in patients with documented history of thrombophilias and DVT whether the number of previous thrombotic events and optimal anticoagulation therapy are associated with the time to venous ulcer healing following the start of compression therapy. Retrospective analysis performed in thrombophilic patients under the age of 50 years old with chronic venous ulcers secondary to DVT at the wound clinic in the National Institute of Medical Sciences and Nutrition 'Salvador Zubirán ' in Mexico City. Variables such as the number or episodes of thrombotic events, type of hypercoagulable disorder, optimal anticoagulation therapy with Warfarin monitored by therapeutic International Normalised Ratio (INR) (2-3) and compliance to compression therapy were examined. Patients that underwent superficial or perforator vein interruption or endovascular recanalisation of deep veins were excluded from the study. From a database of 29 patients with chronic venous ulcers followed in our clinic from January 1992 to September 2012, only 13 patients (61% female) met the inclusion criteria. Mean age±standard deviation (SD) was 32±12 years old. Of these, seven (54%) patients with suboptimal INR presented with an average of two previous thrombotic events and the remaining six (46%) patients with optimal INR only one event (p=0.28), the mean time to the clinical manifestation of a venous ulcer after the first episode of DVT was 39 months (range: 12-72) for patients with suboptimal INR and 82 months (range: 12-216) for those with optimal anticoagulation therapy (p=0.11). During the mean follow-up period of 52 months, all patients in optimal anticoagulation healed their ulcer; their mean time for wound healing was 44 months (range: 4-102). In the suboptimal INR group, only

Implementation of a dose gradient method into optimization of dose distribution in prostate cancer 3D-CRT plans

PubMed Central

Giżyńska, Marta K.; Kukołowicz, Paweł F.; Kordowski, Paweł

2014-01-01

Aim The aim of this work is to present a method of beam weight and wedge angle optimization for patients with prostate cancer. Background 3D-CRT is usually realized with forward planning based on a trial and error method. Several authors have published a few methods of beam weight optimization applicable to the 3D-CRT. Still, none on these methods is in common use. Materials and methods Optimization is based on the assumption that the best plan is achieved if dose gradient at ICRU point is equal to zero. Our optimization algorithm requires beam quality index, depth of maximum dose, profiles of wedged fields and maximum dose to femoral heads. The method was tested for 10 patients with prostate cancer, treated with the 3-field technique. Optimized plans were compared with plans prepared by 12 experienced planners. Dose standard deviation in target volume, and minimum and maximum doses were analyzed. Results The quality of plans obtained with the proposed optimization algorithms was comparable to that prepared by experienced planners. Mean difference in target dose standard deviation was 0.1% in favor of the plans prepared by planners for optimization of beam weights and wedge angles. Introducing a correction factor for patient body outline for dose gradient at ICRU point improved dose distribution homogeneity. On average, a 0.1% lower standard deviation was achieved with the optimization algorithm. No significant difference in mean dose–volume histogram for the rectum was observed. Conclusions Optimization shortens very much time planning. The average planning time was 5 min and less than a minute for forward and computer optimization, respectively. PMID:25337411

Optimization of the intravenous glucose tolerance test in T2DM patients using optimal experimental design.

PubMed

Silber, Hanna E; Nyberg, Joakim; Hooker, Andrew C; Karlsson, Mats O

2009-06-01

Intravenous glucose tolerance test (IVGTT) provocations are informative, but complex and laborious, for studying the glucose-insulin system. The objective of this study was to evaluate, through optimal design methodology, the possibilities of more informative and/or less laborious study design of the insulin modified IVGTT in type 2 diabetic patients. A previously developed model for glucose and insulin regulation was implemented in the optimal design software PopED 2.0. The following aspects of the study design of the insulin modified IVGTT were evaluated; (1) glucose dose, (2) insulin infusion, (3) combination of (1) and (2), (4) sampling times, (5) exclusion of labeled glucose. Constraints were incorporated to avoid prolonged hyper- and/or hypoglycemia and a reduced design was used to decrease run times. Design efficiency was calculated as a measure of the improvement with an optimal design compared to the basic design. The results showed that the design of the insulin modified IVGTT could be substantially improved by the use of an optimized design compared to the standard design and that it was possible to use a reduced number of samples. Optimization of sample times gave the largest improvement followed by insulin dose. The results further showed that it was possible to reduce the total sample time with only a minor loss in efficiency. Simulations confirmed the predictions from PopED. The predicted uncertainty of parameter estimates (CV) was low in all tested cases, despite the reduction in the number of samples/subject. The best design had a predicted average CV of parameter estimates of 19.5%. We conclude that improvement can be made to the design of the insulin modified IVGTT and that the most important design factor was the placement of sample times followed by the use of an optimal insulin dose. This paper illustrates how complex provocation experiments can be improved by sequential modeling and optimal design.

Dose reduction and image quality optimizations in CT of pediatric and adult patients: phantom studies

NASA Astrophysics Data System (ADS)

Jeon, P.-H.; Lee, C.-L.; Kim, D.-H.; Lee, Y.-J.; Jeon, S.-S.; Kim, H.-J.

2014-03-01

Multi-detector computed tomography (MDCT) can be used to easily and rapidly perform numerous acquisitions, possibly leading to a marked increase in the radiation dose to individual patients. Technical options dedicated to automatically adjusting the acquisition parameters according to the patient's size are of specific interest in pediatric radiology. A constant tube potential reduction can be achieved for adults and children, while maintaining a constant detector energy fluence. To evaluate radiation dose, the weighted CT dose index (CTDIw) was calculated based on the CT dose index (CTDI) measured using an ion chamber, and image noise and image contrast were measured from a scanned image to evaluate image quality. The dose-weighted contrast-to-noise ratio (CNRD) was calculated from the radiation dose, image noise, and image contrast measured from a scanned image. The noise derivative (ND) is a quality index for dose efficiency. X-ray spectra with tube voltages ranging from 80 to 140 kVp were used to compute the average photon energy. Image contrast and the corresponding contrast-to-noise ratio (CNR) were determined for lesions of soft tissue, muscle, bone, and iodine relative to a uniform water background, as the iodine contrast increases at lower energy (i.e., k-edge of iodine is 33 keV closer to the beam energy) using mixed water-iodine contrast normalization (water 0, iodine 25, 100, 200, and 1000 HU, respectively). The proposed values correspond to high quality images and can be reduced if only high-contrast organs are assessed. The potential benefit of lowering the tube voltage is an improved CNRD, resulting in a lower radiation dose and optimization of image quality. Adjusting the tube potential in abdominal CT would be useful in current pediatric radiography, where the choice of X-ray techniques generally takes into account the size of the patient as well as the need to balance the conflicting requirements of diagnostic image quality and radiation dose

A National Registry of Thalassemia in Turkey: Demographic and Disease Characteristics of Patients, Achievements, and Challenges in Prevention

PubMed Central

Aydınok, Yeşim; Oymak, Yeşim; Atabay, Berna; Aydoğan, Gönül; Yeşilipek, Akif; Ünal, Selma; Kılınç, Yurdanur; Oflaz, Banu; Akın, Mehmet; Vergin, Canan; Sezgin Evim, Melike; Çalışkan, Ümran; Ünal, Şule; Bay, Ali; Kazancı, Elif; İleri, Talia; Atay, Didem; Patıroğlu, Türkan; Kahraman, Selda; Söker, Murat; Akcan, Mediha; Akdeniz, Aydan; Büyükavcı, Mustafa; Alanoğlu, Güçhan; Bör, Özcan; Soyer, Nur; Özdemir Karadaş, Nihal; Uysalol, Ezgi; Türker, Meral; Akçay, Arzu; Ocak, Süheyla; Güneş, Adalet Meral; Tokgöz, Hüseyin; Ünal, Elif; Tiftik, Naci; Karakaş, Zeynep

2018-01-01

Objective: The Turkish Society of Pediatric Hematology set up a National Hemoglobinopathy Registry to demonstrate the demographic and disease characteristics of patients and assess the efficacy of a hemoglobinopathy control program (HCP) over 10 years in Turkey. Materials and Methods: A total of 2046 patients from 27 thalassemia centers were registered, of which 1988 were eligible for analysis. This cohort mainly comprised patients with β-thalassemia major (n=1658, 83.4%) and intermedia (n=215, 10.8%). Results: The majority of patients were from the coastal areas of Turkey. The high number of patients in Southeastern Anatolia was due to that area having the highest rates of consanguineous marriage and fertility. The most common 11 mutations represented 90% of all β-thalassemia alleles and 47% of those were IVS1-110(G->A) mutations. The probability of undergoing splenectomy within the first 10 years of life was 20%, a rate unchanged since the 1980s. Iron chelators were administered as monotherapy regimens in 95% of patients and deferasirox was prescribed in 81.3% of those cases. Deferasirox administration was the highest (93.6%) in patients aged <10 years. Of the thalassemia major patients, 5.8% had match-related hemopoietic stem cell transplantation with a success rate of 77%. Cardiac disease was detected as a major cause of death and did not show a decreasing trend in 5-year cohorts since 1999. Conclusion: While the HCP has been implemented since 2003, the affected births have shown a consistent decrease only after 2009, being at lowest 34 cases per year. This program failure resulted from a lack of premarital screening in the majority of cases. Additional problems were unawareness of the risk and misinformation of the at-risk couples. In addition, prenatal diagnosis was either not offered to or was not accepted by the at-risk families. This study indicated that a continuous effort is needed for optimizing the management of thalassemia and the development of

A National Registry of Thalassemia in Turkey: Demographic and Disease Characteristics of Patients, Achievements, and Challenges in Prevention.

PubMed

Aydınok, Yeşim; Oymak, Yeşim; Atabay, Berna; Aydoğan, Gönül; Yeşilipek, Akif; Ünal, Selma; Kılınç, Yurdanur; Oflaz, Banu; Akın, Mehmet; Vergin, Canan; Sezgin Evim, Melike; Çalışkan, Ümran; Ünal, Şule; Bay, Ali; Kazancı, Elif; İleri, Talia; Atay, Didem; Patıroğlu, Türkan; Kahraman, Selda; Söker, Murat; Akcan, Mediha; Akdeniz, Aydan; Büyükavcı, Mustafa; Alanoğlu, Güçhan; Bör, Özcan; Soyer, Nur; Özdemir Karadaş, Nihal; Uysalol, Ezgi; Türker, Meral; Akçay, Arzu; Ocak, Süheyla; Güneş, Adalet Meral; Tokgöz, Hüseyin; Ünal, Elif; Tiftik, Naci; Karakaş, Zeynep

2018-03-01

The Turkish Society of Pediatric Hematology set up a National Hemoglobinopathy Registry to demonstrate the demographic and disease characteristics of patients and assess the efficacy of a hemoglobinopathy control program (HCP) over 10 years in Turkey. A total of 2046 patients from 27 thalassemia centers were registered, of which 1988 were eligible for analysis. This cohort mainly comprised patients with β-thalassemia major (n=1658, 83.4%) and intermedia (n=215, 10.8%). The majority of patients were from the coastal areas of Turkey. The high number of patients in Southeastern Anatolia was due to that area having the highest rates of consanguineous marriage and fertility. The most common 11 mutations represented 90% of all β-thalassemia alleles and 47% of those were IVS1-110(G->A) mutations. The probability of undergoing splenectomy within the first 10 years of life was 20%, a rate unchanged since the 1980s. Iron chelators were administered as monotherapy regimens in 95% of patients and deferasirox was prescribed in 81.3% of those cases. Deferasirox administration was the highest (93.6%) in patients aged <10 years. Of the thalassemia major patients, 5.8% had match-related hemopoietic stem cell transplantation with a success rate of 77%. Cardiac disease was detected as a major cause of death and did not show a decreasing trend in 5-year cohorts since 1999. While the HCP has been implemented since 2003, the affected births have shown a consistent decrease only after 2009, being at lowest 34 cases per year. This program failure resulted from a lack of premarital screening in the majority of cases. Additional problems were unawareness of the risk and misinformation of the at-risk couples. In addition, prenatal diagnosis was either not offered to or was not accepted by the at-risk families. This study indicated that a continuous effort is needed for optimizing the management of thalassemia and the development of strategies is essential for further achievements in the

A common optimization principle for motor execution in healthy subjects and parkinsonian patients.

PubMed

Baraduc, Pierre; Thobois, Stéphane; Gan, Jing; Broussolle, Emmanuel; Desmurget, Michel

2013-01-09

Recent research on Parkinson's disease (PD) has emphasized that parkinsonian movement, although bradykinetic, shares many attributes with healthy behavior. This observation led to the suggestion that bradykinesia in PD could be due to a reduction in motor motivation. This hypothesis can be tested in the framework of optimal control theory, which accounts for many characteristics of healthy human movement while providing a link between the motor behavior and a cost/benefit trade-off. This approach offers the opportunity to interpret movement deficits of PD patients in the light of a computational theory of normal motor control. We studied 14 PD patients with bilateral subthalamic nucleus (STN) stimulation and 16 age-matched healthy controls, and tested whether reaching movements were governed by similar rules in these two groups. A single optimal control model accounted for the reaching movements of healthy subjects and PD patients, whatever the condition of STN stimulation (on or off). The choice of movement speed was explained in all subjects by the existence of a preset dynamic range for the motor signals. This range was idiosyncratic and applied to all movements regardless of their amplitude. In PD patients this dynamic range was abnormally narrow and correlated with bradykinesia. STN stimulation reduced bradykinesia and widened this range in all patients, but did not restore it to a normal value. These results, consistent with the motor motivation hypothesis, suggest that constrained optimization of motor effort is the main determinant of movement planning (choice of speed) and movement production, in both healthy and PD subjects.

Using a Delphi process to determine optimal care for patients with pancreatic cancer.

PubMed

Burmeister, Elizabeth A; Jordan, Susan J; O'Connell, Dianne L; Beesley, Vanessa L; Goldstein, David; Gooden, Helen M; Janda, Monika; Merrett, Neil D; Wyld, David; Neale, Rachel E

2016-06-01

Overall 5-year survival for pancreatic cancer is ∼5%. Optimizing the care that pancreatic cancer patients receive may be one way of improving outcomes. The objective of this study was to establish components of care which Australian health professionals believe important to optimally manage patients with pancreatic cancer. Using a Delphi process, a multidisciplinary panel of 250 health professionals were invited to provide a list of factors they considered important for optimal care of pancreatic cancer patients. They were then asked to score and then rescore (from one [no importance/disagree] to 10 [very important/agree]) the factors. The mean and coefficient of variation scores were calculated and categorized into three levels of importance. Overall, 63 (66% of those sent the final questionnaire; 25% of those initially invited) health professionals from nine disciplines completed the final scoring of 55 statements/factors encompassing themes of presentation/staging, surgery and biliary obstruction, multidisciplinary team details and oncology. Mean scores ranged from 3.7 to 9.7 with the highest related to communication and patient assessment. There was substantial intra- and interdisciplinary variation in views about MDT membership and roles. Overall, the opinions of Australian health professionals reflect international guideline recommended care; however, they identified a number of additional factors focusing on where patients should be treated, the importance of clear communication and the need for multidisciplinary care which were not included in current clinical practice guidelines. Differences in priorities between specialty groups were also identified. © 2016 John Wiley & Sons Australia, Ltd.

Optimizing the Nutritional Support of Adult Patients in the Setting of Cirrhosis.

PubMed

Perumpail, Brandon J; Li, Andrew A; Cholankeril, George; Kumari, Radhika; Ahmed, Aijaz

2017-10-13

The aim of this work is to develop a pragmatic approach in the assessment and management strategies of patients with cirrhosis in order to optimize the outcomes in this patient population. A systematic review of literature was conducted through 8 July 2017 on the PubMed Database looking for key terms, such as malnutrition, nutrition, assessment, treatment, and cirrhosis. Articles and studies looking at associations between nutrition and cirrhosis were reviewed. An assessment of malnutrition should be conducted in two stages: the first, to identify patients at risk for malnutrition based on the severity of liver disease, and the second, to perform a complete multidisciplinary nutritional evaluation of these patients. Optimal management of malnutrition should focus on meeting recommended daily goals for caloric intake and inclusion of various nutrients in the diet. The nutritional goals should be pursued by encouraging and increasing oral intake or using other measures, such as oral supplementation, enteral nutrition, or parenteral nutrition. Although these strategies to improve nutritional support have been well established, current literature on the topic is limited in scope. Further research should be implemented to test if this enhanced approach is effective.

Educational achievement in psychiatric patients and their siblings: a register-based study in 30 000 individuals in The Netherlands.

PubMed

Tempelaar, W M; Termorshuizen, F; MacCabe, J H; Boks, M P M; Kahn, R S

2017-03-01

Poor educational achievement is associated with a range of psychiatric disorders. Several studies suggest that this underperformance is due to cognitive deficits that commence before disease onset and reflect a genetic risk for this disorder. However, the specificity and the familial contribution of this cognitive deficit are not clear. We analysed lifetime educational achievement of psychiatric patients diagnosed with schizophrenia, bipolar or depressive disorder and their unaffected siblings. In a register-based case-control study, 1561 patients with schizophrenia, 813 patients with bipolar disorder, 8112 patients with depression, and their siblings were each matched with eight population controls. Patients, siblings and controls were compared on the highest educational stream they completed. Lower educational achievement was present in schizophrenia patients from primary school onwards [completing primary school: odds ratio (OR) 0.69; completing secondary school: OR 0.69; completing academic education: OR 0.46], compared to patients with bipolar disorder or depression. Siblings of schizophrenia, bipolar or depressed patients showed no underachievement at primary or secondary school, but siblings of schizophrenia patients as well as siblings of depressed patients were less successful in their educational achievement after secondary school (completing academic education, schizophrenia siblings: OR 0.90; depressive disorder siblings: OR 0.91). Educational underachievement from primary school onwards is specifically related to schizophrenia and not to bipolar disorder or depression. Moreover, it appears to be a harbinger of the illness, since it is not found in their siblings. These results add to evidence that early cognitive deficits are a distinct feature of the schizophrenia phenotype.

Optimized protocols for cardiac magnetic resonance imaging in patients with thoracic metallic implants.

PubMed

Olivieri, Laura J; Cross, Russell R; O'Brien, Kendall E; Ratnayaka, Kanishka; Hansen, Michael S

2015-09-01

Cardiac magnetic resonance (MR) imaging is a valuable tool in congenital heart disease; however patients frequently have metal devices in the chest from the treatment of their disease that complicate imaging. Methods are needed to improve imaging around metal implants near the heart. Basic sequence parameter manipulations have the potential to minimize artifact while limiting effects on image resolution and quality. Our objective was to design cine and static cardiac imaging sequences to minimize metal artifact while maintaining image quality. Using systematic variation of standard imaging parameters on a fluid-filled phantom containing commonly used metal cardiac devices, we developed optimized sequences for steady-state free precession (SSFP), gradient recalled echo (GRE) cine imaging, and turbo spin-echo (TSE) black-blood imaging. We imaged 17 consecutive patients undergoing routine cardiac MR with 25 metal implants of various origins using both standard and optimized imaging protocols for a given slice position. We rated images for quality and metal artifact size by measuring metal artifact in two orthogonal planes within the image. All metal artifacts were reduced with optimized imaging. The average metal artifact reduction for the optimized SSFP cine was 1.5+/-1.8 mm, and for the optimized GRE cine the reduction was 4.6+/-4.5 mm (P < 0.05). Quality ratings favored the optimized GRE cine. Similarly, the average metal artifact reduction for the optimized TSE images was 1.6+/-1.7 mm (P < 0.05), and quality ratings favored the optimized TSE imaging. Imaging sequences tailored to minimize metal artifact are easily created by modifying basic sequence parameters, and images are superior to standard imaging sequences in both quality and artifact size. Specifically, for optimized cine imaging a GRE sequence should be used with settings that favor short echo time, i.e. flow compensation off, weak asymmetrical echo and a relatively high receiver bandwidth

Heart Rate Dynamics During A Treadmill Cardiopulmonary Exercise Test in Optimized Beta-Blocked Heart Failure Patients

PubMed Central

Carvalho, Vitor Oliveira; Guimarães, Guilherme Veiga; Ciolac, Emmanuel Gomes; Bocchi, Edimar Alcides

2008-01-01

BACKGROUND Calculating the maximum heart rate for age is one method to characterize the maximum effort of an individual. Although this method is commonly used, little is known about heart rate dynamics in optimized beta-blocked heart failure patients. AIM The aim of this study was to evaluate heart rate dynamics (basal, peak and % heart rate increase) in optimized beta-blocked heart failure patients compared to sedentary, normal individuals (controls) during a treadmill cardiopulmonary exercise test. METHODS Twenty-five heart failure patients (49±11 years, 76% male), with an average LVEF of 30±7%, and fourteen controls were included in the study. Patients with atrial fibrillation, a pacemaker or noncardiovascular functional limitations or whose drug therapy was not optimized were excluded. Optimization was considered to be 50 mg/day or more of carvedilol, with a basal heart rate between 50 to 60 bpm that was maintained for 3 months. RESULTS Basal heart rate was lower in heart failure patients (57±3 bpm) compared to controls (89±14 bpm; p<0.0001). Similarly, the peak heart rate (% maximum predicted for age) was lower in HF patients (65.4±11.1%) compared to controls (98.6±2.2; p<0.0001). Maximum respiratory exchange ratio did not differ between the groups (1.2±0.5 for controls and 1.15±1 for heart failure patients; p=0.42). All controls reached the maximum heart rate for their age, while no patients in the heart failure group reached the maximum. Moreover, the % increase of heart rate from rest to peak exercise between heart failure (48±9%) and control (53±8%) was not different (p=0.157). CONCLUSION No patient in the heart failure group reached the maximum heart rate for their age during a treadmill cardiopulmonary exercise test, despite the fact that the percentage increase of heart rate was similar to sedentary normal subjects. A heart rate increase in optimized beta-blocked heart failure patients during cardiopulmonary exercise test over 65% of the

Optimal methotrexate dose is associated with better clinical outcomes than non-optimal dose in daily practice: results from the ESPOIR early arthritis cohort.

PubMed

Gaujoux-Viala, Cécile; Rincheval, Nathalie; Dougados, Maxime; Combe, Bernard; Fautrel, Bruno

2017-12-01

Although methotrexate (MTX) is the consensual first-line disease-modifying antirheumatic drug (DMARD) for rheumatoid arthritis (RA), substantial heterogeneity remains with its prescription and dosage, which are often not optimal. To evaluate the symptomatic and structural impact of optimal MTX dose in patients with early RA in daily clinical practice over 2 years. Patients included in the early arthritis ESPOIR cohort who fulfilled the ACR-EULAR (American College of Rheumatology/European League against Rheumatism) criteria for RA and received MTX as a first DMARD were assessed. Optimal MTX dose was defined as ≥10 mg/week during the first 3 months, with escalation to ≥20 mg/week or 0.3 mg/kg/week at 6 months without Disease Activity Score in 28 joints remission. Symptomatic and structural efficacy with and without optimal MTX dose was assessed by generalised logistic regression with adjustment for appropriate variables. Within the first year of follow-up, 314 patients (53%) with RA received MTX as a first DMARD (mean dose 12.2±3.8 mg/week). Only 26.4% (n=76) had optimal MTX dose. After adjustment, optimal versus non-optimal MTX dose was more efficient in achieving ACR-EULAR remission at 1 year (OR 4.28 (95% CI 1.86 to 9.86)) and normal functioning (Health Assessment Questionnaire ≤0.5; OR at 1 year 4.36 (95% CI 2.03 to 9.39)), with no effect on radiological progression. Results were similar during the second year. Optimal MTX dose is more efficacious than non-optimal dose for remission and function in early arthritis in daily practice, with no impact on radiological progression over 2 years. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Optimized distributed systems achieve significant performance improvement on sorted merging of massive VCF files.

PubMed

Sun, Xiaobo; Gao, Jingjing; Jin, Peng; Eng, Celeste; Burchard, Esteban G; Beaty, Terri H; Ruczinski, Ingo; Mathias, Rasika A; Barnes, Kathleen; Wang, Fusheng; Qin, Zhaohui S

2018-06-01

Sorted merging of genomic data is a common data operation necessary in many sequencing-based studies. It involves sorting and merging genomic data from different subjects by their genomic locations. In particular, merging a large number of variant call format (VCF) files is frequently required in large-scale whole-genome sequencing or whole-exome sequencing projects. Traditional single-machine based methods become increasingly inefficient when processing large numbers of files due to the excessive computation time and Input/Output bottleneck. Distributed systems and more recent cloud-based systems offer an attractive solution. However, carefully designed and optimized workflow patterns and execution plans (schemas) are required to take full advantage of the increased computing power while overcoming bottlenecks to achieve high performance. In this study, we custom-design optimized schemas for three Apache big data platforms, Hadoop (MapReduce), HBase, and Spark, to perform sorted merging of a large number of VCF files. These schemas all adopt the divide-and-conquer strategy to split the merging job into sequential phases/stages consisting of subtasks that are conquered in an ordered, parallel, and bottleneck-free way. In two illustrating examples, we test the performance of our schemas on merging multiple VCF files into either a single TPED or a single VCF file, which are benchmarked with the traditional single/parallel multiway-merge methods, message passing interface (MPI)-based high-performance computing (HPC) implementation, and the popular VCFTools. Our experiments suggest all three schemas either deliver a significant improvement in efficiency or render much better strong and weak scalabilities over traditional methods. Our findings provide generalized scalable schemas for performing sorted merging on genetics and genomics data using these Apache distributed systems.

Both Patient and Facility Contribute to Achieving the Centers for Medicare and Medicaid Services' Pay-for-Performance Target for Dialysis Adequacy

PubMed Central

Tighiouart, Hocine; Meyer, Klemens B.; Miskulin, Dana C.

2011-01-01

The Centers for Medicare and Medicaid Services (CMS) designated the achieved urea reduction ratio (URR) as a pay-for-performance measure, but to what extent this measure reflects patient characteristics and adherence instead of its intent to reflect facility performance is unknown. Here, we quantified the contributions of patient case-mix and adherence to the variability in achieving URR targets across dialysis facilities. We found that 92% of 10,069 hemodialysis patients treated at 173 facilities during the last quarter of 2004 achieved the target URR ≥65%. Mixed-effect models with random intercept for dialysis facility revealed a significant facility effect: 11.5% of the variation in achievement of target URR was attributable to the facility level. Adjusting for patient case-mix reduced the proportion of variation attributable to the facility level to 6.7%. Patient gender, body surface area, dialysis access, and adherence with treatment strongly associated with achievement of the URR target. We could not identify specific facility characteristics that explained the remaining variation between facilities. These data suggest that if adherence is not a modifiable patient characteristic, providers could be unfairly penalized for caring for these patients under current CMS policy. These penalties may have unintended consequences. PMID:22025629

An automatic CFD-based flow diverter optimization principle for patient-specific intracranial aneurysms.

PubMed

Janiga, Gábor; Daróczy, László; Berg, Philipp; Thévenin, Dominique; Skalej, Martin; Beuing, Oliver

2015-11-05

The optimal treatment of intracranial aneurysms using flow diverting devices is a fundamental issue for neuroradiologists as well as neurosurgeons. Due to highly irregular manifold aneurysm shapes and locations, the choice of the stent and the patient-specific deployment strategy can be a very difficult decision. To support the therapy planning, a new method is introduced that combines a three-dimensional CFD-based optimization with a realistic deployment of a virtual flow diverting stent for a given aneurysm. To demonstrate the feasibility of this method, it was applied to a patient-specific intracranial giant aneurysm that was successfully treated using a commercial flow diverter. Eight treatment scenarios with different local compressions were considered in a fully automated simulation loop. The impact on the corresponding blood flow behavior was evaluated qualitatively as well as quantitatively, and the optimal configuration for this specific case was identified. The virtual deployment of an uncompressed flow diverter reduced the inflow into the aneurysm by 24.4% compared to the untreated case. Depending on the positioning of the local stent compression below the ostium, blood flow reduction could vary between 27.3% and 33.4%. Therefore, a broad range of potential treatment outcomes was identified, illustrating the variability of a given flow diverter deployment in general. This method represents a proof of concept to automatically identify the optimal treatment for a patient in a virtual study under certain assumptions. Hence, it contributes to the improvement of virtual stenting for intracranial aneurysms and can support physicians during therapy planning in the future. Copyright © 2015 Elsevier Ltd. All rights reserved.

TH-CD-202-08: Feasibility Study of Planning Phase Optimization Using Patient Geometry-Driven Information for Better Dose Sparing of Organ at Risks

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kang, S; Kim, D; Kim, T

2016-06-15

Purpose: To propose a simple and effective cost value function to search optimal planning phase (gating window) and demonstrated its feasibility for respiratory correlated radiation therapy. Methods: We acquired 4DCT of 10 phases for 10 lung patients who have tumor located near OARs such as esophagus, heart, and spinal cord (i.e., central lung cancer patients). A simplified mathematical optimization function was established by using overlap volume histogram (OVH) between the target and organ at risk (OAR) at each phase and the tolerance dose of selected OARs to achieve surrounding OARs dose-sparing. For all patients and all phases, delineation of themore » target volume and selected OARs (esophagus, heart, and spinal cord) was performed (by one observer to avoid inter-observer variation), then cost values were calculated for all phases. After the breathing phases were ranked according to cost value function, the relationship between score and dose distribution at highest and lowest cost value phases were evaluated by comparing the mean/max dose. Results: A simplified mathematical cost value function showed noticeable difference from phase to phase, implying it is possible to find optimal phases for gating window. The lowest cost value which may result in lower mean/max dose to OARs was distributed at various phases for all patients. The mean doses of the OARs significantly decreased about 10% with statistical significance for all 3 OARs at the phase with the lowest cost value. Also, the max doses of the OARs were decreased about 2∼5% at the phase with the lowest cost value compared to the phase with the highest cost value. Conclusion: It is demonstrated that optimal phases (in dose distribution perspective) for gating window could exist differently through each patient and the proposed cost value function can be a useful tool for determining such phases without performing dose optimization calculations. This research was supported by the Mid-career Researcher

SU-E-T-06: 4D Particle Swarm Optimization to Enable Lung SBRT in Patients with Central And/or Large Tumors

DOE Office of Scientific and Technical Information (OSTI.GOV)

Modiri, A; Gu, X; Hagan, A

2015-06-15

Purpose: Patients presenting with large and/or centrally-located lung tumors are currently considered ineligible for highly potent regimens such as SBRT due to concerns of toxicity to normal tissues and organs-at-risk (OARs). We present a particle swarm optimization (PSO)-based 4D planning technique, designed for MLC tracking delivery, that exploits the temporal dimension as an additional degree of freedom to significantly improve OAR-sparing and reduce toxicity to levels clinically considered as acceptable for SBRT administration. Methods: Two early-stage SBRT-ineligible NSCLC patients were considered, presenting with tumors of maximum dimensions of 7.4cm (central-right lobe; 1.5cm motion) and 11.9cm (upper-right lobe; 1cm motion). Inmore » each case, the target and normal structures were manually contoured on each of the ten 4DCT phases. Corresponding ten initial 3D-conformal plans (Pt#1: 7-beams; Pt#2: 9-beams) were generated using the Eclipse planning system. Using 4D-PSO, fluence weights were optimized over all beams and all phases (70 and 90 apertures for Pt1&2, respectively). Doses to normal tissues and OARs were compared with clinicallyestablished lung SBRT guidelines based on RTOG-0236. Results: The PSO-based 4D SBRT plan yielded tumor coverage and dose—sparing for parallel and serial OARs within the SBRT guidelines for both patients. The dose-sparing compared to the clinically-delivered conventionallyfractionated plan for Patient 1 (Patient 2) was: heart Dmean = 11% (33%); lung V20 = 16% (21%); lung Dmean = 7% (20%); spinal cord Dmax = 5% (16%); spinal cord Dmean = 7% (33%); esophagus Dmax = 0% (18%). Conclusion: Truly 4D planning can significantly reduce dose to normal tissues and OARs. Such sparing opens up the possibility of using highly potent and effective regimens such as lung SBRT for patients who were conventionally considered SBRT non-eligible. Given the large, non-convex solution space, PSO represents an attractive, parallelizable tool to

An ICT and mobile health integrated approach to optimize patients' education on hypertension and its management by physicians: The Patients Optimal Strategy of Treatment(POST) pilot study.

PubMed

Albini, Fabio; Xiaoqiu Liu; Torlasco, Camilla; Soranna, Davide; Faini, Andrea; Ciminaghi, Renata; Celsi, Ada; Benedetti, Matteo; Zambon, Antonella; di Rienzo, Marco; Parati, Gianfranco

2016-08-01

Uncontrolled hypertension is largely attributed to unsatisfactory doctor's engagement in its optimal management and to poor patients' compliance to therapeutic interventions. ICT and mobile Health solutions might improve these conditions, being widely available and providing highly effective communication strategies. To evaluate whether ICT and mobile Health tools are able to improve hypertension control by improving doctors' engagement and by increasing patients' education and involvement, and their compliance to lifestyle modification and prescribed drug therapy. In a pilot study, we have included 690 treated hypertensive patients with uncontrolled office blood pressure (BP), consecutively recruited by 9 general practitioners over 3 months. Patients were alternatively assigned to routine management based on repeated office visits or to an integrated ICT-based Patients Optimal Strategy for Treatment (POST) system including Home BP monitoring teletransmission, a dedicated web-based platform for patients' management by physicians (Misuriamo platform), and a smartphone mobile application (Eurohypertension APP, E-APP), over a follow-up of 6 months. BP values, demographic and clinical data were collected at baseline and at all follow-up visits (at least two). BP control and cardiovascular risk level have been evaluated at the beginning and at the end of the study. 89 patients did not complete the follow-up, thus data analysis was carried out in 601 of them (303 patients in the POST group and 298 in the control group). Office BP control (<;149/90 mmHg) was 40.0% in control group, and 72.3% in POST group at 6 month follow-up. At the same time Home BP control (<;135/85 mmHg average of 6 days) in POST group was 87.5%. this pilot study suggests that ICT based tools might be effective in improving hypertension management, implementing positive patients' involvement with better adherence to treatment prescriptions and providing the physicians with dynamic control of patients

CT dose minimization using personalized protocol optimization and aggressive bowtie

NASA Astrophysics Data System (ADS)

Wang, Hui; Yin, Zhye; Jin, Yannan; Wu, Mingye; Yao, Yangyang; Tao, Kun; Kalra, Mannudeep K.; De Man, Bruno

2016-03-01

In this study, we propose to use patient-specific x-ray fluence control to reduce the radiation dose to sensitive organs while still achieving the desired image quality (IQ) in the region of interest (ROI). The mA modulation profile is optimized view by view, based on the sensitive organs and the ROI, which are obtained from an ultra-low-dose volumetric CT scout scan [1]. We use a clinical chest CT scan to demonstrate the feasibility of the proposed concept: the breast region is selected as the sensitive organ region while the cardiac region is selected as IQ ROI. Two groups of simulations are performed based on the clinical CT dataset: (1) a constant mA scan adjusted based on the patient attenuation (120 kVp, 300 mA), which serves as baseline; (2) an optimized scan with aggressive bowtie and ROI centering combined with patient-specific mA modulation. The results shows that the combination of the aggressive bowtie and the optimized mA modulation can result in 40% dose reduction in the breast region, while the IQ in the cardiac region is maintained. More generally, this paper demonstrates the general concept of using a 3D scout scan for optimal scan planning.

Comparison of therapeutic lipid target achievements among high-risk patients in Oman.

PubMed

Al-Waili, Khalid; Al-Zakwani, Ibrahim; Al-Dughaishi, Tamima; Baneerje, Yajnavalka; Al-Sabti, Hilal; Al-Hashmi, Khamis; Farhan, Hatem; Habsi, Khadija Al; Al-Hinai, Ali T; Al-Rasadi, Khalid

2014-05-01

We compared therapeutic lipid target achievements among patients with diabetes or coronary heart disease (CHD) in Oman. A retrospective chart review of 94 patients was conducted at an outpatient clinic in Sultan Qaboos University Hospital, Muscat, Oman. The variables included low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), and apolipoprotein B (apo B). The overall mean age of the cohort was 59 ± 12 years, 54% were male, 66% were diabetic, 48% hypertensive, 45% had CHD, 94% were on simvastatin, 4% were on fenofibrate, and 2% were on both simvastatin and fenofibrate. Lipid goal attainments of calculated LDL-C (<2.6 mmol/L), apo B (<0.9 g/L), and non-HDL-C (<3.36 mmol/L) were reached in 52%, 39%, and 53% of the patients, respectively. A significant proportion of high-risk patients treated with lipid-lowering agents reach LDL-C but not the apo B treatment targets, suggesting that the use of apo B target values should also be considered.

Framework for computationally efficient optimal irrigation scheduling using ant colony optimization

USDA-ARS?s Scientific Manuscript database

A general optimization framework is introduced with the overall goal of reducing search space size and increasing the computational efficiency of evolutionary algorithm application for optimal irrigation scheduling. The framework achieves this goal by representing the problem in the form of a decisi...

Optimizing patient treatment decisions in an era of rapid technological advances: the case of hepatitis C treatment.

PubMed

Liu, Shan; Brandeau, Margaret L; Goldhaber-Fiebert, Jeremy D

2017-03-01

How long should a patient with a treatable chronic disease wait for more effective treatments before accepting the best available treatment? We develop a framework to guide optimal treatment decisions for a deteriorating chronic disease when treatment technologies are improving over time. We formulate an optimal stopping problem using a discrete-time, finite-horizon Markov decision process. The goal is to maximize a patient's quality-adjusted life expectancy. We derive structural properties of the model and analytically solve a three-period treatment decision problem. We illustrate the model with the example of treatment for chronic hepatitis C virus (HCV). Chronic HCV affects 3-4 million Americans and has been historically difficult to treat, but increasingly effective treatments have been commercialized in the past few years. We show that the optimal treatment decision is more likely to be to accept currently available treatment-despite expectations for future treatment improvement-for patients who have high-risk history, who are older, or who have more comorbidities. Insights from this study can guide HCV treatment decisions for individual patients. More broadly, our model can guide treatment decisions for curable chronic diseases by finding the optimal treatment policy for individual patients in a heterogeneous population.

Recommendations for the optimal care of patients with recent‐onset psychosis in the Asia‐Pacific region

PubMed Central

Warden, Matthew; He, Yanling; Si, Tianmei; Kalyanasundaram, Seshadri; Thirunavukarasu, Manickam; Amir, Nurmiati; Hatim, Ahmad; Bautista, Tomas; Lee, Cheng; Emsley, Robin; Olivares, Jose; Yang, Yen Kuang; Kongsakon, Ronnachai; Castle, David

2016-01-01

Abstract Providing optimal care to patients with recent‐onset psychosis can improve outcomes and reduce relapse. However, there is a lack of consistency of the implementation of guidelines for such patients across the Asia‐Pacific region. We determined a pragmatic set of recommendations for use on a day‐to‐day basis to help provide optimal care at this crucial stage of illness. The recommendations were developed over a series of meetings by an international faculty of 15 experts from the Asia‐Pacific region, Europe, and South Africa. A structured search of the PubMed database was conducted. This was further developed based on the faculty's clinical experience and knowledge of the literature into 10 key aspects of optimal care for patients during the first five years of a diagnosis of a psychotic disorder, with particular relevance to the Asia‐Pacific region. Several common principles emerged: adherence to antipsychotic medications is crucial; substance abuse, psychiatric and medical comorbidities should be addressed; psychosocial interventions play a pivotal role; and family members can play a vital role in overall patient care. By following these recommendations, clinicians may improve outcomes for patients with recent‐onset psychosis. PMID:27062665

Optimal compliance for amblyopia therapy: occlusion with a translucent tape on the lens.

PubMed

Beneish, Raquel G; Polomeno, Robert C; Flanders, Michael E; Koenekoop, Robert K

2009-10-01

To demonstrate that optimal compliance to amblyopia therapy and a better visual outcome can be achieved by occluding the lens over the preferred eye with a translucent tape. Prospective study of amblyopic children. Eighty-four amblyopic children recruited from 2000 to 2006 at the Montreal Children's Vision Centre. A group of bilateral ametropes (mean age 3.8 years) were treated with glasses and occlusion of the sound eye with a translucent tape on the lens over the preferred eye, or an adhesive patch. The translucent tape reduced vision to hand motion at 0.3 m in the sound eye. Patients were divided into 2 groups depending on the treatment received. Group 1 (n = 36) was occluded with a translucent tape, and group 2 (n = 48) with a conventional adhesive patch, later replaced by the translucent tape. Twenty-five previously reported patients, treated with the conventional adhesive patch only, were used as controls (group 3). The mean amblyopic visual acuity was 20/100-2. Compliance was good in 36 patients (group 1), and was poor or deteriorated in 24/48 patients (group 2). Substituting the adhesive patch with a translucent tape permitted uninterrupted and prolonged occlusion, with a successful visual outcome. The amblyopic eye achieved a significantly better final vision (20/30+2; groups 1+2) than the controls (20/40+1; group 3) (p = 0.04). Sixty-four (76.19%) patients achieved >or=20/30. The translucent tape optimizes compliance and yields better vision by lengthening the duration of occlusion therapy and reducing the number of treatment failures due to noncompliance.

Optimal radiotherapy dose schedules under parametric uncertainty

NASA Astrophysics Data System (ADS)

Badri, Hamidreza; Watanabe, Yoichi; Leder, Kevin

2016-01-01

We consider the effects of parameter uncertainty on the optimal radiation schedule in the context of the linear-quadratic model. Our interest arises from the observation that if inter-patient variability in normal and tumor tissue radiosensitivity or sparing factor of the organs-at-risk (OAR) are not accounted for during radiation scheduling, the performance of the therapy may be strongly degraded or the OAR may receive a substantially larger dose than the allowable threshold. This paper proposes a stochastic radiation scheduling concept to incorporate inter-patient variability into the scheduling optimization problem. Our method is based on a probabilistic approach, where the model parameters are given by a set of random variables. Our probabilistic formulation ensures that our constraints are satisfied with a given probability, and that our objective function achieves a desired level with a stated probability. We used a variable transformation to reduce the resulting optimization problem to two dimensions. We showed that the optimal solution lies on the boundary of the feasible region and we implemented a branch and bound algorithm to find the global optimal solution. We demonstrated how the configuration of optimal schedules in the presence of uncertainty compares to optimal schedules in the absence of uncertainty (conventional schedule). We observed that in order to protect against the possibility of the model parameters falling into a region where the conventional schedule is no longer feasible, it is required to avoid extremal solutions, i.e. a single large dose or very large total dose delivered over a long period. Finally, we performed numerical experiments in the setting of head and neck tumors including several normal tissues to reveal the effect of parameter uncertainty on optimal schedules and to evaluate the sensitivity of the solutions to the choice of key model parameters.

Relationship of optimism and suicidal ideation in three groups of patients at varying levels of suicide risk.

PubMed

Huffman, Jeff C; Boehm, Julia K; Beach, Scott R; Beale, Eleanor E; DuBois, Christina M; Healy, Brian C

2016-06-01

Optimism has been associated with reduced suicidal ideation, but there have been few studies in patients at high suicide risk. We analyzed data from three study populations (total N = 319) with elevated risk of suicide: (1) patients with a recent acute cardiovascular event, (2) patients hospitalized for heart disease who had depression or an anxiety disorder, and (3) patients psychiatrically hospitalized for suicidal ideation or following a suicide attempt. For each study we analyzed the association between optimism (measured by the Life-Orientation Test-Revised) and suicidal ideation, and then completed an exploratory random effects meta-analysis of the findings to synthesize this data. The meta-analysis of the three studies showed that higher levels of self-reported optimism were associated with a lower likelihood of suicidal ideation (odds ratio [OR] = .89, 95% confidence interval [CI] = .85-.95, z = 3.94, p < .001), independent of age, gender, and depressive symptoms. This association held when using the subscales of the Life Orientation Test-Revised scale that measured higher optimism (OR = .84, 95% CI = .76-.92, z = 3.57, p < .001) and lower pessimism (OR = .83, 95% CI = .75-.92], z = 3.61, p < .001). These results also held when suicidal ideation was analyzed as an ordinal variable. Our findings suggest that optimism may be associated with a lower risk of suicidal ideation, above and beyond the effects of depressive symptoms, for a wide range of patients with clinical conditions that place them at elevated risk for suicide. Copyright © 2016 Elsevier Ltd. All rights reserved.

Relationship of optimism and suicidal ideation in three groups of patients at varying levels of suicide risk

PubMed Central

Huffman, Jeff C.; Boehm, Julia K.; Beach, Scott R.; Beale, Eleanor E.; DuBois, Christina M.; Healy, Brian C.

2016-01-01

Optimism has been associated with reduced suicidal ideation, but there have been few studies in patients at high suicide risk. We analyzed data from three study populations (total N=319) with elevated risk of suicide: (1) patients with a recent acute cardiovascular event, (2) patients hospitalized for heart disease who had depression or an anxiety disorder, and (3) patients psychiatrically hospitalized for suicidal ideation or following a suicide attempt. For each study we analyzed the association between optimism (measured by the Life-Orientation Test-Revised) and suicidal ideation, and then completed an exploratory random effects meta-analysis of the findings to synthesize this data. The meta-analysis of the three studies showed that higher levels of self-reported optimism were associated with a lower likelihood of suicidal ideation (odds ratio [OR]=.89, 95% confidence interval [CI]=.85–.95, z=3.94, p<.001), independent of age, gender, and depressive symptoms. This association held when using the subscales of the Life Orientation Test-Revised scale that measured higher optimism (OR=.84, 95% CI=.76–.92, z=3.57, p<.001) and lower pessimism (OR=.83, 95% CI= .75–.92], z=3.61, p<.001). These results also held when suicidal ideation was analyzed as an ordinal variable. Our findings suggest that optimism may be associated with a lower risk of suicidal ideation, above and beyond the effects of depressive symptoms, for a wide range of patients with clinical conditions that place them at elevated risk for suicide. PMID:26994340

Optimized distributed systems achieve significant performance improvement on sorted merging of massive VCF files

PubMed Central

Gao, Jingjing; Jin, Peng; Eng, Celeste; Burchard, Esteban G; Beaty, Terri H; Ruczinski, Ingo; Mathias, Rasika A; Barnes, Kathleen; Wang, Fusheng

2018-01-01

Abstract Background Sorted merging of genomic data is a common data operation necessary in many sequencing-based studies. It involves sorting and merging genomic data from different subjects by their genomic locations. In particular, merging a large number of variant call format (VCF) files is frequently required in large-scale whole-genome sequencing or whole-exome sequencing projects. Traditional single-machine based methods become increasingly inefficient when processing large numbers of files due to the excessive computation time and Input/Output bottleneck. Distributed systems and more recent cloud-based systems offer an attractive solution. However, carefully designed and optimized workflow patterns and execution plans (schemas) are required to take full advantage of the increased computing power while overcoming bottlenecks to achieve high performance. Findings In this study, we custom-design optimized schemas for three Apache big data platforms, Hadoop (MapReduce), HBase, and Spark, to perform sorted merging of a large number of VCF files. These schemas all adopt the divide-and-conquer strategy to split the merging job into sequential phases/stages consisting of subtasks that are conquered in an ordered, parallel, and bottleneck-free way. In two illustrating examples, we test the performance of our schemas on merging multiple VCF files into either a single TPED or a single VCF file, which are benchmarked with the traditional single/parallel multiway-merge methods, message passing interface (MPI)–based high-performance computing (HPC) implementation, and the popular VCFTools. Conclusions Our experiments suggest all three schemas either deliver a significant improvement in efficiency or render much better strong and weak scalabilities over traditional methods. Our findings provide generalized scalable schemas for performing sorted merging on genetics and genomics data using these Apache distributed systems. PMID:29762754

96 Week Follow-Up of HIV-Infected Patients in Rescue with Raltegravir Plus Optimized Backbone Regimens: A Multicentre Italian Experience

PubMed Central

Capetti, Amedeo; Landonio, Simona; Meraviglia, Paola; Di Biagio, Antonio; Lo Caputo, Sergio; Sterrantino, Gaetana; Ammassari, Adriana; Menzaghi, Barbara; Franzetti, Marco; De Socio, Giuseppe Vittorio; Pellicanò, Giovanni; Mazzotta, Elena; Soria, Alessandro; Meschiari, Marianna; Trezzi, Michele; Sasset, Lolita; Celesia, Benedetto Maurizio; Zucchi, Patrizia; Melzi, Sara; Ricci, Elena; Rizzardini, Giuliano

2012-01-01

Background Long term efficacy of raltegravir (RAL)-including regimens in highly pre-treated HIV-1-infected patients has been demonstrated in registration trials. However, few studies have assessed durability in routine clinical settings. Methods Antiretroviral treatment-experienced patients initiating a RAL-containing salvage regimen were enrolled. Routine clinical and laboratory follow-up was performed at baseline, week 4, 12, and every 12 weeks thereafter. Data were censored at week 96. Results Out of 320 patients enrolled, 292 (91.25%) subjects maintained their initial regimen for 96 weeks; 28 discontinued prematurely for various reasons: death (11), viral failure (8), adverse events (5), loss to follow-up (3), consent withdrawal (1). Eight among these 28 subjects maintained RAL but changed the accompanying drugs. The mean CD4+ T-cell increase at week 96 was 227/mm3; 273 out of 300 patients (91%), who were still receiving RAL at week 96, achieved viral suppression (HIV-1 RNA <50 copies/mL). When analyzing the immuno-virologic outcome according to the number of drugs used in the regimen, 2 (n = 45), 3 (n = 111), 4 (n = 124), or >4 (n = 40), CD4+ T-cell gain was similar across strata: +270, +214, +216, and +240 cells/mm3, respectively, as was the proportion of subjects with undetectable viral load. Laboratory abnormalities (elevation of liver enzymes, total cholesterol and triglycerides) were rare, ranging from 0.9 to 3.1%. The mean 96-week total cholesterol increase was 23.6 mg/dL. Conclusions In a routine clinical setting, a RAL-based regimen allowed most patients in salvage therapy to achieve optimal viral suppression for at least 96 weeks, with relevant immunologic gain and very few adverse events. PMID:22808029

Global optimization method based on ray tracing to achieve optimum figure error compensation

NASA Astrophysics Data System (ADS)

Liu, Xiaolin; Guo, Xuejia; Tang, Tianjin

2017-02-01

Figure error would degrade the performance of optical system. When predicting the performance and performing system assembly, compensation by clocking of optical components around the optical axis is a conventional but user-dependent method. Commercial optical software cannot optimize this clocking. Meanwhile existing automatic figure-error balancing methods can introduce approximate calculation error and the build process of optimization model is complex and time-consuming. To overcome these limitations, an accurate and automatic global optimization method of figure error balancing is proposed. This method is based on precise ray tracing to calculate the wavefront error, not approximate calculation, under a given elements' rotation angles combination. The composite wavefront error root-mean-square (RMS) acts as the cost function. Simulated annealing algorithm is used to seek the optimal combination of rotation angles of each optical element. This method can be applied to all rotational symmetric optics. Optimization results show that this method is 49% better than previous approximate analytical method.

Optimized multi-electrode stimulation increases focality and intensity at target

NASA Astrophysics Data System (ADS)

Dmochowski, Jacek P.; Datta, Abhishek; Bikson, Marom; Su, Yuzhuo; Parra, Lucas C.

2011-08-01

Transcranial direct current stimulation (tDCS) provides a non-invasive tool to elicit neuromodulation by delivering current through electrodes placed on the scalp. The present clinical paradigm uses two relatively large electrodes to inject current through the head resulting in electric fields that are broadly distributed over large regions of the brain. In this paper, we present a method that uses multiple small electrodes (i.e. 1.2 cm diameter) and systematically optimize the applied currents to achieve effective and targeted stimulation while ensuring safety of stimulation. We found a fundamental trade-off between achievable intensity (at the target) and focality, and algorithms to optimize both measures are presented. When compared with large pad-electrodes (approximated here by a set of small electrodes covering 25cm2), the proposed approach achieves electric fields which exhibit simultaneously greater focality (80% improvement) and higher target intensity (98% improvement) at cortical targets using the same total current applied. These improvements illustrate the previously unrecognized and non-trivial dependence of the optimal electrode configuration on the desired electric field orientation and the maximum total current (due to safety). Similarly, by exploiting idiosyncratic details of brain anatomy, the optimization approach significantly improves upon prior un-optimized approaches using small electrodes. The analysis also reveals the optimal use of conventional bipolar montages: maximally intense tangential fields are attained with the two electrodes placed at a considerable distance from the target along the direction of the desired field; when radial fields are desired, the maximum-intensity configuration consists of an electrode placed directly over the target with a distant return electrode. To summarize, if a target location and stimulation orientation can be defined by the clinician, then the proposed technique is superior in terms of both focality

Optimized management of heart failure patients aged 80 years or more improves outcomes versus usual care: The HF80 randomized trial.

PubMed

Vorilhon, Charles; Jean, Frédéric; Mulliez, Aurélien; Clerfond, Guillaume; Pereira, Bruno; Sapin, Vincent; Souteyrand, Géraud; Citron, Bernard; Motreff, Pascal; Lusson, Jean-René; Eschalier, Romain

2016-12-01

The prevalence and incidence of heart failure (HF) in elderly patients are increasing worldwide. Management of HF with reduced ejection fraction (HF-REF) in patients aged 80 years or more follows international guidelines, despite the lack of a dedicated study in this frail population. To determine whether optimized management of HF-REF in patients aged 80 years or more can improve quality of life at 6 months. Patients aged 80 years or more hospitalized for acute HF-REF were randomized prospectively into an optimized group or a control group (usual care). All patients benefitted from the same in-hospital management. Optimized group patients were also managed at 3, 6 and 9 weeks, and 3, 6, 9 and 12 months after initial hospitalization, to optimize HF-REF treatment. The primary endpoint was quality of life at 6 months. The trial was stopped prematurely, according to prespecified rules and an independent data monitoring board, after 34 patients were included (n=17 in each group). There was no difference in quality of life at baseline and at 6 months between the two groups (P=0.14 and 0.64, respectively), although a significant improvement was observed between baseline and 6 months in the optimized group compared with the control group: -20.2±25.2 (P=0.01) versus -9.9±19.0 (P=0.19). Mortality at 12 months was lower in the optimized group (17.7% vs 47.1%; P=0.03). There was no increase in acute renal failure, hyperkalaemia or falls in the optimized group (P=0.49, 1 and 1, respectively). Optimizing the management of HF-REF in patients aged 80 years or more, according to the modalities of the HF80 study, seems to be both effective and safe. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

[Palliative care and end-of-life patients in emergency situations. Recommendations on optimization of out-patient care].

PubMed

Wiese, C H R; Vagts, D A; Kampa, U; Pfeiffer, G; Grom, I-U; Gerth, M A; Graf, B M; Zausig, Y A

2011-02-01

At the end of life acute exacerbations of medical symptoms (e.g. dyspnea) in palliative care patients often result in emergency medical services being alerted. The goals of this study were to discuss cooperation between emergency medical and palliative care structures to optimize the quality of care in emergencies involving palliative care patients. For data collection an open discussion of the main topics by experts in palliative and emergency medical care was employed. Main outcome measures and recommendations included responses regarding current practices related to expert opinions and international literature sources. As the essential points of consensus the following recommendations for optimization of care were named: (1) integration of palliative care in the emergency medicine curricula for pre-hospital emergency physicians and paramedics, (2) development of outpatient palliative care, (3) integration of palliative care teams into emergency medical structures, (4) cooperation between palliative and emergency medical care, (5) integration of crisis intervention into outpatient palliative emergency medical care, (6) provision of emergency plans and emergency medical boxes, (7) provision of palliative crisis cards and do not attempt resuscitation (DNAR) orders, (8) psychosocial aspects concerning palliative emergencies and (9) definition of palliative patients and their special situation by the physician responsible for prior treatment. Prehospital emergency physicians are confronted with emergencies in palliative care patients every day. In the treatment of these emergencies there are potentially serious conflicts due to the different therapeutic concepts of palliative medical care and emergency medical services. This study demonstrates that there is a need for regulated criteria for the therapy of palliative patients and patients at the end of life in emergency situations. Overall, more clinical investigations concerning end-of-life care and unresponsive

Satisfaction with tolterodine: assessing symptom-specific patient-reported goal achievement in the treatment of overactive bladder in female patients (STARGATE study).

PubMed

Choo, M-S; Doo, C K; Lee, K-S

2008-02-01

Open-label study to evaluate the effect of tolterodine extended-release (ER) on symptom-specific patient-reported goal achievement (PGA) of overactive bladder (OAB) symptoms in females. Eligible patients who had frequency >or= 8 and urgency >or= 2 episodes per 24 h with or without urgency incontinence were treated with 12-week tolterodine ER (4 mg once daily). Primary end-point was the rate of PGA by a visual analogue scale compared with initial expectation with treatment. At baseline, patients were asked to set their personal goals for each OAB symptom with treatment. Secondary efficacy variables were changes in symptom severity, voiding diary and patient perception of bladder condition (PPBC), global impression of improvement (GII), and willingness to continue treatment. A total of 56 patients were entered. The median rate of symptom-specific PGA and reductions in symptom severity were for frequency (60%, 45%), episodes of urgency 60%, 55%), urge incontinence (80%, 71%), nocturia (50%, 52%) and tenesmus (30%, 26%) after 12 weeks treatment. There was a significant improvement in all OAB symptoms in voiding diary. Thirty-five patients (62.5%) experienced an improvement of >or= 2 points in PPBC. Thirty (53.6%) and 22 (39.3%) of patients reported much and little improvement of their symptoms in GII. A total of 41 (73.2%) patients wanted to continue taking the medication at the end of the study. Most OAB patients reported improvement of their OAB symptoms with 12-week tolterodine ER 4 mg treatment. There was a significant achievement of symptom-specific goal on the key OAB symptoms. But, PGA did not correlate with objective outcomes.

Optimizing density patterns to achieve desired light extraction for displays

NASA Astrophysics Data System (ADS)

Davenport, T. L. R.; Cassarly, W. J.

2007-01-01

In displays such as backlights and signage, it is often desirable to produce a particular spatial luminance distribution of light. This work demonstrates an iterative optimization technique for determining the density of light extractors required to produce desired luminance distributions.

Key elements of optimal treatment decision-making for surgeons and older patients with colorectal or pancreatic cancer: A qualitative study.

PubMed

Geessink, Noralie H; Schoon, Yvonne; van Herk, Hanneke C P; van Goor, Harry; Olde Rikkert, Marcel G M

2017-03-01

To identify key elements of optimal treatment decision-making for surgeons and older patients with colorectal (CRC) or pancreatic cancer (PC). Six focus groups with different participants were performed: three with older CRC/PC patients and relatives, and three with physicians. Supplementary in-depth interviews were conducted in another seven patients. Framework analysis was used to identify key elements in decision-making. 23 physicians, 22 patients and 14 relatives participated. Three interacting components were revealed: preconditions, content and facilitators of decision-making. To provide optimal information about treatments' impact on an older patient's daily life, physicians should obtain an overall picture and take into account patients' frailty. Depending on patients' preferences and capacities, dividing decision-making into more sessions will be helpful and simultaneously emphasize patients' own responsibility. GPs may have a valuable contribution because of their background knowledge and supportive role. Stakeholders identified several crucial elements in the complex surgical decision-making of older CRC/PC patients. Structured qualitative research may also be of great help in optimizing other treatment directed decision-making processes. Surgeons should be trained in examining preconditions and useful facilitators in decision-making in older CRC/PC patients to optimize its content and to improve the quality of shared care. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Implementation of a post-cardiac arrest care bundle including therapeutic hypothermia and hemodynamic optimization in comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest: a feasibility study.

PubMed

Walters, Elizabeth Lea; Morawski, Kyle; Dorotta, Ihab; Ramsingh, Davinder; Lumen, Kelly; Bland, David; Clem, Kathleen; Nguyen, H Bryant

2011-04-01

Patients who present to the emergency department (ED) with return of spontaneous circulation after cardiac arrest generally have poor outcomes. Guidelines for treatment can be complicated and difficult to implement. This study examined the feasibility of implementing a care bundle including therapeutic hypothermia (TH) and early hemodynamic optimization for comatose patients with return of spontaneous circulation after out-of-hospital cardiac arrest. The study included patients over a 2-year period in the ED and intensive care unit of an academic tertiary-care medical center. The first year (prebundle) provided a historical control, followed by a prospective observational period of bundle implementation during the second year. The bundle elements included (a) TH initiated; (b) central venous pressure/central venous oxygen saturation monitoring in 2 h; (c) target temperature in 4 h; (d) central venous pressure greater than 12 mmHg in 6 h; (e) MAP greater than 65 mmHg in 6 h; (f) central venous oxygen saturation greater than 70% in 6 h; (g) TH maintained for 24 h; and (h) decreasing lactate in 24 h. Fifty-five patients were enrolled, 26 patients in the prebundle phase and 29 patients in the bundle phase. Seventy-seven percent of bundle elements were completed during the bundle phase. In-hospital mortality in bundle compared with prebundle patients was 55.2% vs. 69.2% (P = 0.29). In the bundle patients, those patients who received all elements of the care bundle had mortality 33.3% compared with 60.9% in those receiving some of the bundle elements (P = 0.22). Bundle patients tended to achieve good neurologic outcome compared with prebundle patients, Cerebral Performance Category 1 or 2 in 31 vs. 12% patients, respectively (P = 0.08). Our study demonstrated that a post-cardiac arrest care bundle that incorporates TH and early hemodynamic optimization can be implemented in the ED and intensive care unit collaboratively and can achieve similar clinical benefits compared

Impact of body weight on the achievement of minimal disease activity in patients with rheumatic diseases: a systematic review and meta-analysis.

PubMed

Lupoli, Roberta; Pizzicato, Paolo; Scalera, Antonella; Ambrosino, Pasquale; Amato, Manuela; Peluso, Rosario; Di Minno, Matteo Nicola Dario

2016-12-13

In this study, we evaluated the impact of obesity and/or overweight on the achievement of minimal disease activity (MDA) in patients with psoriatic arthritis (PsA) and patients with rheumatoid arthritis (RA) receiving an anti-rheumatic treatment. Obesity can be considered a low-grade, chronic systemic inflammatory disease and some studies suggested that obese patients with rheumatic diseases exhibit a lower rate of low disease activity achievement during treatment with anti-rheumatic drugs. A systematic search was performed in major electronic databases (PubMed, Web of Science, Scopus, Embase) to identify studies reporting MDA achievement in obese and/or overweight patients with RA or PsA and in normal-weight RA or PsA control subjects. Results were expressed as Odds Ratios (ORs) with pertinent 95% Confidence Intervals (95%CIs). We included 17 studies (10 on RA and 7 on PsA) comprising a total of 6693 patients (1562 with PsA and 5131 with RA) in the analysis. The MDA achievement rate was significantly lower in obese patients than in normal-weight subjects (OR 0.447, 95% CI 0.346-0.577, p < 0.001, I 2  = 62.6%, p < 0.001). Similarly, overweight patients showed a significantly lower prevalence of MDA achievement than normal-weight subjects (OR 0.867, 95% CI 0.757-0.994, p = 0.041, I 2  = 64%, p = 0.007). Interestingly, the effect of obesity on MDA was confirmed when we separately analyzed data on patients with RA and patients with PsA. In contrast, when we evaluated the effect of overweight, our results were confirmed for PsA but not for RA. A meta-regression analysis showed that follow-up duration, age, male sex, and treatment duration are covariates significantly affecting the effect of obesity/overweight on MDA achievement. The results of our meta-analysis suggest that obesity and overweight reduce the chances to achieve MDA in patients with rheumatic diseases receiving treatment with traditional or biologic disease-modifying antirheumatic

Optimal combination treatment and vascular outcomes in recent ischemic stroke patients by premorbid risk level.

PubMed

Park, Jong-Ho; Ovbiagele, Bruce

2015-08-15

Optimal combination of secondary stroke prevention treatment including antihypertensives, antithrombotic agents, and lipid modifiers is associated with reduced recurrent vascular risk including stroke. It is unclear whether optimal combination treatment has a differential impact on stroke patients based on level of vascular risk. We analyzed a clinical trial dataset comprising 3680 recent non-cardioembolic stroke patients aged ≥35 years and followed for 2 years. Patients were categorized by appropriateness levels 0 to III depending on the number of the drugs prescribed divided by the number of drugs potentially indicated for each patient (0=none of the indicated medications prescribed and III=all indicated medications prescribed [optimal combination treatment]). High-risk was defined as having a history of stroke or coronary heart disease (CHD) prior to the index stroke event. Independent associations of medication appropriateness level with a major vascular event (stroke, CHD, or vascular death), ischemic stroke, and all-cause death were analyzed. Compared with level 0, for major vascular events, the HR of level III in the low-risk group was 0.51 (95% CI: 0.20-1.28) and 0.32 (0.14-0.70) in the high-risk group; for stroke, the HR of level III in the low-risk group was 0.54 (0.16-1.77) and 0.25 (0.08-0.85) in the high-risk group; and for all-cause death, the HR of level III in the low-risk group was 0.66 (0.09-5.00) and 0.22 (0.06-0.78) in the high-risk group. Optimal combination treatment is related to a significantly lower risk of future vascular events and death among high-risk patients after a recent non-cardioembolic stroke. Copyright © 2015 Elsevier B.V. All rights reserved.

Optimizing Patient Management and Adherence for Children Receiving Growth Hormone.

PubMed

Acerini, Carlo L; Wac, Katarzyna; Bang, Peter; Lehwalder, Dagmar

2017-01-01

Poor adherence with growth hormone (GH) therapy has been associated with worse clinical outcomes, which in children relates specifically to their linear growth and loss of quality of life. The "360° GH in Europe" meeting, held in Lisbon, Portugal, in June 2016 and funded by Merck KGaA (Germany), examined many aspects of GH diseases. The three sessions, entitled " Short Stature Diagnosis and Referral ," " Optimizing Patient Management ," and " Managing Transition ," each benefited from three guest speaker presentations, followed by an open discussion and are reported as a manuscript, authored by the speakers. Reported here is a summary of the proceedings of the second session, which reviewed the determinants of GH therapy response, factors affecting GH therapy adherence and the development of innovative technologies to improve GH treatment in children. Response to GH therapy varies widely, particularly in regard to the underlying diagnosis, although there is little consensus on the definition of a poor response. If the growth response is seen to be less than expected, the possible reasons should be discussed with patients and their parents, including compliance with the therapy regimen. Understanding and addressing the multiple factors that influence adherence, in order to optimize GH therapy, requires a multi-disciplinary approach. Because therapy continues over many years, various healthcare professionals will be involved at different periods of the patient's journey. The role of the injection device for GH therapy, frequent monitoring of response, and patient support are all important for maintaining adherence. New injection devices are incorporating electronic technologies for automated monitoring and recording of clinically relevant information on injections. Study results are indicating that such devices can at least maintain GH adherence; however, acceptance of novel devices needs to be assessed and there remains an on-going need for innovations.

Optimizing Patient Treatment Decisions in an Era of Rapid Technological Advances: The Case of Hepatitis C Treatment

PubMed Central

Liu, Shan; Goldhaber-Fiebert, Jeremy D.; Brandeau, Margaret L.

2015-01-01

How long should a patient with a treatable chronic disease wait for more effective treatments before accepting the best available treatment? We develop a framework to guide optimal treatment decisions for a deteriorating chronic disease when treatment technologies are improving over time. We formulate an optimal stopping problem using a discrete-time, finite-horizon Markov decision process. The goal is to maximize a patient’s quality-adjusted life expectancy. We derive structural properties of the model and analytically solve a three-period treatment decision problem. We illustrate the model with the example of treatment for chronic hepatitis C virus (HCV). Chronic HCV affects 3–4 million Americans and has been historically difficult to treat, but increasingly effective treatments have been commercialized in the past few years. We show that the optimal treatment decision is more likely to be to accept currently available treatment—despite expectations for future treatment improvement—for patients who have high-risk history, who are older, or who have more comorbidities. Insights from this study can guide HCV treatment decisions for individual patients. More broadly, our model can guide treatment decisions for curable chronic diseases by finding the optimal treatment policy for individual patients in a heterogeneous population. PMID:26188961

Acoustic-noise-optimized diffusion-weighted imaging.

PubMed

Ott, Martin; Blaimer, Martin; Grodzki, David M; Breuer, Felix A; Roesch, Julie; Dörfler, Arnd; Heismann, Björn; Jakob, Peter M

2015-12-01

This work was aimed at reducing acoustic noise in diffusion-weighted MR imaging (DWI) that might reach acoustic noise levels of over 100 dB(A) in clinical practice. A diffusion-weighted readout-segmented echo-planar imaging (EPI) sequence was optimized for acoustic noise by utilizing small readout segment widths to obtain low gradient slew rates and amplitudes instead of faster k-space coverage. In addition, all other gradients were optimized for low slew rates. Volunteer and patient imaging experiments were conducted to demonstrate the feasibility of the method. Acoustic noise measurements were performed and analyzed for four different DWI measurement protocols at 1.5T and 3T. An acoustic noise reduction of up to 20 dB(A) was achieved, which corresponds to a fourfold reduction in acoustic perception. The image quality was preserved at the level of a standard single-shot (ss)-EPI sequence, with a 27-54% increase in scan time. The diffusion-weighted imaging technique proposed in this study allowed a substantial reduction in the level of acoustic noise compared to standard single-shot diffusion-weighted EPI. This is expected to afford considerably more patient comfort, but a larger study would be necessary to fully characterize the subjective changes in patient experience.

Optimal Transport Destination for Ischemic Stroke Patients With Unknown Vessel Status: Use of Prehospital Triage Scores.

PubMed

Schlemm, Eckhard; Ebinger, Martin; Nolte, Christian H; Endres, Matthias; Schlemm, Ludwig

2017-08-01

Patients with acute ischemic stroke (AIS) and large vessel occlusion may benefit from direct transportation to an endovascular capable comprehensive stroke center (mothership approach) as opposed to direct transportation to the nearest stroke unit without endovascular therapy (drip and ship approach). The optimal transport strategy for patients with AIS and unknown vessel status is uncertain. The rapid arterial occlusion evaluation scale (RACE, scores ranging from 0 to 9, with higher scores indicating higher stroke severity) correlates with the National Institutes of Health Stroke Scale and was developed to identify patients with large vessel occlusion in a prehospital setting. We evaluate how the RACE scale can help to inform prehospital triage decisions for AIS patients. In a model-based approach, we estimate probabilities of good outcome (modified Rankin Scale score of ≤2 at 3 months) as a function of severity of stroke symptoms and transport times for the mothership approach and the drip and ship approach. We use these probabilities to obtain optimal RACE cutoff scores for different transfer time settings and combinations of treatment options (time-based eligibility for secondary transfer under the drip and ship approach, time-based eligibility for thrombolysis at the comprehensive stroke center under the mothership approach). In our model, patients with AIS are more likely to benefit from direct transportation to the comprehensive stroke center if they have more severe strokes. Values of the optimal RACE cutoff scores range from 0 (mothership for all patients) to >9 (drip and ship for all patients). Shorter transfer times and longer door-to-needle and needle-to-transfer (door out) times are associated with lower optimal RACE cutoff scores. Use of RACE cutoff scores that take into account transport times to triage AIS patients to the nearest appropriate hospital may lead to improved outcomes. Further studies should examine the feasibility of translation into

Automatic CT simulation optimization for radiation therapy: A general strategy.

PubMed

Li, Hua; Yu, Lifeng; Anastasio, Mark A; Chen, Hsin-Chen; Tan, Jun; Gay, Hiram; Michalski, Jeff M; Low, Daniel A; Mutic, Sasa

2014-03-01

of 38, 43, 48, 53, and 58 cm were 120, 140, 140, 140, and 140 kVp, respectively, and the corresponding minimum CTDIvol for achieving the optimal image quality index 4.4 were 9.8, 32.2, 100.9, 241.4, and 274.1 mGy, respectively. For patients with lateral sizes of 43-58 cm, 120-kVp scan protocols yielded up to 165% greater radiation dose relative to 140-kVp protocols, and 140-kVp protocols always yielded a greater image quality index compared to the same dose-level 120-kVp protocols. The trace of target and organ dosimetry coverage and the γ passing rates of seven IMRT dose distribution pairs indicated the feasibility of the proposed image quality index for the predication strategy. A general strategy to predict the optimal CT simulation protocols in a flexible and quantitative way was developed that takes into account patient size, treatment planning task, and radiation dose. The experimental study indicated that the optimal CT simulation protocol and the corresponding radiation dose varied significantly for different patient sizes, contouring accuracy, and radiation treatment planning tasks.

Aircraft optimization by a system approach: Achievements and trends

NASA Technical Reports Server (NTRS)

Sobieszczanski-Sobieski, Jaroslaw

1992-01-01

Recently emerging methodology for optimal design of aircraft treated as a system of interacting physical phenomena and parts is examined. The methodology is found to coalesce into methods for hierarchic, non-hierarchic, and hybrid systems all dependent on sensitivity analysis. A separate category of methods has also evolved independent of sensitivity analysis, hence suitable for discrete problems. References and numerical applications are cited. Massively parallel computer processing is seen as enabling technology for practical implementation of the methodology.

SU-F-J-06: Optimized Patient Inclusion for NaF PET Response-Based Biopsies

DOE Office of Scientific and Technical Information (OSTI.GOV)

Roth, A; Harmon, S; Perk, T

Purpose: A method to guide mid-treatment biopsies using quantitative [F-18]NaF PET/CT response is being investigated in a clinical trial. This study aims to develop methodology to identify patients amenable to mid-treatment biopsy based on pre-treatment imaging characteristics. Methods: 35 metastatic prostate cancer patients had NaF PET/CT scans taken prior to the start of treatment and 9–12 weeks into treatment. For mid-treatment biopsy targeting, lesions must be at least 1.5 cm{sup 3} and located in a clinically feasible region (lumbar/sacral spine, pelvis, humerus, or femur). Three methods were developed based on number of lesions present prior to treatment: a feasibility-restricted method,more » a location-restricted method, and an unrestricted method. The feasibility restricted method only utilizes information from lesions meeting biopsy requirements in the pre-treatment scan. The unrestricted method accounts for all lesions present in the pre-treatment scan. For each method, optimized classification cutoffs for candidate patients were determined. Results: 13 of the 35 patients had enough lesions at the mid-treatment for biopsy candidacy. Of 1749 lesions identified in all 35 patients at mid-treatment, only 9.8% were amenable to biopsy. Optimizing the feasibility-restricted method required 4 lesions at pre-treatment meeting volume and region requirements for biopsy, resulting patient identification sensitivity of 0.8 and specificity of 0.7. Of 6 false positive patients, only one patient lacked lesions for biopsy. Restricting for location alone showed poor results (sensitivity 0.2 and specificity 0.3). The optimized unrestricted method required patients have at least 37 lesions in pretreatment scan, resulting in a sensitivity of 0.8 and specificity of 0.8. There were 5 false positives, only one lacked lesions for biopsy. Conclusion: Incorporating the overall pre-treatment number of NaF PET/CT identified lesions provided best prediction for identifying

The power of collaboration with patient safety programs: building safe passage for patients, nurses, and clinical staff.

PubMed

Kerfoot, Karlene M; Rapala, Kathryn; Ebright, Patricia; Rogers, Suzanne M

2006-12-01

Patient safety is a relatively new field, with many opinions and few effectively proven approaches. One factor is clear: optimal patient safety outcomes cannot be achieved in isolation. Although it is well recognized that multidisciplinary collaboration in the healthcare setting is necessary to effect patient safety, collaboration with resources external to healthcare-academia and industry in particular-will not only aid but also quicken the patient safety efforts. The authors outline a healthcare system's use of all available resources to build a patient safety program.

Optimized survey design for electrical resistivity tomography: combined optimization of measurement configuration and electrode placement

NASA Astrophysics Data System (ADS)

Uhlemann, Sebastian; Wilkinson, Paul B.; Maurer, Hansruedi; Wagner, Florian M.; Johnson, Timothy C.; Chambers, Jonathan E.

2018-07-01

Within geoelectrical imaging, the choice of measurement configurations and electrode locations is known to control the image resolution. Previous work has shown that optimized survey designs can provide a model resolution that is superior to standard survey designs. This paper demonstrates a methodology to optimize resolution within a target area, while limiting the number of required electrodes, thereby selecting optimal electrode locations. This is achieved by extending previous work on the `Compare-R' algorithm, which by calculating updates to the resolution matrix optimizes the model resolution in a target area. Here, an additional weighting factor is introduced that allows to preferentially adding measurement configurations that can be acquired on a given set of electrodes. The performance of the optimization is tested on two synthetic examples and verified with a laboratory study. The effect of the weighting factor is investigated using an acquisition layout comprising a single line of electrodes. The results show that an increasing weight decreases the area of improved resolution, but leads to a smaller number of electrode positions. Imaging results superior to a standard survey design were achieved using 56 per cent fewer electrodes. The performance was also tested on a 3-D acquisition grid, where superior resolution within a target at the base of an embankment was achieved using 22 per cent fewer electrodes than a comparable standard survey. The effect of the underlying resistivity distribution on the performance of the optimization was investigated and it was shown that even strong resistivity contrasts only have minor impact. The synthetic results were verified in a laboratory tank experiment, where notable image improvements were achieved. This work shows that optimized surveys can be designed that have a resolution superior to standard survey designs, while requiring significantly fewer electrodes. This methodology thereby provides a means for

Optimized survey design for Electrical Resistivity Tomography: combined optimization of measurement configuration and electrode placement

NASA Astrophysics Data System (ADS)

Uhlemann, Sebastian; Wilkinson, Paul B.; Maurer, Hansruedi; Wagner, Florian M.; Johnson, Timothy C.; Chambers, Jonathan E.

2018-03-01

Within geoelectrical imaging, the choice of measurement configurations and electrode locations is known to control the image resolution. Previous work has shown that optimized survey designs can provide a model resolution that is superior to standard survey designs. This paper demonstrates a methodology to optimize resolution within a target area, while limiting the number of required electrodes, thereby selecting optimal electrode locations. This is achieved by extending previous work on the `Compare-R' algorithm, which by calculating updates to the resolution matrix optimizes the model resolution in a target area. Here, an additional weighting factor is introduced that allows to preferentially adding measurement configurations that can be acquired on a given set of electrodes. The performance of the optimization is tested on two synthetic examples and verified with a laboratory study. The effect of the weighting factor is investigated using an acquisition layout comprising a single line of electrodes. The results show that an increasing weight decreases the area of improved resolution, but leads to a smaller number of electrode positions. Imaging results superior to a standard survey design were achieved using 56 per cent fewer electrodes. The performance was also tested on a 3D acquisition grid, where superior resolution within a target at the base of an embankment was achieved using 22 per cent fewer electrodes than a comparable standard survey. The effect of the underlying resistivity distribution on the performance of the optimization was investigated and it was shown that even strong resistivity contrasts only have minor impact. The synthetic results were verified in a laboratory tank experiment, where notable image improvements were achieved. This work shows that optimized surveys can be designed that have a resolution superior to standard survey designs, while requiring significantly fewer electrodes. This methodology thereby provides a means for improving

Achieving stable remission with maintenance electroconvulsive therapy in a patient with treatment-resistant schizophrenia

PubMed Central

Moeller, Sebastian; Kalkwarf, Neele; Lücke, Caroline; Ortiz, Diana; Jahn, Sonja; Först, Christiane; Braun, Niclas; Philipsen, Alexandra; Müller, Helge H.O.

2017-01-01

Abstract Rationale: Up to one third of all schizophrenic patients are classified as having treatment-resistant schizophrenia (TRS). This subgroup faces remarkable medical and psychosocial damages, and pharmacotherapy is often limited due to nonresponse and/or side effects. Maintenance electroconvulsive therapy (M-ECT) might be effective in TRS. Patient concerns: We present a case of a 26-year-old male patient with a TRS. Diagnoses: He received a treatment series of ECT sessions and a course of 24 M-ECTs. Interventions: The entire treatment was tolerated without significant side effects. Outcomes: Moreover, the Psychotic Symptom Rating Scale (PSYRATS) scores for both positive and negative symptoms decreased and remained stable over the course of M-ECT. Lessons: Because of the remarkable improvement in the negative and positive symptom clusters, we propose systematic examinations in the field of M-ECT in TRS patients. These studies should integrate long-term outcome and tolerance measurements, gaining insight into the optimal duration of treatment for this indication. PMID:29310360

Patients’ empowerment, physicians’ perceptions, and achievement of therapeutic goals in patients with type 1 and type 2 diabetes mellitus in Mexico

PubMed Central

Lavalle-González, Fernando J; Chiquete, Erwin

2016-01-01

Background Physicians’ perception may not parallel objective measures of therapeutic targets in patients with diabetes. This is an issue rarely addressed in the medical literature. We aimed to analyze physicians’ perception and characteristics of adequate control of patients with diabetes. Patients and methods We studied information on physicians and their patients who participated in the third wave of the International Diabetes Management Practices Study registry in Mexico. This analysis was performed on 2,642 patients, 203 with type 1 diabetes mellitus (T1DM) and 2,439 with type 2 diabetes mellitus (T2DM), treated by 200 physicians. Results The patients perceived at target had lower hemoglobin A1c (HbA1c) and fasting blood glucose than those considered not at target. However, overestimation of the frequency of patients with HbA1c <7% was 41.5% in patients with T1DM and 31.7% in patients with T2DM (underestimation: 2.8% and 8.0%, respectively). The agreement between the physicians’ perception and the class of HbA1c was suboptimal (κ: 0.612). Diabetologists and endocrinologists tested HbA1c more frequently than primary care practitioners, internists, or cardiologists; however, no differences were observed in mean HbA1c, for both T1DM (8.4% vs 7.2%, P=0.42) and T2DM (8.03% vs 8.01%, P=0.87) patients. Nevertheless, insulin users perceived at target, who practiced self-monitoring and self-adjustment of insulin, had a lower mean HbA1c than patients without these characteristics (mean HbA1c in T1DM: 6.8% vs 9.6%, respectively; mean HbA1c in T2DM: 7.0% vs 10.1%, respectively). Conclusion Although there is a significant physicians’ overestimation about the optimal glycemic control, this global impression and characteristics of patients’ empowerment, such as self-monitoring and self-adjustment of insulin, are associated with the achievement of targets. PMID:27555751

Factors Associated with Failure to Achieve SVR in Hepatitis C Genotype 3 Patients Within an Integrated Care Delivery System.

PubMed

Cheetham, T Craig; Niu, Fang; Chiang, Kevin; Yuan, Yong; Kalsekar, Anu; Hechter, Rulin; Hay, Joel W; Nyberg, Lisa

2015-08-01

Achievement of sustained virologic response (SVR) and factors associated with treatment failure in hepatitis C virus (HCV) genotype 3 have been described in tertiary and referral care settings, with rates of SVR reported to range between 72% and 89%. Fewer data exist on SVR outside of these settings. To describe rates of SVR and characterize factors associated with achievement of SVR within an integrated health care delivery system. A retrospective cohort study of genotype 3 HCV patients treated with dual therapy (pegylated interferon-alpha plus ribavirin) was conducted at Kaiser Permanente Southern California. Adult patients diagnosed with HCV and testing positive for HCV-RNA genotype 3 were identified from electronic medical records. Data were collected on patient demographics, baseline health status, and comorbid conditions. A multivariate logistic regression model was used to determine the association between baseline patient factors and SVR. A total of 484 HCV genotype 3 patients met the eligibility criteria. The median age was 49 years, and 65.7% were male. Overall, 252 (52.1%) achieved SVR. Aged ≥ 45 years and male gender were associated with lower rates of SVR; cirrhosis and chronic diseases (diabetes and chronic obstructive pulmonary disease) were also associated with lower rates of SVR. SVR was lower in patients within an integrated care delivery system than in those in tertiary and referral centers. Males and older patients had lower rates of SVR, as well as patients with cirrhosis, diabetes, and chronic obstructive pulmonary disease.

Optimizing point-of-care testing in clinical systems management.

PubMed

Kost, G J

1998-01-01

The goal of improving medical and economic outcomes calls for leadership based on fundamental principles. The manager of clinical systems works collaboratively within the acute care center to optimize point-of-care testing through systematic approaches such as integrative strategies, algorithms, and performance maps. These approaches are effective and efficacious for critically ill patients. Optimizing point-of-care testing throughout the entire health-care system is inherently more difficult. There is potential to achieve high-quality testing, integrated disease management, and equitable health-care delivery. Despite rapid change and economic uncertainty, a macro-strategic, information-integrated, feedback-systems, outcomes-oriented approach is timely, challenging, effective, and uplifting to the creative human spirit.

Achieving Guideline-Driven High-Intensity Statin Dose in Cardiac Rehabilitation Patients With Coronary Artery Disease.

PubMed

Lin, Jonathan; Banathy, Alexandra; Winters, Carla; Andersen, Lars; Hudson, Cindy; Testa, Heidi; Reardon, Joy; Alagona, Peter

2018-05-12

The 2013 American College of Cardiology/American Heart Association Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults recommends high-intensity statin therapy in patients aged ≤75 y with clinical coronary artery disease (CAD). The effectiveness of cardiac rehabilitation (CR) in lipid management and guideline adherence is unknown. The purpose of this study is to determine whether CR participation affects guideline-driven achievement for statin use. This multicenter retrospective study evaluated statin utilization in patients pre- and post-CR between January 1, 2014, and August 31, 2015. Records for patients with known CAD who completed 18 or more CR sessions were reviewed for statin-drug use and dose before and after CR and documented statin intolerance. Of the total 468 patients, 76% were male with mean age ± SD = 66.0 ± 10.8 y and range of 32 to 89 y. Patients aged ≤75 y (n = 375) showed a modest but statistically significant increase (P = .0006) in high-intensity statin use post-CR (56.3%-61.1%). Males demonstrated a significant increase in high-intensity statin use (P = .0005). Of the 146 patients aged ≤75 y not on high-intensity statins post-CR, only 21 had history of statin intolerance. Of the subjects aged >75 y (n = 93), 91% were already on high- or moderate-intensity statins with no significant change during CR. Patients aged ≤75 y following CR completion increased high-intensity statin use but only by 4.8% and 33% of subjects were inadequately treated. The updated 2013 treatment recommendations simplified statin use, yet substantial data continue to reveal that guideline achievement even post-CR remains limited.

Long-Term Benefit of Mesalamine Granules for Patients Who Achieved Corticosteroid-Induced Ulcerative Colitis Remission.

PubMed

Lichtenstein, Gary R; Gordon, Glenn L; Zakko, Salam; Murthy, Uma; Sedghi, Shahriar; Pruitt, Ron; Barrett, Andrew C; Bortey, Enoch; Paterson, Craig; Forbes, William P

2016-01-01

Patients with ulcerative colitis (UC) who achieve remission with corticosteroids often relapse after tapering or discontinuation; alternative treatments limiting steroid exposure and UC relapse would be beneficial. It remains uncertain whether patients with corticosteroid-induced remission experience benefit with mesalamine granules (MG), a locally acting aminosalicylate extended-release capsule formulation for maintenance of UC remission in adults. Efficacy and safety of MG 1.5 g once daily was evaluated in patients with UC in corticosteroid-induced remission. Data from patients with previous corticosteroid use to achieve baseline UC remission were analyzed from two 6-month randomized, double-blind, placebo-controlled trials and a 24-month open-label extension (OLE). Six-month relapse-free rates were assessed using the revised Sutherland Disease Activity Index. UC-related adverse events (AEs) were recorded during the 30 months. Included were 158 steroid-treated patients in UC remission (MG, n = 105; placebo, n = 53) and 74/105 MG-treated patients who continued MG in the OLE. A significantly larger percentage of patients remained relapse-free at 6 months with MG (77.1 %) versus placebo (54.7 %; P = 0.006), with a 55 % reduction in relapse risk (hazard ratio [HR] 0.45; 95 % CI 0.25-0.79). There was a similar (49.2 %) reduction in risk of UC-related AEs at 6 months (HR 0.51; 95 % CI 0.31-0.84; P = 0.009) that was sustained during the OLE. MG 1.5 g once daily administered for maintenance of corticosteroid-induced remission was associated with low risk of relapse and UC-related AEs. CLINICALTRIALS.GOV: NCT00744016, NCT00767728, and NCT00326209.

Vitamin D in corticosteroid-naïve and corticosteroid-treated Duchenne muscular dystrophy: what dose achieves optimal 25(OH) vitamin D levels?

PubMed

Alshaikh, Nahla; Brunklaus, Andreas; Davis, Tracey; Robb, Stephanie A; Quinlivan, Ros; Munot, Pinki; Sarkozy, Anna; Muntoni, Francesco; Manzur, Adnan Y

2016-10-01

Assessment of the efficacy of vitamin D replenishment and maintenance doses required to attain optimal levels in boys with Duchenne muscular dystrophy (DMD). 25(OH)-vitamin D levels and concurrent vitamin D dosage were collected from retrospective case-note review of boys with DMD at the Dubowitz Neuromuscular Centre. Vitamin D levels were stratified as deficient at <25 nmol/L, insufficient at 25-49 nmol/L, adequate at 50-75 nmol/L and optimal at >75 nmol/L. 617 vitamin D samples were available from 197 boys (range 2-18 years)-69% from individuals on corticosteroids. Vitamin D-naïve boys (154 samples) showed deficiency in 28%, insufficiency in 42%, adequate levels in 24% and optimal levels in 6%. The vitamin D-supplemented group (463 samples) was tested while on different maintenance/replenishment doses. Three-month replenishment of daily 3000 IU (23 samples) or 6000 IU (37 samples) achieved optimal levels in 52% and 84%, respectively. 182 samples taken on 400 IU revealed deficiency in 19 (10%), insufficiency in 84 (47%), adequate levels in 67 (37%) and optimal levels in 11 (6%). 97 samples taken on 800 IU showed deficiency in 2 (2%), insufficiency in 17 (17%), adequate levels in 56 (58%) and optimal levels in 22 (23%). 81 samples were on 1000 IU and 14 samples on 1500 IU, with optimal levels in 35 (43%) and 9 (64%), respectively. No toxic level was seen (highest level 230 nmol/L). The prevalence of vitamin D deficiency and insufficiency in DMD is high. A 2-month replenishment regimen of 6000 IU and maintenance regimen of 1000-1500 IU/day was associated with optimal vitamin D levels. These data have important implications for optimising vitamin D dosing in DMD. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Two Blades-Up Runs Using the JetStream Navitus Atherectomy Device Achieve Optimal Tissue Debulking of Nonocclusive In-Stent Restenosis: Observations From a Porcine Stent/Balloon Injury Model.

PubMed

Shammas, Nicolas W; Aasen, Nicole; Bailey, Lynn; Budrewicz, Jay; Farago, Trent; Jarvis, Gary

2015-08-01

To determine the number of runs with blades up (BU) using the JetStream Navitus to achieving optimal debulking in a porcine model of femoropopliteal artery in-stent restenosis (ISR). In this porcine model, 8 limbs were implanted with overlapping nitinol self-expanding stents. ISR was treated initially with 2 blades-down (BD) runs followed by 4 BU runs (BU1 to BU4). Quantitative vascular angiography (QVA) was performed at baseline, after 2 BD runs, and after each BU run. Plaque surface area and percent stenosis within the treated stented segment were measured. Intravascular ultrasound (IVUS) was used to measure minimum lumen area (MLA) and determine IVUS-derived plaque surface area. QVA showed that plaque surface area was significantly reduced between baseline (83.9%±14.8%) and 2 BD (67.7%±17.0%, p=0.005) and BU1 (55.4%±9.0%, p=0.005) runs, and between BU1 and BU2 runs (50.7%±9.7%, p<0.05). Percent stenosis behaved similarly with no further reduction after BU2. There were no further reductions in plaque surface area or percent stenosis with BU 3 and 4 runs (p=0.10). Similarly, IVUS (24 lesions) confirmed optimal results with BU2 runs and no additional gain in MLA or reduction in plaque surface area with BU3 and 4. IVUS confirmed no orbital cutting with JetStream Navitus. There were no stent strut discontinuities on high-resolution radiographs following atherectomy. JetStream Navitus achieved optimal tissue debulking after 2 BD and 2 BU runs with no further statistical gain in debulking after the BU2 run. Operators treating ISR with JetStream Navitus may be advised to limit their debulking to 2 BD and 2 BU runs to achieve optimal debulking. © The Author(s) 2015.

Optimal programming management of ventricular tachycardia storm in ICD patients

PubMed Central

Qian, Zhiyong; Guo, Jianghong; Zhang, Zhiyong; Wang, Yao; Hou, Xiaofeng; Zou, Jiangang

2015-01-01

Abstract Ventricular tachycardia storm (VTS) is defined as a life-threatening syndrome of three or more separate episodes of ventricular tachycardia (VT) leading to implantable cardioverter defibrillator (ICD) therapy within 24 hours. Patients with VTS have poor outcomes and require immediate medical attention. ICD shocks have been shown to be associated with increased mortality in several studies. Optimal programming in minimization of ICD shocks may decrease mortality. Large controlled trials showed that long detection time and high heart rate detection threshold reduced ICD shock burden without an increase in syncope or death. As a fundamental therapy of ICD, antitachycardia pacing (ATP) can terminate most slow VT with a low risk of acceleration. For fast VT, burst pacing is more effective and less likely to result in acceleration than ramp pacing. One algorithm of optimal programming management during a VTS is presented in the review. PMID:25745473

Optimizing perioperative outcomes for older patients with rheumatoid arthritis undergoing arthroplasty: emphasis on medication management.

PubMed

Goodman, Susan M

2015-05-01

Patients with rheumatoid arthritis continue to undergo arthroplasty despite widespread use of potent disease-modifying drugs (DMARDs), including the biologic tumor necrosis-α inhibitors. In fact, over 80 % of RA patients are taking DMARDs or biologics at the time of arthroplasty. While many RA-specific factors including disease activity and disability may contribute to the increase in infection in RA patients undergoing arthroplasty, immunosuppressant medications may also play a role. As the age of patients with RA undergoing arthroplasty is rising, and the incidence of arthroplasty among the older population is increasing, optimal perioperative management of DMARDs and biologics in older patients with RA is an increasing challenge. Although evidence is sparse, most evidence supports withholding tumor necrosis-α inhibitors and other biologics prior to surgery based on the dosing interval, and continuing methotrexate and hydroxychloroquine through the perioperative period. There is no consensus regarding leflunomide, and rituximab risk does not appear related to the interval between infusion and surgery. This paper reviews arthroplasty outcomes including complications in patients with RA, and discusses the rationale for strategies for the optimal medication management of DMARDs and biologics in the perioperative period to minimize complications and improve outcomes.

Thyroidectomy as primary treatment optimizes body mass index in patients with hyperthyroidism.

PubMed

Schneider, David F; Nookala, Ratnam; Jaraczewski, Taylor J; Chen, Herbert; Solorzano, Carmen C; Sippel, Rebecca S

2014-07-01

The purpose of this study was to determine how the timing of thyroidectomy influenced postoperative weight change. We conducted a two-institution study, identifying patients treated with total thyroidectomy for hyperthyroidism. Patients were classified as 'early' if they were referred for surgery as the first treatment option, or 'delayed' if they were previously treated with radioactive iodine (RAI). Groups were compared with the Student's t-test or χ (2) test where appropriate. There were 204 patients undergoing thyroidectomy for hyperthyroidism. Of these, 171 patients were classified as early and 33 were classified as delayed. Overall, patients gained 6.0 % ± 0.8 of their preoperative body weight at last follow-up. Preoperative body mass indexes (BMIs) were similar between groups (p = 0.98), and the median follow-up time was 388 days (range 15-1,584 days). Both groups gained weight until they achieved a normal thyroid-stimulating hormone (TSH) postoperatively. After achieving a normal TSH, the early group stabilized or lost weight (-0.2 lbs/day), while the delayed group continued to gain weight (0.02 lbs/day; p = 0.61). At last follow-up, there were significantly more patients in the delayed group who increased their BMI category compared with the early group (42.4 vs. 21.6 %; p = 0.01). Twice as many patients in the delayed group moved up or into an unhealthy BMI category (overweight or obese) compared with the early group (39.4 vs. 19.3 %; p = 0.01). Compared with patients initially treated with RAI, patients with hyperthyroidism who underwent surgery as the first treatment were less likely to become overweight or obese postoperatively.

Harmony search optimization for HDR prostate brachytherapy

NASA Astrophysics Data System (ADS)

Panchal, Aditya

In high dose-rate (HDR) prostate brachytherapy, multiple catheters are inserted interstitially into the target volume. The process of treating the prostate involves calculating and determining the best dose distribution to the target and organs-at-risk by means of optimizing the time that the radioactive source dwells at specified positions within the catheters. It is the goal of this work to investigate the use of a new optimization algorithm, known as Harmony Search, in order to optimize dwell times for HDR prostate brachytherapy. The new algorithm was tested on 9 different patients and also compared with the genetic algorithm. Simulations were performed to determine the optimal value of the Harmony Search parameters. Finally, multithreading of the simulation was examined to determine potential benefits. First, a simulation environment was created using the Python programming language and the wxPython graphical interface toolkit, which was necessary to run repeated optimizations. DICOM RT data from Varian BrachyVision was parsed and used to obtain patient anatomy and HDR catheter information. Once the structures were indexed, the volume of each structure was determined and compared to the original volume calculated in BrachyVision for validation. Dose was calculated using the AAPM TG-43 point source model of the GammaMed 192Ir HDR source and was validated against Varian BrachyVision. A DVH-based objective function was created and used for the optimization simulation. Harmony Search and the genetic algorithm were implemented as optimization algorithms for the simulation and were compared against each other. The optimal values for Harmony Search parameters (Harmony Memory Size [HMS], Harmony Memory Considering Rate [HMCR], and Pitch Adjusting Rate [PAR]) were also determined. Lastly, the simulation was modified to use multiple threads of execution in order to achieve faster computational times. Experimental results show that the volume calculation that was

Toward optimizing patient-specific IMRT QA techniques in the accurate detection of dosimetrically acceptable and unacceptable patient plans

PubMed Central

McKenzie, Elizabeth M.; Balter, Peter A.; Stingo, Francesco C.; Jones, Jimmy; Followill, David S.; Kry, Stephen F.

2014-01-01

Purpose: The authors investigated the performance of several patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA) dosimeters in terms of their ability to correctly identify dosimetrically acceptable and unacceptable IMRT patient plans, as determined by an in-house-designed multiple ion chamber phantom used as the gold standard. A further goal was to examine optimal threshold criteria that were consistent and based on the same criteria among the various dosimeters. Methods: The authors used receiver operating characteristic (ROC) curves to determine the sensitivity and specificity of (1) a 2D diode array undergoing anterior irradiation with field-by-field evaluation, (2) a 2D diode array undergoing anterior irradiation with composite evaluation, (3) a 2D diode array using planned irradiation angles with composite evaluation, (4) a helical diode array, (5) radiographic film, and (6) an ion chamber. This was done with a variety of evaluation criteria for a set of 15 dosimetrically unacceptable and 9 acceptable clinical IMRT patient plans, where acceptability was defined on the basis of multiple ion chamber measurements using independent ion chambers and a phantom. The area under the curve (AUC) on the ROC curves was used to compare dosimeter performance across all thresholds. Optimal threshold values were obtained from the ROC curves while incorporating considerations for cost and prevalence of unacceptable plans. Results: Using common clinical acceptance thresholds, most devices performed very poorly in terms of identifying unacceptable plans. Grouping the detector performance based on AUC showed two significantly different groups. The ion chamber, radiographic film, helical diode array, and anterior-delivered composite 2D diode array were in the better-performing group, whereas the anterior-delivered field-by-field and planned gantry angle delivery using the 2D diode array performed less well. Additionally, based on the AUCs, there

Toward optimizing patient-specific IMRT QA techniques in the accurate detection of dosimetrically acceptable and unacceptable patient plans.

PubMed

McKenzie, Elizabeth M; Balter, Peter A; Stingo, Francesco C; Jones, Jimmy; Followill, David S; Kry, Stephen F

2014-12-01

The authors investigated the performance of several patient-specific intensity-modulated radiation therapy (IMRT) quality assurance (QA) dosimeters in terms of their ability to correctly identify dosimetrically acceptable and unacceptable IMRT patient plans, as determined by an in-house-designed multiple ion chamber phantom used as the gold standard. A further goal was to examine optimal threshold criteria that were consistent and based on the same criteria among the various dosimeters. The authors used receiver operating characteristic (ROC) curves to determine the sensitivity and specificity of (1) a 2D diode array undergoing anterior irradiation with field-by-field evaluation, (2) a 2D diode array undergoing anterior irradiation with composite evaluation, (3) a 2D diode array using planned irradiation angles with composite evaluation, (4) a helical diode array, (5) radiographic film, and (6) an ion chamber. This was done with a variety of evaluation criteria for a set of 15 dosimetrically unacceptable and 9 acceptable clinical IMRT patient plans, where acceptability was defined on the basis of multiple ion chamber measurements using independent ion chambers and a phantom. The area under the curve (AUC) on the ROC curves was used to compare dosimeter performance across all thresholds. Optimal threshold values were obtained from the ROC curves while incorporating considerations for cost and prevalence of unacceptable plans. Using common clinical acceptance thresholds, most devices performed very poorly in terms of identifying unacceptable plans. Grouping the detector performance based on AUC showed two significantly different groups. The ion chamber, radiographic film, helical diode array, and anterior-delivered composite 2D diode array were in the better-performing group, whereas the anterior-delivered field-by-field and planned gantry angle delivery using the 2D diode array performed less well. Additionally, based on the AUCs, there was no significant difference

Achieving deeper molecular response is associated with a better clinical outcome in chronic myeloid leukemia patients on imatinib front-line therapy

PubMed Central

Etienne, Gabriel; Dulucq, Stéphanie; Nicolini, Franck-Emmanuel; Morisset, Stéphane; Fort, Marie-Pierre; Schmitt, Anna; Etienne, Madeleine; Hayette, Sandrine; Lippert, Eric; Bureau, Caroline; Tigaud, Isabelle; Adiko, Didier; Marit, Gérald; Reiffers, Josy; Mahon, François-Xavier

2014-01-01

Sustained imatinib treatment in chronic myeloid leukemia patients can result in complete molecular response allowing discontinuation without relapse. We set out to evaluate the frequency of complete molecular response in imatinib de novo chronic phase chronic myeloid leukemia patients, to identify base-line and under-treatment predictive factors of complete molecular response in patients achieving complete cytogenetic response, and to assess if complete molecular response is associated with a better outcome. A random selection of patients on front-line imatinib therapy (n=266) were considered for inclusion. Complete molecular response was confirmed and defined as MR 4.5 with undetectable BCR-ABL transcript levels. Median follow up was 4.43 years (range 0.79–10.8 years). Sixty-five patients (24%) achieved complete molecular response within a median time of 32.7 months. Absence of spleen enlargement at diagnosis, achieving complete cytogenetic response before 12 months of therapy, and major molecular response during the year following complete cytogenetic response was predictive of achieving further complete molecular response. Patients who achieved complete molecular response had better event-free and failure-free survivals than those with complete cytogenetic response irrespective of major molecular response status (95.2% vs. 64.7% vs. 27.7%, P=0.00124; 98.4% vs. 82.3% vs. 56%, P=0.0335), respectively. Overall survival was identical in the 3 groups. In addition to complete cytogenetic response and major molecular response, further deeper molecular response is associated with better event-free and failure-free survivals, and complete molecular response confers the best outcome. PMID:24362549

Linear energy transfer incorporated intensity modulated proton therapy optimization

NASA Astrophysics Data System (ADS)

Cao, Wenhua; Khabazian, Azin; Yepes, Pablo P.; Lim, Gino; Poenisch, Falk; Grosshans, David R.; Mohan, Radhe

2018-01-01

The purpose of this study was to investigate the feasibility of incorporating linear energy transfer (LET) into the optimization of intensity modulated proton therapy (IMPT) plans. Because increased LET correlates with increased biological effectiveness of protons, high LETs in target volumes and low LETs in critical structures and normal tissues are preferred in an IMPT plan. However, if not explicitly incorporated into the optimization criteria, different IMPT plans may yield similar physical dose distributions but greatly different LET, specifically dose-averaged LET, distributions. Conventionally, the IMPT optimization criteria (or cost function) only includes dose-based objectives in which the relative biological effectiveness (RBE) is assumed to have a constant value of 1.1. In this study, we added LET-based objectives for maximizing LET in target volumes and minimizing LET in critical structures and normal tissues. Due to the fractional programming nature of the resulting model, we used a variable reformulation approach so that the optimization process is computationally equivalent to conventional IMPT optimization. In this study, five brain tumor patients who had been treated with proton therapy at our institution were selected. Two plans were created for each patient based on the proposed LET-incorporated optimization (LETOpt) and the conventional dose-based optimization (DoseOpt). The optimized plans were compared in terms of both dose (assuming a constant RBE of 1.1 as adopted in clinical practice) and LET. Both optimization approaches were able to generate comparable dose distributions. The LET-incorporated optimization achieved not only pronounced reduction of LET values in critical organs, such as brainstem and optic chiasm, but also increased LET in target volumes, compared to the conventional dose-based optimization. However, on occasion, there was a need to tradeoff the acceptability of dose and LET distributions. Our conclusion is that the

An optimal frequency range for assessing the pressure reactivity index in patients with traumatic brain injury.

PubMed

Howells, Tim; Johnson, Ulf; McKelvey, Tomas; Enblad, Per

2015-02-01

The objective of this study was to identify the optimal frequency range for computing the pressure reactivity index (PRx). PRx is a clinical method for assessing cerebral pressure autoregulation based on the correlation of spontaneous variations of arterial blood pressure (ABP) and intracranial pressure (ICP). Our hypothesis was that optimizing the methodology for computing PRx in this way could produce a more stable, reliable and clinically useful index of autoregulation status. The patients studied were a series of 131 traumatic brain injury patients. Pressure reactivity indices were computed in various frequency bands during the first 4 days following injury using bandpass filtering of the input ABP and ICP signals. Patient outcome was assessed using the extended Glasgow Outcome Scale (GOSe). The optimization criterion was the strength of the correlation with GOSe of the mean index value over the first 4 days following injury. Stability of the indices was measured as the mean absolute deviation of the minute by minute index value from 30-min moving averages. The optimal index frequency range for prediction of outcome was identified as 0.018-0.067 Hz (oscillations with periods from 55 to 15 s). The index based on this frequency range correlated with GOSe with ρ=-0.46 compared to -0.41 for standard PRx, and reduced the 30-min variation by 23%.

Implementing optimal thinning strategies

Treesearch

Kurt H. Riitters; J. Douglas Brodie

1984-01-01

Optimal thinning regimes for achieving several management objectives were derived from two stand-growth simulators by dynamic programming. Residual mean tree volumes were then plotted against stand density management diagrams. The results supported the use of density management diagrams for comparing, checking, and implementing the results of optimization analyses....

Achieving ventricular rate control using metoprolol in β-blocker-naive patients vs patients on chronic β-blocker therapy.

PubMed

Kuang, Patricia; Mah, Nathan D; Barton, Cassie A; Miura, Andrea J; Tanas, Laura R; Ran, Ran

2016-03-01

The objective of the study is to evaluate the difference in ventricular rate control using an intravenous (IV) metoprolol regimen commonly used in clinical practice in patients receiving chronic β-blocker therapy compared to patients considered β-blocker naive admitted to the emergency department (ED) for atrial fibrillation (AF) with rapid ventricular rate. A single-center retrospective cohort study of adult ED patients who were admitted with a rapid ventricular rate of 120 beats per minute (bpm) or greater and treated with IV metoprolol was performed. Rate control was defined as either a decrease in ventricular rate to less than 100 bpm or a 20% decrease in heart rate to less than 120 bpm after metoprolol administration. Patient demographics, differences in length of stay, and adverse events were recorded. A total of 398 patients were included in the study, with 79.4% (n=316) receiving chronic β-blocker therapy. Patients considered to be β-blocker naive were more likely to achieve successful rate control with IV metoprolol compared to patients on chronic β-blocker therapy (56.1% vs 42.4%; P=.03). β-Blocker-naive status was associated with a shorter length of stay in comparison to patients receiving chronic β-blocker therapy (1.79 vs 2.64 days; P<.01). Intravenous metoprolol for the treatment of atrial fibrillation with rapid ventricular rate was associated with a higher treatment response in patients considered β-blocker naive compared to patients receiving chronic β-blocker therapy. Copyright © 2015 Elsevier Inc. All rights reserved.

Portfolio optimization with mean-variance model

NASA Astrophysics Data System (ADS)

Hoe, Lam Weng; Siew, Lam Weng

2016-06-01

Investors wish to achieve the target rate of return at the minimum level of risk in their investment. Portfolio optimization is an investment strategy that can be used to minimize the portfolio risk and can achieve the target rate of return. The mean-variance model has been proposed in portfolio optimization. The mean-variance model is an optimization model that aims to minimize the portfolio risk which is the portfolio variance. The objective of this study is to construct the optimal portfolio using the mean-variance model. The data of this study consists of weekly returns of 20 component stocks of FTSE Bursa Malaysia Kuala Lumpur Composite Index (FBMKLCI). The results of this study show that the portfolio composition of the stocks is different. Moreover, investors can get the return at minimum level of risk with the constructed optimal mean-variance portfolio.

New Insights into Dialysis Vascular Access: What Is the Optimal Vascular Access Type and Timing of Access Creation in CKD and Dialysis Patients?

PubMed

Woo, Karen; Lok, Charmaine E

2016-08-08

Optimal vascular access planning begins when the patient is in the predialysis stages of CKD. The choice of optimal vascular access for an individual patient and determining timing of access creation are dependent on a multitude of factors that can vary widely with each patient, including demographics, comorbidities, anatomy, and personal preferences. It is important to consider every patient's ESRD life plan (hence, their overall dialysis access life plan for every vascular access creation or placement). Optimal access type and timing of access creation are also influenced by factors external to the patient, such as surgeon experience and processes of care. In this review, we will discuss the key determinants in optimal access type and timing of access creation for upper extremity arteriovenous fistulas and grafts. Copyright © 2016 by the American Society of Nephrology.

Achieving normothermia in patients with febrile subarachnoid hemorrhage: feasibility and safety of a novel intravascular cooling catheter.

PubMed

Badjatia, Neeraj; O'Donnell, Joan; Baker, John R; Huang, David; Ayata, Cenk; Greer, David M; Carter, Bob S; Ogilvy, Christopher S; McDonald, Colin T

2004-01-01

Fever is common and difficult to control in patients with subarachnoid hemorrhage (SAH). We have previously shown an inverse relationship between fever and outcome in patients with SAH. This was a prospective, single-arm, feasibility trial in which nine patients with SAH underwent temperature management using an intravascular cooling catheter (ICC) to restore and maintain 24 hours of normothermia (36.5 degrees+/-0.2 degrees C). Enrollment occurred after development of a fever of at least 38.3 degrees C within 7 days of SAH that was refractory to acetaminophen treatment. The ICC was placed at the bedside through an introducer sheath via the femoral vein into the inferior vena cava (IVC). Portable X-ray confirmed placement. Normothermia was achieved in seven of the nine patients treated (78%); it was achieved in 100% of the patients with a 14F catheter (n=4) and in 60% of the patients with a 9F catheter (n=5). The two patients not reaching normothermia were not adequately treated for shivering. All other patients reached normothermia irrespective of intubation status. Overall, normothermia was well tolerated and not discontinued because of discomfort or adverse events. Two incidences of deep vein thrombosis were diagnosis by ultrasound that were not associated with clinical sequelae, and IVC filters were placed. No unanticipated adverse events occurred. We have demonstrated that fever can be safely and effectively controlled in patients with SAH for at least 24 hours using an ICC. Future studies are needed to assess the effect of such sustained therapy on outcome in patients with SAH.

Rational therapeutic choice for older patients with lymphoma.

PubMed

Bron, Dominique; Soubeyran, Pierre

2017-09-01

The choice for an optimal treatment in older lymphoma patients is a real challenge for hemato-oncologists. They have to treat a potentially curative lymphoma, and concomitantly protect their patients from unacceptable toxicities. Some recommendations are provided for the major subtypes of lymphomas including the antitumoral treatment and primarily the optimal supportive care. All the recent literature data converge to say that the approach of an older patient with a malignant hemopathy is a multistep procedure. This process comprises the appraisal of life expectancy of the patient with or without the disease, the prognostic factors of the tumor, the functional, physiological and cognitive functions evaluation, the socio-economical environment and the patient's expectancy in terms of quality of life. Major progresses have been achieved in the management of diffuse large B cell lymphoma and mantle cell lymphoma in patients up to 80 and above 80 years old. With all these information in hands, the hematologist will decide if the treatment's objective is the standard treatment with optimal supportive care (fit patients), tailor-made adapted chemotherapy (unfit patients) or preservation of quality of life (frail patients).

Achieving timely percutaneous reperfusion for rural ST-elevation myocardial infarction patients by direct transport to an urban PCI-hospital.

PubMed

Bennin, Charles-Lwanga K; Ibrahim, Saif; Al-Saffar, Farah; Box, Lyndon C; Strom, Joel A

2016-10-01

ST-elevation myocardial infarction (STEMI) guidelines recommend reperfusion by primary percutaneous coronary intervention (PCI) ≤ 90 min from time of first medical contact (FMC). This strategy is challenging in rural areas lacking a nearby PCI-capable hospital. Recommended reperfusion times can be achieved for STEMI patients presenting in rural areas without a nearby PCI-capable hospital by ground transportation to a central PCI-capable hospital by use of protocol-driven emergency medical service (EMS) STEMI field triage protocol. Sixty STEMI patients directly transported by EMS from three rural counties (Nassau, Camden and Charlton Counties) within a 50-mile radius of University of Florida Health-Jacksonville (UFHJ) from 01/01/2009 to 12/31/2013 were identified from its PCI registry. The STEMI field triage protocol incorporated three elements: (1) a cooperative agreement between each of the rural emergency medical service (EMS) agency and UFHJ; (2) performance of a pre-hospital ECG to facilitate STEMI identification and laboratory activation; and (3) direct transfer by ground transportation to the UFHJ cardiac catheterization laboratory. FMC-to-device (FMC2D), door-to-device (D2D), and transit times, the day of week, time of day, and EMS shift times were recorded, and odds ratio (OR) of achieving FMC2D times was calculated. FMC2D times were shorter for in-state STEMIs (81 ± 17 vs . 87 ± 19 min), but D2D times were similar (37 ± 18 vs . 39 ± 21 min). FMC2D ≤ 90 min were achieved in 82.7% in-state STEMIs compared to 52.2% for out-of-state STEMIs (OR = 4.4, 95% CI: 1.24-15.57; P = 0.018). FMC2D times were homogenous after adjusting for weekday vs . weekend, EMS shift times. Nine patients did not meet FMC2D ≤ 90 min. Six were within 10 min of target; all patient achieved FMC2D ≤ 120 min. Guideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use of protocol-driven EMS ground

Systematic review of decreased intracranial pressure with optimal head elevation in postcraniotomy patients: a meta-analysis.

PubMed

Jiang, Yan; Ye, Zeng pan-pan; You, Chao; Hu, Xin; Liu, Yi; Li, Hao; Lin, Sen; Li, Ji-Pin

2015-10-01

To determine an optimal head elevation degree to decrease intracranial pressure in postcraniotomy patients by meta-analysis. A change in head position can lead to a change in intracranial pressure; however, there are conflicting data regarding the optimal degree of elevation that decreases intracranial pressure in postcraniotomy patients. Quantitative systematic review with meta-analysis following Cochrane methods. The data were collected during 2014; three databases (PubMed, Embase and China National Knowledge Internet) were searched for published and unpublished studies in English. The bibliographies of the articles were also reviewed. The inclusion criteria referred to different elevation degrees and effects on intracranial pressure in postcraniotomy patients. According to pre-determined inclusion criteria and exclusion criteria, two reviewers extracted the eligible studies using a standard data form. These included a total of 237 participants who were included in the meta-analysis. (1) Compared with 0 degree: 10, 15, 30 and 45 degrees of head elevation resulted in lower intracranial pressure. (2) Intracranial pressure at 30 degrees was not significantly different in comparison to 45 degrees and was lower than that at 10 and 15 degrees. Patients with increased intracranial pressure significantly benefitted from a head elevation of 10, 15, 30 and 45 degrees compared with 0 degrees. A head elevation of 30 or 45 degrees is optimal for decreasing intracranial pressure. Research about the relationship of position changes and the outcomes of patient primary diseases is absent. © 2015 John Wiley & Sons Ltd.

Feasibility and robustness of dose painting by numbers in proton therapy with contour-driven plan optimization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Barragán, A. M., E-mail: ana.barragan@uclouvain.be; Differding, S.; Lee, J. A.

Purpose: To prove the ability of protons to reproduce a dose gradient that matches a dose painting by numbers (DPBN) prescription in the presence of setup and range errors, by using contours and structure-based optimization in a commercial treatment planning system. Methods: For two patients with head and neck cancer, voxel-by-voxel prescription to the target volume (GTV{sub PET}) was calculated from {sup 18}FDG-PET images and approximated with several discrete prescription subcontours. Treatments were planned with proton pencil beam scanning. In order to determine the optimal plan parameters to approach the DPBN prescription, the effects of the scanning pattern, number ofmore » fields, number of subcontours, and use of range shifter were separately tested on each patient. Different constant scanning grids (i.e., spot spacing = Δx = Δy = 3.5, 4, and 5 mm) and uniform energy layer separation [4 and 5 mm WED (water equivalent distance)] were analyzed versus a dynamic and automatic selection of the spots grid. The number of subcontours was increased from 3 to 11 while the number of beams was set to 3, 5, or 7. Conventional PTV-based and robust clinical target volumes (CTV)-based optimization strategies were considered and their robustness against range and setup errors assessed. Because of the nonuniform prescription, ensuring robustness for coverage of GTV{sub PET} inevitably leads to overdosing, which was compared for both optimization schemes. Results: The optimal number of subcontours ranged from 5 to 7 for both patients. All considered scanning grids achieved accurate dose painting (1% average difference between the prescribed and planned doses). PTV-based plans led to nonrobust target coverage while robust-optimized plans improved it considerably (differences between worst-case CTV dose and the clinical constraint was up to 3 Gy for PTV-based plans and did not exceed 1 Gy for robust CTV-based plans). Also, only 15% of the points in the GTV{sub PET} (worst

Irreversible electroporation of stage 3 locally advanced pancreatic cancer: optimal technique and outcomes

PubMed Central

2015-01-01

Objective Irreversible electroporation (IRE) of stage 3 pancreatic adenocarcinoma has been used to provide quality of life time in patients who have undergone appropriate induction therapy. The optimal technique has been reported within the literature, but not in video form. IRE of locally advanced pancreatic cancer is technically demanding requiring precision ultrasound use for continuous imaging in multiple needle placements and during IRE energy delivery. Methods Appropriate patients with locally advanced pancreatic cancer should have undergone appropriate induction chemotherapy for a reasonable duration. The safe and effective technique for irreversible electroporation is preformed through an open approach with the emphasis on intra-operative ultrasound and intra-operative electroporation management. Results The technique of open irreversible electroporation of the pancreas involves bracketing the target tumor with IRE probes and any and all invaded vital structures including the celiac axis, superior mesenteric artery (SMA), superior mesenteric-portal vein, and bile duct with continuous intraoperative ultrasound imaging through a caudal to cranial approach. Optimal IRE delivery requires a change in amperage of at least 12 amps from baseline tissue conductivity in order to achieve technical success. Multiple pull-backs are necessary since the IRE ablation probe lengths are 1 cm and thus needed to achieve technical success along the caudal to cranial plane. Conclusions Irreversible electroporation in combination with multi-modality therapy for locally advanced pancreatic carcinoma is feasible for appropriate patients with locally advanced cancer. Technical demands are high and require the highest quality ultrasound for precise spacing measurements and optimal delivery to ensure adequate change in tissue resistance. PMID:29075594

Dosage optimization in positron emission tomography: state-of-the-art methods and future prospects

PubMed Central

Karakatsanis, Nicolas A; Fokou, Eleni; Tsoumpas, Charalampos

2015-01-01

Positron emission tomography (PET) is widely used nowadays for tumor staging and therapy response in the clinic. However, average PET radiation exposure has increased due to higher PET utilization. This study aims to review state-of-the-art PET tracer dosage optimization methods after accounting for the effects of human body attenuation and scan protocol parameters on the counting rate. In particular, the relationship between the noise equivalent count rate (NECR) and the dosage (NECR-dosage curve) for a range of clinical PET systems and body attenuation sizes will be systematically studied to prospectively estimate the minimum dosage required for sufficiently high NECR. The optimization criterion can be determined either as a function of the peak of the NECR-dosage curve or as a fixed NECR score when NECR uniformity across a patient population is important. In addition, the systematic NECR assessments within a controllable environment of realistic simulations and phantom experiments can lead to a NECR-dosage response model, capable of predicting the optimal dosage for every individual PET scan. Unlike conventional guidelines suggesting considerably large dosage levels for obese patients, NECR-based optimization recommends: i) moderate dosage to achieve 90% of peak NECR for obese patients, ii) considerable dosage reduction for slimmer patients such that uniform NECR is attained across the patient population, and iii) prolongation of scans for PET/MR protocols, where longer PET acquisitions are affordable due to lengthy MR sequences, with motion compensation becoming important then. Finally, the need for continuous adaptation of dosage optimization to emerging technologies will be discussed. PMID:26550543

Supply-Chain Optimization Template

NASA Technical Reports Server (NTRS)

Quiett, William F.; Sealing, Scott L.

2009-01-01

The Supply-Chain Optimization Template (SCOT) is an instructional guide for identifying, evaluating, and optimizing (including re-engineering) aerospace- oriented supply chains. The SCOT was derived from the Supply Chain Council s Supply-Chain Operations Reference (SCC SCOR) Model, which is more generic and more oriented toward achieving a competitive advantage in business.

[Internal drainage in cancer patients: optimizing treatment of stent-related symptoms].

PubMed

Martov, A G; Ergakov, D V; Novikov, A B; Muzhetskaya, N G; Esen'yan, G L

2016-04-01

The so-called stent-related symptoms caused mainly by detrusor overactivity due to distal ("cystic") curl of the internal stent are common among patients with this type of drainage. The need for long-term stenting makes the quality of life of cancer patients one of the challenging problems of modern urology. The aim of this study was to optimize treatment of stent-related symptoms in cancer patients with internal long-term stents by complementing the treatment regimen with m-anticholinergic solifenacin. From November 2013 to November 2015 68 cancer patients (26 males, 42 females, age 36-79 years) underwent elective internal ureteral stenting for drainage of the upper urinary tract (UUT) with special long-term stents coated with the hydrogel. The urinary tract obstruction was caused by urological (24), gynecological (26) and colorectal (18) cancers. Before deciding on urinary tract drainage, all patients were treated with radiation or chemotherapy, 28 (41.2%) patients underwent surgery, but on admission all of them had contraindications to radical surgery for different reasons. In 52 (76.5%) patients UUT stenting was performed using transurethral access, in 12 (17.6%) by percutaneous access and in another 4 (5.9%) by the combined access with patients in the supine position. Percutaneous and combined access was used in cases of impracticability (failure) of transurethral stenting. Patients in group 1 (n=32) after stent placement received standard therapy co-administered with solifenacin 5 mg daily, group 2 (n=36) - only standard therapy. The data analyzed were the technical features of the internal drainage, optimal access and registered solifenacin-related adverse events. Control examinations were scheduled once in 3 months after stent placement according to the following algorithm: ultrasound scanning, laboratory test monitoring and, if indicated, plain urography. To objectify the severity of stent-related symptoms, a survey of patients using a special

Proceedings of the 2016 Clinical Nutrition Week Research Workshop-The Optimal Dose of Protein Provided to Critically Ill Patients.

PubMed

Heyland, Daren K; Rooyakers, Olav; Mourtzakis, Marina; Stapleton, Renee D

2017-02-01

Recent literature has created considerable confusion about the optimal amount of protein/amino acids that should be provided to the critically ill patient. In fact, the evidentiary basis that directly tries to answer this question is relatively small. As a clinical nutrition research community, there is an urgent need to develop the optimal methods to assess the impact of exogenous protein/amino acid administration in the intensive care unit setting. That assessment can be conducted at various levels: (1) impact on stress response pathways, (2) impact on muscle synthesis and protein balance, (3) impact on muscle mass and function, and (4) impact on the patient's recovery. The objective of this research workshop was to review current literature relating to protein/amino acid administration for the critically ill patient and clinical outcomes and to discuss the key measurement and methodological features of future studies that should be done to inform the optimal protein/amino acid dose provided to critically ill patients.

The clinical benefit of cardiac resynchronization therapy optimization using a device-based hemodynamic sensor in a patient with dilated cardiomyopathy: a case report.

PubMed

Volpicelli, Mario; Covino, Gregorio; Capogrosso, Paolo

2015-12-19

Results on the evolution of the clinical status of patients undergoing cardiac resynchronization therapy with a defibrillator after automatic optimization of their cardiac resynchronization therapy are scarce. We observed a rapid and important change in the clinical status of our non-responding patient following activation of a sensor capable of weekly atrioventricular and interventricular delays' optimization. A 78-year-old Caucasian man presented with dilated cardiomyopathy, left bundle branch block, a left ventricular ejection fraction of 35 %, New York Heart Association class III/IV heart failure, and paroxysmal atrial fibrillation. Our patient was implanted with a cardiac resynchronization device with a defibrillator and the SonRtip atrial lead. Right ventricular and left ventricular leads were also implanted. Because of the recurrence of atrial fibrillation, the automatic optimization was set off at discharge. Consequently, the device did not optimize atrioventricular and interventricular delays (programming at discharge: 125 ms for the atrioventricular delay and 0 ms for the interventriculardelay). Our patient was treated with an anti-arrhythmic drug. Five months after implantation, his clinical status remained impaired (left ventricular ejection fraction = 30 %). The SonR signal amplitude had also decreased from 0.52 g to 0.29 g. Nevertheless, because our patient was no longer presenting with atrial fibrillation, the anti-arrhythmic treatment was stopped and the SonR optimization system was activated. After 2 months of automatic cardiac resynchronization therapy with defibrillator optimization, our patient's clinical status had significantly improved (left ventricular ejection fraction = 60 %, New York Heart Association class II) and the SonR signal amplitude had doubled shortly after the first weekly automatic optimization. In this non-responding patient, device-based automatic cardiac resynchronization therapy optimization was shown to significantly

Behavioural contracting as a tool to help patients achieve better health.

PubMed

Neale, A V

1991-12-01

Behavioural contracting is an intervention technique in which a client signs an agreement to make certain behaviour changes within a specified time, usually with explicitly defined rewards for adherence or success. Contracting is being increasingly used by health professionals to assist patients in making beneficial life style changes. This paper presents data on the outcome of behavioural contracting interventions to lower serum cholesterol and to increase exercise activity. Of 223 primary care patients enrolled in a health promotion programme, 179 met with the project health educator to improve their cardiovascular risk profile; 144 of these were classified as having 'high cholesterol' and 51 signed contracts to adopt the American Heart Association guidelines diet within a 3-month period. Everyone was encouraged to sign a contract to engage in aerobic exercise three times per week; 96 did so. The results indicate that contractors achieved greater beneficial health changes than non-contractors, and that the group which fully met their contract obligations experienced the greatest health benefit of all (either a lowering of cholesterol or a decreased exercising heart rate).

[Optimization of organizational approaches to management of patients with atherosclerosis].

PubMed

Barbarash, L S; Barbarash, O L; Artamonova, G V; Sumin, A N

2014-01-01

Despite undoubted achievements of modern cardiology in prevention and treatment of atherosclerosis, cardiologists, neurologists, and vascular surgeons are still facing severe stenotic atherosclerotic lesions in different vascular regions, both symptomatic and asymptomatic. As a rule hemodynamically significant stenoses of different locations are found after development of acute vascular events. In this regard, active detection of arterial stenoses localized in different areas just at primary contact of patients presenting with symptoms of ischemia of various locations with care providers appears to be crucial. Further monitoring of these stenoses is also important. The article is dedicated to innovative organizational approaches to provision of healthcare to patients suffering from circulatory system diseases that have contributed to improvement of demographic situation in Kuzbass.

Improving the performance of surgery-based clinical pathways: a simulation-optimization approach.

PubMed

Ozcan, Yasar A; Tànfani, Elena; Testi, Angela

2017-03-01

This paper aims to improve the performance of clinical processes using clinical pathways (CPs). The specific goal of this research is to develop a decision support tool, based on a simulation-optimization approach, which identify the proper adjustment and alignment of resources to achieve better performance for both the patients and the health-care facility. When multiple perspectives are present in a decision problem, critical issues arise and often require the balancing of goals. In our approach, meeting patients' clinical needs in a timely manner, and to avoid worsening of clinical conditions, we assess the level of appropriate resources. The simulation-optimization model seeks and evaluates alternative resource configurations aimed at balancing the two main objectives-meeting patient needs and optimal utilization of beds and operating rooms.Using primary data collected at a Department of Surgery of a public hospital located in Genoa, Italy. The simulation-optimization modelling approach in this study has been applied to evaluate the thyroid surgical treatment together with the other surgery-based CPs. The low rate of bed utilization and the long elective waiting lists of the specialty under study indicates that the wards were oversized while the operating room capacity was the bottleneck of the system. The model enables hospital managers determine which objective has to be given priority, as well as the corresponding opportunity costs.

Impact of Pharmacy Practice Model Expansion on Pharmacokinetic Services: Optimization of Vancomycin Dosing and Improved Patient Safety.

PubMed

Han, Zhe; Pettit, Natasha N; Landon, Emily M; Brielmaier, Benjamin D

2017-04-01

Background: The impact of pharmacy interventions on optimizing vancomycin therapy has been described, however interventions vary among studies and the most optimal pharmacy practice model (PPM) for pharmacokinetic (PK) services has not been established. Objective: The purpose of this study is to demonstrate the value of 24 hours a day, 7 days a week (24/7) PK services. Methods: New PK services were implemented in 2 phases with institutional PPM expansion. Phase 1 included universal monitoring by pharmacists with recommendations made to prescribers during business hours. Phase 2 expanded clinical pharmacists' coverage to 24/7 and provided an optional 24/7 pharmacist-managed PK consult service. We compared vancomycin therapeutic trough attainment, dosing, and clinical and safety outcomes between phases 1 and 2 in adult inpatients receiving therapeutic intravenous vancomycin. Results. One hundred and fifty patients were included in each phase. Phase 2 had a greater proportion of vancomycin courses with therapeutic initial trough concentrations (27.5% vs 46.1%; p = 0.002), higher initial trough concentrations (10.9 mcg/mL vs 16.4 mcg/mL; p < 0.001), and optimized initial vancomycin dosing (13.5 mg/kg vs 16.2 mg/kg; p < 0.001). Phase 2 also saw significant reduction in the incidence of vancomycin-associated nephrotoxicity (21.1% vs 11.7%; p = 0.038). Dose optimization and improvement in initial target trough attainment were most notable among intensive care unit (ICU) patients. Conclusions. Our study demonstrated that 24/7 PK services implemented with institutional PPM expansion optimized vancomycin target trough attainment and improved patient safety.

Optimism, Symptom Distress, Illness Appraisal, and Coping in Patients With Advanced-Stage Cancer Diagnoses Undergoing Chemotherapy Treatment.

PubMed

Sumpio, Catherine; Jeon, Sangchoon; Northouse, Laurel L; Knobf, M Tish

2017-05-01

To explore the relationships between optimism, self-efficacy, symptom distress, treatment complexity, illness appraisal, coping, and mood disturbance in patients with advanced-stage cancer.
. Cross-sectional study.
. Smilow Cancer Hospital at Yale New Haven in Connecticut, an outpatient comprehensive cancer center.
. A convenience sample of 121 adult patients with stages III-IV cancer undergoing active chemotherapy.
. Participants completed common self-report questionnaires to measure variables. Treatment hours and visits were calculated from data retrieved from medical record review. Mediation and path analysis were conducted to identify direct and indirect pathways from the significant antecedent variables to mood disturbance.
. Dispositional optimism, self-efficacy, social support, treatment complexity, symptom distress, illness appraisal, coping, and mood disturbance.
. Greater optimism and self-efficacy were associated with less negative illness appraisal, less avoidant coping, and decreased mood disturbance. Conversely, greater symptom distress was associated with greater negative illness appraisal, greater avoidant coping, and greater mood disturbance. In the final model, optimism and symptom distress had direct and indirect effects on mood disturbance. Indirect effects were partially mediated by illness appraisal.
. Mood disturbance resulted from an interaction of disease stressors, personal resources, and cognitive appraisal of illness. Avoidant coping was associated with greater disturbed mood, but neither avoidant nor active coping had a significant effect on mood in the multivariate model. 
. Illness appraisal, coping style, and symptom distress are important targets for intervention. Optimism is a beneficial trait and should be included, along with coping style, in comprehensive nursing assessments of patients with cancer.

Cancer-related fatigue and depression in breast cancer patients postchemotherapy: Different associations with optimism and stress appraisals.

PubMed

Levkovich, Inbar; Cohen, Miri; Pollack, Shimon; Drumea, Karen; Fried, Georgeta

2015-10-01

Symptoms of depression and cancer-related fatigue (CRF) are common among breast cancer patients postchemotherapy and may seriously impair quality of life (QoL). This study aimed to assess the relationship between depression and CRF in breast cancer patients postchemotherapy and to examine their relationships to optimism and to threat and challenge appraisals. Participants included 95 breast cancer patients (stages 1-3) 1 to 6 months after completion of chemotherapy. Patients submitted personal and medical details and completed the following: physical symptom questionnaires (EORTC QLQ-C30, and QLQ-BR23), a symptoms of depression questionnaire (CES-D), the Fatigue Symptom Inventory (FSI), the Life Orientation Test (LOT-R), and a stress appraisals questionnaire. We found levels of depression, CRF, and appraisals of cancer as a threat to bemoderate and levels of optimism and appraisals of cancer as a challenge to be high. Depression and CRF were positively associated. A multivariate regression analysis revealed that 51% of the CRF variancewas explained; physical symptoms and threat appraisal were significantly associated with CRF. A 67% of the CRF variance of depression was explained; challenge and threat appraisals were significantly associated with depression [corrected]. Although CRF and depression were often experienced simultaneously and both were found to be higher among individuals who gave higher appraisals of cancer as a threat, only depression was related to optimism and challenge appraisals, while CRF was related mainly to intensity of physical symptoms. The different pattern of associations between optimism and appraisals warrants further clinical attention as well as future study.

The expanded invasive weed optimization metaheuristic for solving continuous and discrete optimization problems.

PubMed

Josiński, Henryk; Kostrzewa, Daniel; Michalczuk, Agnieszka; Switoński, Adam

2014-01-01

This paper introduces an expanded version of the Invasive Weed Optimization algorithm (exIWO) distinguished by the hybrid strategy of the search space exploration proposed by the authors. The algorithm is evaluated by solving three well-known optimization problems: minimization of numerical functions, feature selection, and the Mona Lisa TSP Challenge as one of the instances of the traveling salesman problem. The achieved results are compared with analogous outcomes produced by other optimization methods reported in the literature.

Illness representations as mediators of the relationship between dispositional optimism and depression in patients with chronic tinnitus: a cross-sectional study.

PubMed

Vollmann, Manja; Scharloo, Margreet; Langguth, Berthold; Kalkouskaya, Natallia; Salewski, Christel

2013-01-01

Both dispositional optimism and illness representations are related to psychological health in chronic patients. In a group of chronic tinnitus sufferers, the interplay between these two variables was examined. Specifically, it was tested to what extent the relationship between dispositional optimism and depression is mediated by more positive illness representations. The study had a cross-sectional design. One hundred and eighteen patients diagnosed with chronic tinnitus completed questionnaires assessing optimism (Life Orientation Test-Revised [LOT-R]), illness representations (Illness Perceptions Questionnaire-Revised [IPQ-R]) and depression (Hospital Anxiety and Depression Scale [HADS]). Correlation analysis showed that optimism was associated with more positive illness representations and lower levels of depression. Simple mediation analyses revealed that the relationship between optimism and depression was partially mediated by the illness representation dimensions consequences, treatment control, coherence, emotional representations and internal causes. A multiple mediation analysis indicated that the total mediation effect of illness representations is particularly due to the dimension consequences. Optimism influences depression in tinnitus patients both directly and indirectly. The indirect effect indicates that optimism is associated with more positive tinnitus-specific illness representations which, in turn, are related to less depression. These findings contribute to a better understanding of the interplay between generalised expectancies, illness-specific perceptions and psychological adjustment to medical conditions.

[Optimal use of peritoneal dialysis with multi-disciplinary management].

PubMed

Elios Russo, Gaspare; Martinez, A; Mazzaferro, S; Nunzi, A; Testorio, M; Rocca, A R; Lai, S; Morgia, A; Borzacca, B; Gnerre Musto, T

2013-01-01

Considering the increasing incidence of chronic kidney disease and the increased use of peritoneal dialysis, we wanted to assess whether the multidisciplinary management of patients in peritoneal dialysis might produce improvement in the quality of patients' lives when compared to management by a routine team of operators. Our study observed 40 patients on peritoneal dialysis in our Department between 2010 and 2012. They were randomly assigned to either group A, the routine team which consisted of a nephrologist and a nurse, or group B, a multidisciplinary team comprising several medical specialists, a nurse, a psychologist and a social worker. Two tests, KDQOL-SF and MMPI-2, were administered to both groups. In group B, the number of days of hospitalization and day hospital were more than 88% lower when compared to group A. The multidisciplinary team achieved better results with the KDQOL-SF test with regards to both emotional and objective dimensions. The Pearson coefficient between the results of the two questionnaires shows how multidisciplinary management can positively influence the perceived well-being of the patient and his or her adherence to treatment. In a multidisciplinary team, each operator, in addition to his or her specific role, also contributes to the achievement of the overall objective, namely of ensuring an optimal quality of life to the patient on peritoneal dialysis thereby allowing these patients to continue their professional and social lives.

The optimal imaging strategy for patients with stable chest pain: a cost-effectiveness analysis.

PubMed

Genders, Tessa S S; Petersen, Steffen E; Pugliese, Francesca; Dastidar, Amardeep G; Fleischmann, Kirsten E; Nieman, Koen; Hunink, M G Myriam

2015-04-07

The optimal imaging strategy for patients with stable chest pain is uncertain. To determine the cost-effectiveness of different imaging strategies for patients with stable chest pain. Microsimulation state-transition model. Published literature. 60-year-old patients with a low to intermediate probability of coronary artery disease (CAD). Lifetime. The United States, the United Kingdom, and the Netherlands. Coronary computed tomography (CT) angiography, cardiac stress magnetic resonance imaging, stress single-photon emission CT, and stress echocardiography. Lifetime costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios. The strategy that maximized QALYs and was cost-effective in the United States and the Netherlands began with coronary CT angiography, continued with cardiac stress imaging if angiography found at least 50% stenosis in at least 1 coronary artery, and ended with catheter-based coronary angiography if stress imaging induced ischemia of any severity. For U.K. men, the preferred strategy was optimal medical therapy without catheter-based coronary angiography if coronary CT angiography found only moderate CAD or stress imaging induced only mild ischemia. In these strategies, stress echocardiography was consistently more effective and less expensive than other stress imaging tests. For U.K. women, the optimal strategy was stress echocardiography followed by catheter-based coronary angiography if echocardiography induced mild or moderate ischemia. Results were sensitive to changes in the probability of CAD and assumptions about false-positive results. All cardiac stress imaging tests were assumed to be available. Exercise electrocardiography was included only in a sensitivity analysis. Differences in QALYs among strategies were small. Coronary CT angiography is a cost-effective triage test for 60-year-old patients who have nonacute chest pain and a low to intermediate probability of CAD. Erasmus University Medical Center.

The Effect of Anxiety, Depression, and Optimism on Postoperative Satisfaction and Clinical Outcomes in Lumbar Spinal Stenosis and Degenerative Spondylolisthesis Patients: Cohort Study.

PubMed

Lee, Jaewon; Kim, Hong-Sik; Shim, Kyu-Dong; Park, Ye-Soo

2017-06-01

The aim of this study is to evaluate the effect of depression, anxiety, and optimism on postoperative satisfaction and clinical outcomes in patients who underwent less than two-level posterior instrumented fusions for lumbar spinal stenosis and degenerative spondylolisthesis. Preoperative psychological status of subjects, such as depression, anxiety, and optimism, was evaluated using the Hospital Anxiety and Depression Scale (HADS) and the Revised Life Orientation Test (LOT-R). Clinical evaluation was determined by measuring changes in a visual analogue scale (VAS) and the Oswestry Disability Index (ODI) before and after surgery. Postoperative satisfaction of subjects assessed using the North American Spine Society lumbar spine questionnaire was comparatively analyzed against the preoperative psychological status. The correlation between patient's preoperative psychological status (depression, anxiety, and optimism) and clinical outcomes (VAS and ODI) was evaluated. VAS and ODI scores significantly decreased after surgery ( p < 0.001), suggesting clinically favorable outcomes. Preoperative psychological status of patients (anxiety, depression, and optimism) was not related to the degree of improvement in clinical outcomes (VAS and ODI) after surgery. However, postoperative satisfaction was moderately correlated with optimism. Anxiety and optimism were more correlated with patient satisfaction than clinical outcomes. Accordingly, the surgeon can predict postoperative satisfaction of patients based on careful evaluation of psychological status before surgery.

Assisting Pupils in Mathematics Achievement (The Common Core Standards)

ERIC Educational Resources Information Center

Ediger, Marlow

2011-01-01

Mathematics teachers must expect reasonably high standards of achievement from pupils. Too frequently, pupils attain at a substandard level and more optimal achievement is necessary. Thus, pupils should have self esteem needs met in the school and classroom setting. Thus, learners feel that mathematics is worthwhile and effort must be put forth to…

Discontinuation of tofacitinib after achieving low disease activity in patients with rheumatoid arthritis: a multicentre, observational study.

PubMed

Kubo, Satoshi; Yamaoka, Kunihiro; Amano, Koichi; Nagano, Shuji; Tohma, Shigeto; Suematsu, Eiichi; Nagasawa, Hayato; Iwata, Kanako; Tanaka, Yoshiya

2017-08-01

To determine whether tofacitinib can be discontinued in patients with RA who achieve low disease activity (LDA). RA patients with LDA after tofacitinib treatment in a phase III and long-term extension study were enrolled in this multicentre, non-randomized, open, prospective, observational study. The decision of discontinuation or continuation of tofacitinib was determined based on patient-physician decision making with informed consent. The primary endpoint was the proportion of patients who remained tofacitinib-free at post-treatment week 52. Clinical outcome was compared between those who continued and those who discontinued tofacitinib. The last observation carried forward method was used for patients who could not discontinue tofacitinib before week 52. Of 64 patients, 54 discontinued and 10 continued tofacitinib therapy. At post-treatment week 52, 20 of the 54 patients (37%) of the discontinuation group remained tofacitinib-free without disease flare. Disease activity at post-treatment week 52 was higher in the discontinuation group than the continuation group. Among the discontinuation group, the RF titre at baseline was significantly lower in patients who remained tofacitinib-free than those who did not (40 vs 113 U/ml). In fact, a higher proportion of patients with lower RF remained tofacitinib-free at week 52 compared with those with higher RF at baseline. In patients who could not achieve tofacitinib-free status, re-initiation of tofacitinib or other biologics improved disease activity. It is possible to discontinue tofacitinib without flare in about a third of patients with RA. A low RF predicts maintenance of LDA after discontinuation of tofacitinib. © The Author 2017. Published by Oxford University Press on behalf of the British Society for Rheumatology. All rights reserved. For Permissions, please email: journals.permissions@oup.com

Use of response surface methodology in a fed-batch process for optimization of tricarboxylic acid cycle intermediates to achieve high levels of canthaxanthin from Dietzia natronolimnaea HS-1.

PubMed

Nasri Nasrabadi, Mohammad Reza; Razavi, Seyed Hadi

2010-04-01

In this work, we applied statistical experimental design to a fed-batch process for optimization of tricarboxylic acid cycle (TCA) intermediates in order to achieve high-level production of canthaxanthin from Dietzia natronolimnaea HS-1 cultured in beet molasses. A fractional factorial design (screening test) was first conducted on five TCA cycle intermediates. Out of the five TCA cycle intermediates investigated via screening tests, alfaketoglutarate, oxaloacetate and succinate were selected based on their statistically significant (P<0.05) and positive effects on canthaxanthin production. These significant factors were optimized by means of response surface methodology (RSM) in order to achieve high-level production of canthaxanthin. The experimental results of the RSM were fitted with a second-order polynomial equation by means of a multiple regression technique to identify the relationship between canthaxanthin production and the three TCA cycle intermediates. By means of this statistical design under a fed-batch process, the optimum conditions required to achieve the highest level of canthaxanthin (13172 + or - 25 microg l(-1)) were determined as follows: alfaketoglutarate, 9.69 mM; oxaloacetate, 8.68 mM; succinate, 8.51 mM. Copyright 2009 The Society for Biotechnology, Japan. Published by Elsevier B.V. All rights reserved.

Need for optimizing catalyst loading for achieving affordable microbial fuel cells.

PubMed

Singh, Inderjeet; Chandra, Amreesh

2013-08-01

Microbial fuel cell (MFC) technology is a promising technology for electricity production together with simultaneous water treatment. Catalysts play an important role in deciding the MFC performance. In most reports, effect of catalyst - both type and quantity is not optimized. In this paper, synthesis of nanorods of MnO2-catalyst particles for application in Pt-free MFCs is reported. The effect of catalyst loading i.e., weight ratio, with respect to conducting element and binder has been optimized by employing large number of combinations. Using simple theoretical model, it is shown that too high (or low) concentration of catalysts result in loss of MFC performance. The operation of MFC has been investigated using domestic wastewater as source of bio-waste for obtaining real world situation. Maximum power density of ∼61 mW/m(2) was obtained when weight ratio of catalyst and conducting species was 1:1. Suitable reasons are given to explain the outcomes. Copyright © 2013 Elsevier Ltd. All rights reserved.

[Optimization of information on the medication of polypharmacy patients in primary care].

PubMed

Nicieza-García, María Luisa; Salgueiro-Vázquez, María Esther; Jimeno-Demuth, Francisco José; Manso, Gloria

2016-01-01

As part of the protocol of the Health Service of the Principality of Asturias (Spain), primary care physicians periodically receive listings of the treatments of patients of any age taking 10 or more drugs/day for 6 months. Currently, the Health Service of the Principality of Asturias is developing a project that aims to assess the medications of polypharmacy patients. The aim is to identify: 1) the consumption of medicines of low therapeutic usefulness, 2) the consumption of potentially nephrotoxic drugs in patients with a low glomerular filtration rate, and 3) potentially inappropriate prescribing in patients aged 65 years or older. The project was started in Health Area II and the aim is to extend it to the remaining health areas. In our opinion, its automation and general implementation could be useful to optimize drug prescription. Copyright © 2015 SESPAS. Published by Elsevier Espana. All rights reserved.

Rationale and Design of the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study

PubMed Central

Coburn, Brian W; Cheetham, T Craig; Rashid, Nazia; Chang, John M; Levy, Gerald D; Kerimian, Artak; Low, Kimberly J; Redden, David T; Bridges, S Louis; Saag, Kenneth G; Curtis, Jeffrey R; Mikuls, Ted R

2016-01-01

Background Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA < 6.0 mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. Methods To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18 years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA < 6.0 mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. Conclusion Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients. PMID:27449546

Rationale and design of the randomized evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) Study.

PubMed

Coburn, Brian W; Cheetham, T Craig; Rashid, Nazia; Chang, John M; Levy, Gerald D; Kerimian, Artak; Low, Kimberly J; Redden, David T; Bridges, S Louis; Saag, Kenneth G; Curtis, Jeffrey R; Mikuls, Ted R

2016-09-01

Despite the availability of effective therapies, most gout patients achieve suboptimal treatment outcomes. Current best practices suggest gradual dose-escalation of urate lowering therapy and serial serum urate (sUA) measurement to achieve sUA<6.0mg/dl. However, this strategy is not routinely used. Here we present the study design rationale and development for a pharmacist-led intervention to promote sUA goal attainment. To overcome barriers in achieving optimal outcomes, we planned and implemented the Randomized Evaluation of an Ambulatory Care Pharmacist-Led Intervention to Optimize Urate Lowering Pathways (RAmP-UP) study. This is a large pragmatic cluster-randomized trial designed to assess a highly automated, pharmacist-led intervention to optimize allopurinol treatment in gout. Ambulatory clinics (n=101) from a large health system were randomized to deliver either the pharmacist-led intervention or usual care to gout patients over the age of 18years newly initiating allopurinol. All participants received educational materials and could opt-out of the study. For intervention sites, pharmacists conducted outreach primarily via an automated telephone interactive voice recognition system. The outreach, guided by a gout care algorithm developed for this study, systematically promoted adherence assessment, facilitated sUA testing, provided education, and adjusted allopurinol dosing. The primary study outcomes are achievement of sUA<6.0mg/dl and treatment adherence determined after one year. With follow-up ongoing, study results will be reported subsequently. Ambulatory care pharmacists and automated calling technology represent potentially important, underutilized resources for improving health outcomes for gout patients. Copyright © 2016 Elsevier Inc. All rights reserved.

Robust optimization methods for cardiac sparing in tangential breast IMRT

DOE Office of Scientific and Technical Information (OSTI.GOV)

Mahmoudzadeh, Houra, E-mail: houra@mie.utoronto.ca; Lee, Jenny; Chan, Timothy C. Y.

Purpose: In left-sided tangential breast intensity modulated radiation therapy (IMRT), the heart may enter the radiation field and receive excessive radiation while the patient is breathing. The patient’s breathing pattern is often irregular and unpredictable. We verify the clinical applicability of a heart-sparing robust optimization approach for breast IMRT. We compare robust optimized plans with clinical plans at free-breathing and clinical plans at deep inspiration breath-hold (DIBH) using active breathing control (ABC). Methods: Eight patients were included in the study with each patient simulated using 4D-CT. The 4D-CT image acquisition generated ten breathing phase datasets. An average scan was constructedmore » using all the phase datasets. Two of the eight patients were also imaged at breath-hold using ABC. The 4D-CT datasets were used to calculate the accumulated dose for robust optimized and clinical plans based on deformable registration. We generated a set of simulated breathing probability mass functions, which represent the fraction of time patients spend in different breathing phases. The robust optimization method was applied to each patient using a set of dose-influence matrices extracted from the 4D-CT data and a model of the breathing motion uncertainty. The goal of the optimization models was to minimize the dose to the heart while ensuring dose constraints on the target were achieved under breathing motion uncertainty. Results: Robust optimized plans were improved or equivalent to the clinical plans in terms of heart sparing for all patients studied. The robust method reduced the accumulated heart dose (D10cc) by up to 801 cGy compared to the clinical method while also improving the coverage of the accumulated whole breast target volume. On average, the robust method reduced the heart dose (D10cc) by 364 cGy and improved the optBreast dose (D99%) by 477 cGy. In addition, the robust method had smaller deviations from the planned dose to the

Optimizing HIV Care by Expanding the Nursing Role: Patient and Provider Perspectives

PubMed Central

Chen, Wei-Ti; Shiu, Cheng-Shi; Simoni, Jane; Fredriksen-Goldsen, Karen; Zhang, Fujie; Zhao, Hongxin

2009-01-01

Aim This paper is a report of a study conducted to explore HIV healthcare services from the perspectives of both healthcare providers and patients in order to understand how to optimize HIV nursing care. Background In China, healthcare providers usually first diagnose HIV in a general hospital. Then, HIV-positive individuals are transferred to a specialist hospital. Between healthcare providers and healthcare institutions, there are many gaps in the process from diagnosis to treatment. Methods One focus group with 6 healthcare providers and 29 in-depth interviews with people living with HIV/AIDS were conducted during 2005. Findings Patients who were diagnosed with HIV in a general hospital often did not discuss their condition with a healthcare provider before being sent to a specialist hospital. Furthermore, since the patients had already been diagnosed, healthcare providers in the specialist hospital did not deal adequately with the disclosure process and emotional reactions to the diagnosis. They reported feeling overwhelmed in their role in providing healthcare services. Nurses reported that they were responsible for many “non-nursing” tasks and did not have the opportunity to give the type of care they were trained to offer. Conclusion Optimizing HIV care in China will involve establishing clear boundaries between general and specialist hospitals and a division of labour among healthcare providers that eases the burden of care and takes advantage of the full scope of practice that nurses are trained to provide. PMID:20423409

Achieving Consistent Near-Optimal Pattern Recognition Accuracy Using Particle Swarm Optimization to Pre-Train Artificial Neural Networks

ERIC Educational Resources Information Center

Nikelshpur, Dmitry O.

2014-01-01

Similar to mammalian brains, Artificial Neural Networks (ANN) are universal approximators, capable of yielding near-optimal solutions to a wide assortment of problems. ANNs are used in many fields including medicine, internet security, engineering, retail, robotics, warfare, intelligence control, and finance. "ANNs have a tendency to get…

Refractive Outcomes, Contrast Sensitivity, HOAs, and Patient Satisfaction in Moderate Myopia: Wavefront-Optimized Versus Tissue-Saving PRK.

PubMed

Nassiri, Nader; Sheibani, Kourosh; Azimi, Abbas; Khosravi, Farinaz Mahmoodi; Heravian, Javad; Yekta, Abasali; Moghaddam, Hadi Ostadi; Nassiri, Saman; Yasseri, Mehdi; Nassiri, Nariman

2015-10-01

To compare refractive outcomes, contrast sensitivity, higher-order aberrations (HOAs), and patient satisfaction after photorefractive keratectomy for correction of moderate myopia with two methods: tissue saving versus wavefront optimized. In this prospective, comparative study, 152 eyes (80 patients) with moderate myopia with and without astigmatism were randomly divided into two groups: the tissue-saving group (Technolas 217z Zyoptix laser; Bausch & Lomb, Rochester, NY) (76 eyes of 39 patients) or the wavefront-optimized group (WaveLight Allegretto Wave Eye-Q laser; Alcon Laboratories, Inc., Fort Worth, TX) (76 eyes of 41 patients). Preoperative and 3-month postoperative refractive outcomes, contrast sensitivity, HOAs, and patient satisfaction were compared between the two groups. The mean spherical equivalent was -4.50 ± 1.02 diopters. No statistically significant differences were detected between the groups in terms of uncorrected and corrected distance visual acuity and spherical equivalent preoperatively and 3 months postoperatively. No statistically significant differences were seen in the amount of preoperative to postoperative contrast sensitivity changes between the two groups in photopic and mesopic conditions. HOAs and Q factor increased in both groups postoperatively (P = .001), with the tissue-saving method causing more increases in HOAs (P = .007) and Q factor (P = .039). Patient satisfaction was comparable between both groups. Both platforms were effective in correcting moderate myopia with or without astigmatism. No difference in refractive outcome, contrast sensitivity changes, and patient satisfaction between the groups was observed. Postoperatively, the tissue-saving method caused a higher increase in HOAs and Q factor compared to the wavefront-optimized method, which could be due to larger optical zone sizes in the tissue-saving group. Copyright 2015, SLACK Incorporated.

SU-E-T-368: Evaluating Dosimetric Outcome of Modulated Photon Radiotherapy (XMRT) Optimization for Head and Neck Patients

DOE Office of Scientific and Technical Information (OSTI.GOV)

McGeachy, P; Villarreal-Barajas, JE; Khan, R

2015-06-15

Purpose: The dosimetric outcome of optimized treatment plans obtained by modulating the photon beamlet energy and fluence on a small cohort of four Head and Neck (H and N) patients was investigated. This novel optimization technique is denoted XMRT for modulated photon radiotherapy. The dosimetric plans from XMRT for H and N treatment were compared to conventional, 6 MV intensity modulated radiotherapy (IMRT) optimization plans. Methods: An arrangement of two non-coplanar and five coplanar beams was used for all four H and N patients. Both XMRT and IMRT were subject to the same optimization algorithm, with XMRT optimization allowing bothmore » 6 and 18 MV beamlets while IMRT was restricted to 6 MV only. The optimization algorithm was based on a linear programming approach with partial-volume constraints implemented via the conditional value-at-risk method. H and N constraints were based off of those mentioned in the Radiation Therapy Oncology Group 1016 protocol. XMRT and IMRT solutions were assessed using metrics suggested by International Commission on Radiation Units and Measurements report 83. The Gurobi solver was used in conjunction with the CVX package to solve each optimization problem. Dose calculations and analysis were done in CERR using Monte Carlo dose calculation with VMC{sub ++}. Results: Both XMRT and IMRT solutions met all clinical criteria. Trade-offs were observed between improved dose uniformity to the primary target volume (PTV1) and increased dose to some of the surrounding healthy organs for XMRT compared to IMRT. On average, IMRT improved dose to the contralateral parotid gland and spinal cord while XMRT improved dose to the brainstem and mandible. Conclusion: Bi-energy XMRT optimization for H and N patients provides benefits in terms of improved dose uniformity to the primary target and reduced dose to some healthy structures, at the expense of increased dose to other healthy structures when compared with IMRT.« less

Risk-Assessment Score and Patient Optimization as Cost Predictors for Ventral Hernia Repair.

PubMed

Saleh, Sherif; Plymale, Margaret A; Davenport, Daniel L; Roth, John Scott

2018-04-01

Ventral hernia repair (VHR) is associated with complications that significantly increase healthcare costs. This study explores the associations between hospital costs for VHR and surgical complication risk-assessment scores, need for cardiac or pulmonary evaluation, and smoking or obesity counseling. An IRB-approved retrospective study of patients having undergone open VHR over 3 years was performed. Ventral Hernia Risk Score (VHRS) for surgical site occurrence and surgical site infection, and the Ventral Hernia Working Group grade were calculated for each case. Also recorded were preoperative cardiology or pulmonary evaluations, smoking cessation and weight reduction counseling, and patient goal achievement. Hospital costs were obtained from the cost accounting system for the VHR hospitalization stratified by major clinical cost drivers. Univariate regression analyses were used to compare the predictive power of the risk scores. Multivariable analysis was performed to develop a cost prediction model. The mean cost of index VHR hospitalization was $20,700. Total and operating room costs correlated with increasing CDC wound class, VHRS surgical site infection score, VHRS surgical site occurrence score, American Society of Anesthesiologists class, and Ventral Hernia Working Group (all p < 0.01). The VHRS surgical site infection scores correlated negatively with contribution margin (-280; p < 0.01). Multivariable predictors of total hospital costs for the index hospitalization included wound class, hernia defect size, age, American Society of Anesthesiologists class 3 or 4, use of biologic mesh, and 2+ mesh pieces; explaining 73% of the variance in costs (p < 0.001). Weight optimization significantly reduced direct and operating room costs (p < 0.05). Cardiac evaluation was associated with increased costs. Ventral hernia repair hospital costs are more accurately predicted by CDC wound class than VHR risk scores. A straightforward 6-factor model predicted most cost

Spatio-temporal optimization of agricultural practices to achieve a sustainable development at basin level; framework of a case study in Colombia

NASA Astrophysics Data System (ADS)

Uribe, Natalia; corzo, Gerald; Solomatine, Dimitri

2016-04-01

The flood events present during the last years in different basins of the Colombian territory have raised questions on the sensitivity of the regions and if this regions have common features. From previous studies it seems important features in the sensitivity of the flood process were: land cover change, precipitation anomalies and these related to impacts of agriculture management and water management deficiencies, among others. A significant government investment in the outreach activities for adopting and promoting the Colombia National Action Plan on Climate Change (NAPCC) is being carried out in different sectors and regions, having as a priority the agriculture sector. However, more information is still needed in the local environment in order to assess were the regions have this sensitivity. Also the continuous change in one region with seasonal agricultural practices have been pointed out as a critical information for optimal sustainable development. This combined spatio-temporal dynamics of crops cycle in relation to climate change (or variations) has an important impact on flooding events at basin areas. This research will develop on the assessment and optimization of the aggregated impact of flood events due to determinate the spatio-temporal dynamic of changes in agricultural management practices. A number of common best agricultural practices have been identified to explore their effect in a spatial hydrological model that will evaluate overall changes. The optimization process consists on the evaluation of best performance in the agricultural production, without having to change crops activities or move to other regions. To achieve this objectives a deep analysis of different models combined with current and future climate scenarios have been planned. An algorithm have been formulated to cover the parametric updates such that the optimal temporal identification will be evaluated in different region on the case study area. Different hydroinformatics

Affectionless control by the same-sex parents increases dysfunctional attitudes about achievement.

PubMed

Otani, Koichi; Suzuki, Akihito; Matsumoto, Yoshihiko; Sadahiro, Ryoichi; Enokido, Masanori

2014-08-01

The affectionless control parenting has been associated with depression in recipients. The aim of this study was to examine the effect of this parenting style on dysfunctional attitudes predisposing to depression. The subjects were 666 Japanese volunteers. Perceived parental rearing was evaluated by the Parental Bonding Instrument, which has the care and protection subscales. Parental rearing was classified into four types, i.e., optimal parenting (high care/low protection), affectionate constraint (high care/high protection), neglectful parenting (low care/low protection), and affectionless control (low care/high protection). Dysfunctional attitudes were evaluated by the 24-item Dysfunctional Attitude Scale, which has the achievement, dependency and self-control subscales. Males with paternal affectionless control had higher achievement scores than those with paternal optimal parenting (P=.016). Similarly, females with maternal affectionless control had higher achievement scores than those with maternal optimal parenting (P=.016). The present study suggests that affectionless control by the same-sex parents increases dysfunctional attitudes about achievement. Copyright © 2014 The Authors. Published by Elsevier Inc. All rights reserved.

Insights into the Functional Anatomy Behind the PREEMPT Injection Paradigm: Guidance on Achieving Optimal Outcomes.

PubMed

Blumenfeld, Andrew M; Silberstein, Stephen D; Dodick, David W; Aurora, Sheena K; Brin, Mitchell F; Binder, William J

2017-05-01

To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis. Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy. Each muscle involved in the standardized PREEMPT injection paradigm is reviewed with a thorough description of each muscle's anatomy (ie, muscle description and location, innervation, vascular supply) and function. Key insights based on clinical experience are also provided to help improve outcomes. The identification of the muscles in the PREEMPT injection paradigm should be based on each patient's unique anatomy and injections should be administered using the advised techniques. A thorough examination of the patient prior to treatment is also critical to determine if any preexisting conditions may increase the risk for unwanted outcomes and appropriate expectations should be communicated. Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient's baseline condition to anticipate the risk for unwanted outcomes that may result from treatment. © 2017 Allergan plc. Headache published by Wiley Periodicals, Inc. on behalf of American Headache Society.

Insights into the Functional Anatomy Behind the PREEMPT Injection Paradigm: Guidance on Achieving Optimal Outcomes

PubMed Central

Silberstein, Stephen D.; Dodick, David W.; Aurora, Sheena K.; Brin, Mitchell F.; Binder, William J.

2017-01-01

Objective To provide clinically relevant insights on the identification of the muscles and techniques involved in the safe and effective use of onabotulinumtoxinA for chronic migraine prophylaxis. Background Although guidance on the use of onabotulinumtoxinA for chronic migraine is available, based on the Phase III Research Evaluating Migraine Prophylaxis Therapy (PREEMPT) clinical program, clinical experience has shown that insufficient understanding of the anatomy and function of the head and neck muscles may lead to undesirable outcomes and suboptimal efficacy. Design/Methods Each muscle involved in the standardized PREEMPT injection paradigm is reviewed with a thorough description of each muscle's anatomy (ie, muscle description and location, innervation, vascular supply) and function. Key insights based on clinical experience are also provided to help improve outcomes. Results The identification of the muscles in the PREEMPT injection paradigm should be based on each patient's unique anatomy and injections should be administered using the advised techniques. A thorough examination of the patient prior to treatment is also critical to determine if any preexisting conditions may increase the risk for unwanted outcomes and appropriate expectations should be communicated. Conclusions Thorough knowledge of the functional anatomy of the muscles involved in the standardized PREEMPT injection paradigm is critical to achieve the efficacy and safety observed in clinical trials. In addition, it is important to assess a patient's baseline condition to anticipate the risk for unwanted outcomes that may result from treatment. PMID:28387038

Academic Optimism and Collective Responsibility: An Organizational Model of the Dynamics of Student Achievement

ERIC Educational Resources Information Center

Wu, Jason H.

2013-01-01

This study was designed to examine the construct of academic optimism and its relationship with collective responsibility in a sample of Taiwan elementary schools. The construct of academic optimism was tested using confirmatory factor analysis, and the whole structural model was tested with a structural equation modeling analysis. The data were…

Cost of Glycemic Target Achievement with Sodium Glucose Co-transporter 2 Inhibitors in Patients with Type 2 Diabetes in the UK.

PubMed

Evans, Marc; Achha, Sayeed; Neslusan, Cheryl

2017-10-01

Diabetes-related costs make up a large portion of healthcare expenditures in the UK. Many of these costs are related to treatment of diabetes-related complications. Reducing HbA1c to <7.0% (53 mmol/mol) reduces the incidence of complications and comorbidities. Metformin plus sulfonylurea is the most common dual oral combination therapy in the UK. The costs of achieving HbA1c <7.0% in patients inadequately controlled on metformin plus sulfonylurea were analyzed for the sodium glucose co-transporter 2 (SGLT2) inhibitors canagliflozin, dapagliflozin, and empagliflozin from the perspective of the UK National Health System. A Bayesian network meta-analysis (NMA) was used to compare the proportion of patients with type 2 diabetes mellitus inadequately controlled on metformin plus sulfonylurea that achieved HbA1c <7.0% after 26 weeks with canagliflozin 100 and 300 mg, dapagliflozin 10 mg, and empagliflozin 10 and 25 mg; odds ratios (ORs) and pairwise probabilities (P) for canagliflozin versus dapagliflozin and empagliflozin were calculated. The costs associated with achieving HbA1c <7.0% were estimated on the basis of medication costs and the proportion of patients achieving the HbA1c goal. NMA results showed that a higher proportion of patients treated with canagliflozin 300 mg achieved HbA1c <7.0% (41%) compared with those treated with dapagliflozin 10 mg (25%), empagliflozin 10 mg (23%), empagliflozin 25 mg (28%), or canagliflozin 100 mg (27%). The odds of achieving HbA1c <7.0% were greater with canagliflozin 300 mg than with dapagliflozin 10 mg (OR 2.03 [P = 94%]), empagliflozin 10 mg (OR 2.29 [P = 99%]), or empagliflozin 25 mg (OR 1.71 [P = 93%]). The per patient costs of achieving HbA1c <7.0% at 26 weeks were £881, £580, £951, £1034, and £849 with canagliflozin 100 and 300 mg, dapagliflozin 10 mg, and empagliflozin 10 and 25 mg. This analysis suggests that, in the UK, canagliflozin 300 mg provides the best value for money among all SGLT

Private Prayer and Optimism in Middle-Aged and Older Patients Awaiting Cardiac Surgery

ERIC Educational Resources Information Center

Ai, Amy L.; Peterson, Christopher; Bolling, Steven F.; Koenig, Harold

2002-01-01

Purpose: This study investigated the use of private prayer among middle-aged and older patients as a way of coping with cardiac surgery and prayer's relationship to optimism. Design and Methods: The measure of prayer included three aspects: (a) belief in the importance of private prayer, (b) faith in the efficacy of prayer on the basis of previous…

Achieving optimal welfare for the Nile hippopotamus (Hippopotamus amphibius) in North American zoos and aquariums.

PubMed

Tennant, Kaylin S; Segura, Valerie D; Morris, Megan C; Snyder, Kristen Denninger; Bocian, David; Maloney, Dan; Maple, Terry L

2017-07-29

Compared to other megafauna managed in zoos and aquariums, the current state of welfare for the Nile hippopotamus (Hippopotamus amphibius) is poorly understood. Complex behavior and physiological characteristics make hippos a difficult species to manage. Thus, hippos in managed care are currently at risk for a decreased state of welfare. In an effort to assess and improve conditions for this species, a survey was administered to North American institutions housing Nile hippos. This assessment utilized a multiple-choice format and consisted of questions relating to group structure, behavior, and exhibit design, allowing for the creation of cross-institutional, welfare-based analysis. Responses were gathered from 85.29% of the institutions to which the survey was distributed. Despite recommendations for maintaining groups of at least five individuals (Forthman, 1998), only 34.25% of hippos in North America were housed in groups of three or more. The survey also highlighted that 39.29% of institutions secure their hippos in holding areas overnight, despite their highly active nocturnal propensities. A better understanding of hippo behavior and environmental preferences can be used to inform wellness-oriented management practices to achieve a state of "optimal welfare". Copyright © 2017 Elsevier B.V. All rights reserved.

Optimization in Radiation Therapy: Applications in Brachytherapy and Intensity Modulated Radiation Therapy

NASA Astrophysics Data System (ADS)

McGeachy, Philip David

Over 50% of cancer patients require radiation therapy (RT). RT is an optimization problem requiring maximization of the radiation damage to the tumor while minimizing the harm to the healthy tissues. This dissertation focuses on two main RT optimization problems: 1) brachytherapy and 2) intensity modulated radiation therapy (IMRT). The brachytherapy research involved solving a non-convex optimization problem by creating an open-source genetic algorithm optimizer to determine the optimal radioactive seed distribution for a given set of patient volumes and constraints, both dosimetric- and implant-based. The optimizer was tested for a set of 45 prostate brachytherapy patients. While all solutions met the clinical standards, they also benchmarked favorably with those generated by a standard commercial solver. Compared to its compatriot, the salient features of the generated solutions were: slightly reduced prostate coverage, lower dose to the urethra and rectum, and a smaller number of needles required for an implant. Historically, IMRT requires modulation of fluence while keeping the photon beam energy fixed. The IMRT-related investigation in this thesis aimed at broadening the solution space by varying photon energy. The problem therefore involved simultaneous optimization of photon beamlet energy and fluence, denoted by XMRT. Formulating the problem as convex, linear programming was applied to obtain solutions for optimal energy-dependent fluences, while achieving all clinical objectives and constraints imposed. Dosimetric advantages of XMRT over single-energy IMRT in the improved sparing of organs at risk (OARs) was demonstrated in simplified phantom studies. The XMRT algorithm was improved to include clinical dose-volume constraints and clinical studies for prostate and head and neck cancer patients were investigated. Compared to IMRT, XMRT provided improved dosimetric benefit in the prostate case, particularly within intermediate- to low-dose regions (≤ 40 Gy

Safety of an i.v. β-adrenergic blockade protocol for heart rate optimization before coronary CT angiography.

PubMed

Kassamali, Rahil H; Kim, Daniel H; Patel, Hiten; Raichura, Nitin; Hoey, Edward T D; Hodson, James; Hussain, Shahid

2014-10-01

The purpose of this study was to assess the safety of heart rate optimization by use of β-adrenergic blockade solely by the i.v. route before coronary CT angiography. The records of 679 patients undergoing CT coronary angiography after receiving i.v. β-adrenergic blockade were retrospectively analyzed. Health screening was completed before scanning, and heart rate was optimized by administration of i.v. metoprolol titrated to a maximum of 70 mg to achieve a heart rate less than 65 beats/min. The median i.v. dose was 20 mg (range, 5-70 mg). The 679 patients analyzed had a total of 10 complications (1.47%). Major complications, defined as not resolving with observation and analgesia alone, occurred in only three patients (0.44%). These complications included a second-degree atrioventricular block. A total of 299 patients (44.0%) needed more than 20 mg of i.v. metoprolol to achieve target heart rate. Only three patients needed the maximum i.v. dose of 70 mg metoprolol. Target heart rate was reached successfully in 666 patients (98.1%) with doses of less than 70 mg. This study did not show a statistically significant association between increasing complication frequency and increasing dose. This study showed that high doses of i.v. metoprolol can be used effectively and with a low rate of major complications to control heart rate before coronary CT angiography in correctly screened patients.

Multiobjective Particle Swarm Optimization for the optimal design of photovoltaic grid-connected systems

DOE Office of Scientific and Technical Information (OSTI.GOV)

Kornelakis, Aris

2010-12-15

Particle Swarm Optimization (PSO) is a highly efficient evolutionary optimization algorithm. In this paper a multiobjective optimization algorithm based on PSO applied to the optimal design of photovoltaic grid-connected systems (PVGCSs) is presented. The proposed methodology intends to suggest the optimal number of system devices and the optimal PV module installation details, such that the economic and environmental benefits achieved during the system's operational lifetime period are both maximized. The objective function describing the economic benefit of the proposed optimization process is the lifetime system's total net profit which is calculated according to the method of the Net Present Valuemore » (NPV). The second objective function, which corresponds to the environmental benefit, equals to the pollutant gas emissions avoided due to the use of the PVGCS. The optimization's decision variables are the optimal number of the PV modules, the PV modules optimal tilt angle, the optimal placement of the PV modules within the available installation area and the optimal distribution of the PV modules among the DC/AC converters. (author)« less

Proposal of a pharmacokinetically optimized dosage regimen of antibiotics in patients receiving continuous hemodiafiltration.

PubMed

Yamamoto, Takehito; Yasuno, Nobuhiro; Katada, Shoichi; Hisaka, Akihiro; Hanafusa, Norio; Noiri, Eisei; Yahagi, Naoki; Fujita, Toshiro; Suzuki, Hiroshi

2011-12-01

The aim of the study was to quantitatively predict the clearance of three antibiotics, amikacin, vancomycin, and teicoplanin, during continuous hemodiafiltration (CHDF) and to propose their optimal dosage in patients receiving CHDF. For this goal, in vitro CHDF experiments with a polyacrylonitrile (PAN) membrane were first performed using these antibiotics, and then the clearances were compared with in vivo CHDF situations determined in 16 critically ill patients. The in vitro CHDF clearances were described as the product of the outflow rate of a drain (Q(outflow)) and the drug unbound fraction in artificial plasma, indicating that drug adsorption to the PAN membrane has minor effect on drug clearance in our settings. The observed in vivo clearances also agreed very well with the predicted values, with a product of Q(outflow) and plasma unbound fraction, when residual creatinine clearance (CL(CR)) was taken into account (within a range of 0.67- to 1.5-fold for 15 of 16 patients). Based on these results, a nomogram of the optimized dosages of amikacin, vancomycin, and teicoplanin was proposed, and it was evident that Q(outflow) and residual CL(CR) are major determinants of the dosage and dosing interval for these antibiotics. Although the applicability needs to be confirmed with another type of membrane or higher Q(outflow), our nomogram can help determine the dosage setting in critically ill patients receiving CHDF.

Therapeutic lipid target achievements among high and highest risk patients: results from the CEPHEUS study in the Arabian Gulf.

PubMed

Al-Rasadi, Khalid; Al-Zakwani, Ibrahim; Al Mahmeed, Wael; Arafah, Mohamed; Al-Hinai, Ali T; Shehab, Abdullah; Al Tamimi, Omer; Alawadhi, Mahmoud

2014-12-01

To determine lipid target achievements of low-density lipoprotein cholesterol (LDL-C), non-high density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B (apo B) in the Centralized Pan-Middle East Survey on the undertreatment of hypercholesterolemia (CEPHEUS) in Arabian Gulf States patients with high and highest risk according to the joint Consensus Statement of the American Diabetes Association (ADA) and American College of Cardiology Foundation (ACC). CEPHEUS was conducted in patients (≥ 18 years of age) in six Middle Eastern countries between November 2009 and July 2010 on lipid lowering drugs (LLDs). Serum samples collected included total cholesterol (TC), LDL-C, HDL-C, triglycerides (TGs), apo B, and apolipoprotein A1 (apo A1). The overall mean age of the cohort (n = 5275) was 56 ± 13 years, 58% (n = 3060) were male and 69% (n = 3635) were highest risk. LDL-C target was achieved in 25%, non-HDL-C in 36% and apo B in 38% of patients in the highest risk cohort compared with LDL-C 46%, non-HDL-C 58% and apo B 51% in the high risk group. In patients with TGs ≥ 2.2 mmol/L, LDL-C target was achieved in 16% and apo B in 15% of patients in the highest risk group compared with LDL-C 32% and apo B 22% in the high risk cohort. Despite being on LLDs, a large proportion of high and highest risk patients in the Arabian Gulf are not at recommended lipid targets and remain at a substantial residual risk for cardiovascular diseases. Apo B may be used as an additional target in patients with triglycerides ≥ 2.2 mmol/L. The findings should be interpreted in light of the study's limitations.

Comparison of the progressive resolution optimizer and photon optimizer in VMAT optimization for stereotactic treatments.

PubMed

Liu, Han; Sintay, Benjamin; Pearman, Keith; Shang, Qingyang; Hayes, Lane; Maurer, Jacqueline; Vanderstraeten, Caroline; Wiant, David

2018-05-20

The photon optimization (PO) algorithm was recently released by Varian Medical Systems to improve volumetric modulated arc therapy (VMAT) optimization within Eclipse (Version 13.5). The purpose of this study is to compare the PO algorithm with its predecessor, progressive resolution optimizer (PRO) for lung SBRT and brain SRS treatments. A total of 30 patients were selected retrospectively. Previously, all the plans were generated with the PRO algorithm within Eclipse Version 13.6. In the new version of PO algorithm (Version 15), dynamic conformal arcs (DCA) were first conformed to the target, then VMAT inverse planning was performed to achieve the desired dose distributions. PTV coverages were forced to be identical for the same patient for a fair comparison. SBRT plan quality was assessed based on selected dose-volume parameters, including the conformity index, V 20 for lung, V 30 Gy for chest wall, and D 0.035 cc for other critical organs. SRS plan quality was evaluated based on the conformity index and normal tissue volumes encompassed by the 12 and 6 Gy isodose lines (V 12 and V 6 ). The modulation complexity score (MCS) was used to compare plan complexity of two algorithms. No statistically significant differences between the PRO and PO algorithms were found for any of the dosimetric parameters studied, which indicates both algorithms produce comparable plan quality. Significant improvements in the gamma passing rate (increased from 97.0% to 99.2% for SBRT and 96.1% to 98.4% for SRS), MCS (average increase of 0.15 for SBRT and 0.10 for SRS), and delivery efficiency (MU reduction of 29.8% for SBRT and 28.3% for SRS) were found for the PO algorithm. MCS showed a strong correlation with the gamma passing rate, and an inverse correlation with total MUs used. The PO algorithm offers comparable plan quality to the PRO, while minimizing MLC complexity, thereby improving the delivery efficiency and accuracy. © 2018 The Authors. Journal of Applied Clinical Medical

Use of hematopoietic cell transplants to achieve tolerance in patients with solid organ transplants.

PubMed

Strober, Samuel

2016-03-24

The goals of tolerance in patients with solid organ transplants are to eliminate the lifelong need for immunosuppressive (IS) drugs and to prevent graft loss due to rejection or drug toxicity. Tolerance with complete withdrawal of IS drugs has been achieved in recipients of HLA-matched and mismatched living donor kidney transplants in 3 medical centers using hematopoietic cell transplants to establish mixed or complete chimerism. © 2016 by The American Society of Hematology.

Improving patient safety by optimizing the use of nursing human resources.

PubMed

Rochefort, Christian M; Buckeridge, David L; Abrahamowicz, Michal

2015-06-14

Recent ecological studies have suggested that inadequate nurse staffing may contribute to the incidence of adverse events in acute care hospitals. However, longitudinal studies are needed to further examine these associations and to identify the staffing patterns that are of greatest risk. The aims of this study are to determine if (a) nurse staffing levels are associated with an increased risk of adverse events, (b) the risk of adverse events in relationship to nurse staffing levels is modified by the complexity of patient requirements, and (c) optimal nurse staffing levels can be established. A dynamic cohort of all adult medical, surgical, and intensive care unit patients admitted between 2010 and 2015 to a Canadian academic health center will be followed during the inpatient and 7-day post-discharge period to assess the occurrence and frequency of adverse events in relationship to antecedent nurse staffing levels. Four potentially preventable adverse events will be measured: (a) hospital-acquired pneumonia, (b) ventilator-associated pneumonia, (c) venous thromboembolism, and (d) in-hospital fall. These events were selected for their high incidence, morbidity and mortality rates, and because they are hypothesized to be related to nurse staffing levels. Adverse events will be ascertained from electronic health record data using validated automated detection algorithms. Patient exposure to nurse staffing will be measured on every shift of the hospitalization using electronic payroll records. To examine the association between nurse staffing levels and the risk of adverse events, four Cox proportional hazards regression models will be used (one for each adverse event), while adjusting for patient characteristics and risk factors of adverse event occurrence. To determine if the association between nurse staffing levels and the occurrence of adverse events is modified by the complexity of patient requirements, interaction terms will be included in the regression

Relationship between optimism and quality of life in patients with two chronic rheumatic diseases: axial spondyloarthritis and chronic low back pain: a cross sectional study of 288 patients.

PubMed

Kreis, Sarah; Molto, Anna; Bailly, Florian; Dadoun, Sabrina; Fabre, Stéphanie; Rein, Christopher; Hudry, Christophe; Zenasni, Franck; Rozenberg, Sylvie; Pertuiset, Edouard; Fautrel, Bruno; Gossec, Laure

2015-06-10

Axial Spondyloarthritis (AxSpA) and chronic low back pain are rheumatic diseases that impact patients' health-related quality of life (HRQoL). In other chronic conditions, HRQoL was positively associated with dispositional optimism, a personality trait. The objective was to explore the relationship between optimism and HRQoL in these two diseases. A cross-sectional study was performed in 2 tertiary care hospitals and 2 private practices in France. Patients had definite AxSpA or chronic low back pain according to the rheumatologist. A generic HRQoL questionnaire (Short Form, SF-12) with physical and mental composite scores (PCS and MCS respectively) and an optimism questionnaire (the Life Orientation Test-revised, LOT-R) were collected. Analyses included non-parametric correlations and multiple regression analyses to study the effect of optimism on PCS and MCS. In all, 288 (199 AxSpA and 89 low back pain) patients were included: mean age, 47.3 ± 11.9 years, 48.6 % were males. Pain levels (0-10) were 4.5 ± 2.4 and 4.3 ± 2.4 in AxSpA and LOW BACK PAIN patients, respectively. HRQoL was similarly altered in both diseases, for both physical and mental composite scores (mean PCS: 43.7 ± 8.2 vs. 41.9 ± 7.1; mean 45.9 ± 7.8 vs. 46.7 ± 8.1 for AxSpA and low back pain respectively). Optimism was moderate and similar in both populations. Optimism was positively correlated to MCS in both diseases (rho = 0.54 and 0.58, respectively, both p <0.01) and these relations persisted in multivariate analyses (beta = 1.03 and 1.40, both p <0.0001). Optimism was similar in these 2 chronic diseases and was an explanatory factor of the mental component of HRQoL, but not physical HRQoL. Physical HRQoL may reflect more the disease process than character traits.

Role of step size and max dwell time in anatomy based inverse optimization for prostate implants

PubMed Central

Manikandan, Arjunan; Sarkar, Biplab; Rajendran, Vivek Thirupathur; King, Paul R.; Sresty, N.V. Madhusudhana; Holla, Ragavendra; Kotur, Sachin; Nadendla, Sujatha

2013-01-01

In high dose rate (HDR) brachytherapy, the source dwell times and dwell positions are vital parameters in achieving a desirable implant dose distribution. Inverse treatment planning requires an optimal choice of these parameters to achieve the desired target coverage with the lowest achievable dose to the organs at risk (OAR). This study was designed to evaluate the optimum source step size and maximum source dwell time for prostate brachytherapy implants using an Ir-192 source. In total, one hundred inverse treatment plans were generated for the four patients included in this study. Twenty-five treatment plans were created for each patient by varying the step size and maximum source dwell time during anatomy-based, inverse-planned optimization. Other relevant treatment planning parameters were kept constant, including the dose constraints and source dwell positions. Each plan was evaluated for target coverage, urethral and rectal dose sparing, treatment time, relative target dose homogeneity, and nonuniformity ratio. The plans with 0.5 cm step size were seen to have clinically acceptable tumor coverage, minimal normal structure doses, and minimum treatment time as compared with the other step sizes. The target coverage for this step size is 87% of the prescription dose, while the urethral and maximum rectal doses were 107.3 and 68.7%, respectively. No appreciable difference in plan quality was observed with variation in maximum source dwell time. The step size plays a significant role in plan optimization for prostate implants. Our study supports use of a 0.5 cm step size for prostate implants. PMID:24049323

Reduction of exposure to acrylamide: achievements, potential of optimization, and problems encountered from the perspectives of a Swiss enforcement laboratory.

PubMed

Grob, Koni

2005-01-01

The most important initiatives taken in Switzerland to reduce exposure of consumers to acrylamide are the separate sale of potatoes low in reducing sugars for roasting and frying, the optimization of the raw material and preparation of french fries, and campaigns to implement suitable preparation methods in the gastronomy and homes. Industry works on improving a range of other products. Although these measures can reduce high exposures by some 80%, they have little effect on the background exposure resulting from coffee, bread, and numerous other products for which no substantial improvement is in sight. At this stage, improvements should be achieved by supporting voluntary activity rather than legal limits. Committed and consistent risk communication is key, and the support of improvements presupposes innovative approaches.

Risk factors for the treatment outcome of retreated pulmonary tuberculosis patients in China: an optimized prediction model.

PubMed

Wang, X-M; Yin, S-H; Du, J; Du, M-L; Wang, P-Y; Wu, J; Horbinski, C M; Wu, M-J; Zheng, H-Q; Xu, X-Q; Shu, W; Zhang, Y-J

2017-07-01

Retreatment of tuberculosis (TB) often fails in China, yet the risk factors associated with the failure remain unclear. To identify risk factors for the treatment failure of retreated pulmonary tuberculosis (PTB) patients, we analyzed the data of 395 retreated PTB patients who received retreatment between July 2009 and July 2011 in China. PTB patients were categorized into 'success' and 'failure' groups by their treatment outcome. Univariable and multivariable logistic regression were used to evaluate the association between treatment outcome and socio-demographic as well as clinical factors. We also created an optimized risk score model to evaluate the predictive values of these risk factors on treatment failure. Of 395 patients, 99 (25·1%) were diagnosed as retreatment failure. Our results showed that risk factors associated with treatment failure included drug resistance, low education level, low body mass index (6 months), standard treatment regimen, retreatment type, positive culture result after 2 months of treatment, and the place where the first medicine was taken. An Optimized Framingham risk model was then used to calculate the risk scores of these factors. Place where first medicine was taken (temporary living places) received a score of 6, which was highest among all the factors. The predicted probability of treatment failure increases as risk score increases. Ten out of 359 patients had a risk score >9, which corresponded to an estimated probability of treatment failure >70%. In conclusion, we have identified multiple clinical and socio-demographic factors that are associated with treatment failure of retreated PTB patients. We also created an optimized risk score model that was effective in predicting the retreatment failure. These results provide novel insights for the prognosis and improvement of treatment for retreated PTB patients.

Mixed-Strategy Chance Constrained Optimal Control

NASA Technical Reports Server (NTRS)

Ono, Masahiro; Kuwata, Yoshiaki; Balaram, J.

2013-01-01

This paper presents a novel chance constrained optimal control (CCOC) algorithm that chooses a control action probabilistically. A CCOC problem is to find a control input that minimizes the expected cost while guaranteeing that the probability of violating a set of constraints is below a user-specified threshold. We show that a probabilistic control approach, which we refer to as a mixed control strategy, enables us to obtain a cost that is better than what deterministic control strategies can achieve when the CCOC problem is nonconvex. The resulting mixed-strategy CCOC problem turns out to be a convexification of the original nonconvex CCOC problem. Furthermore, we also show that a mixed control strategy only needs to "mix" up to two deterministic control actions in order to achieve optimality. Building upon an iterative dual optimization, the proposed algorithm quickly converges to the optimal mixed control strategy with a user-specified tolerance.

Robotic radical prostatectomy for elderly patients: probability of achieving continence and potency 1 year after surgery.

PubMed

Shikanov, Sergey; Desai, Vikas; Razmaria, Aria; Zagaja, Gregory P; Shalhav, Arieh L

2010-05-01

We assessed the probability of achieving continence and potency after robotic radical prostatectomy in elderly patients. The cohort included 1,436 robotic radical prostatectomy cases performed at our institution between 2003 and 2008. Continence (pad-free) and potency (erection sufficient for intercourse) at baseline and 1 year after surgery were evaluated by the UCLA-PCI questionnaire. Point estimates of the predicted probabilities of continence and potency for age 65, 70 and 75 years were calculated from multivariate logistic regression models adjusting for age, nerve sparing status, baseline International Prostate Symptom Score and baseline Sexual Health Inventory for Men score. Patients who were impotent before surgery or those who received hormones or radiation within 1 year after surgery were censored. Mean patient age was 60 years (range 38 to 85) with 25% older than 65 years and 77 (5%) 70 years old or older. Age (OR 0.97, p = 0.002), baseline I-PSS (OR 0.98, p = 0.02) and Sexual Health Inventory for Men scores (OR 1.02, p = 0.005) were independently associated with being pad-free. Age (OR 0.92, p <0.0001), baseline Sexual Health Inventory for Men score (OR 1.1, p <0.0001) and bilateral nerve sparing (OR 2.92, p <0.0001) were independently associated with achieving potency. Predicted probabilities (95% CI) of postoperative 1-year continence at age 65, 70 and 75 years were 0.66 (0.63, 0.69), 0.63 (0.57, 0.68) and 0.59 (0.52, 0.66), respectively. The corresponding probabilities of postoperative 1-year potency after bilateral nerve sparing were 0.66 (0.62, 0.71), 0.56 (0.49, 0.64) and 0.46 (0.36, 0.56). In our experience there is an acceptable probability of achieving continence and potency after robotic radical prostatectomy in selected elderly patients. 2010 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

[Heart rate control in chronic heart failure patients received cardiovascular implantable electronic device therapy: effects of optimized medication].

PubMed

Gao, Y; Liang, Y C; Yu, H B; Yan, X L; Xu, B G; Liu, R; Wang, N; Xu, G Q; Wang, Z L

2018-03-24

Objective: To investigate the heart rate control situation of chronic heart failure (CHF) patients who received cardiovascular implantable electronic device (CIED) therapy, and to assess the heart rate control efficacy by optimized medication adjustment. Methods: We performed a perspective study in heart failure with reduced left ventricular ejection fraction (HFrEF) patients who received CIED according to guideline recommendations, patients were enrolled from January 2012 to January 2017. Resting heart rate (RHR) recorded by electrocardiogram after 10 minutes' rest and medication usage within 1 month were recorded at baseline. RHR less than 70 beats per minute (bpm) was regarded as well controlled. β-receptor blockers and (or) ivabradine would be added in patients whose RHR were over 70 bpm. RHR after optimized medication adjustment was recorded during follow-up period. Results: One hundred and fifty patients were included in this study with average RHR (80.6±11.9) bpm. RHR was<70 bpm in 27.3% (41/150) patients at baseline and β-receptor blockers was underused in 80.7% patients (88/109) whose RHR was>70 bpm. The overall RHR decreased to (73.1±10.4) bpm and percent of patients with RHR<70 bpm increased to 70.0% (105/150) after up-titration of β-receptor blockers compared to baseline (χ 2 =52.958, P< 0.001). Ivabradine was added in the rest 45 patients and RHR was<70 bpm in 43 out of 45 patients after ivabradine use. The overall RHR decreased to (67.1±2.7) bpm and percent of RHR<70 bpm significantly increased to 98.7% (148/150) (χ 2 =44.504, P< 0.001 vs. up-titration of β-receptor blockers only). Conclusion: RHR in CHF patients who received CIED therapy is not ideally controlled in this patient cohort, individual up-titration ofβ-receptor blockers and ivabradine use may help to optimize RHR in these patients.

Optimal vitamin D plasma levels are associated with lower bacterial DNA translocation in HIV/hepatitis c virus coinfected patients.

PubMed

García-Álvarez, Mónica; Berenguer, Juan; Jiménez-Sousa, Maria Ángeles; Vázquez-Morón, Sonia; Carrero, Ana; Gutiérrez-Rivas, Mónica; Aldámiz-Echevarría, Teresa; López, Juan Carlos; García-Broncano, Pilar; Resino, Salvador

2016-04-24

Vitamin D has been linked to the immune response modulation and the integrity of the intestinal mucosal barrier. Therefore, vitamin D might be involved in bacterial translocation related to HIV infection. Our major aim was to analyze the association between plasma levels of 25-hydroxy-vitamin D [25(OH)D] and bacterial 16S ribosomal DNA (bactDNA) in 120 HIV/hepatitis c virus (HCV) coinfected patients. Cross-sectional study. Plasma 25(OH)D levels were quantified by enzyme immunoassay. The vitamin D status was defined as deficient (<25 nmol/l), insufficient (25-74 nmol/l), and optimal (≥75 nmol/l) plasma levels. Plasma bactDNA levels were measured by quantitative real-time PCR. For bactDNA levels the cutoffs used were as follows: low [p75th). Eighteen (15%) patients had 25(OH)D deficiency, 93 (77.5%) had insufficiency and nine (7.5%) had 25(OH)D optimal values. The bactDNA levels were lower in patients with 25(OH)D at least 75 nmol/l [37 copies/μl] than in patients with 25(OH)D insufficiency [84.2 copies/μl; P = 0.042]. Conversely, low bactDNA levels (patients with 25(OH)D optimal levels, whereas bactDNA levels above p25th were found only in 11.1% of them (P = 0.029). The plasma 25(OH)D not less than 75 nmol/l was associated with low bactDNA levels (patients with optimal vitamin D status [25(OH)D ≥75 nmol/l] had lower plasma levels of CCL7 (P = 0.047) and basic fibroblast growth factor (P = 0.042). The optimal vitamin D status was associated with low bacterial translocation and inflammation in HIV/HCV coinfected patients.

Enhancing Self-Efficacy for Optimized Patient Outcomes through the Theory of Symptom Self-Management

PubMed Central

Hoffman, Amy J.

2012-01-01

Background In today’s world, greater patient empowerment is imperative since 90 million Americans live with one or more chronic conditions such as cancer. Evidence reveals that healthy behaviors such as effective symptom self-management can prevent or reduce much of the suffering from cancer. Oncology nurses play a pivotal role in developing a symptom self-management plan that is critical to optimizing a patient’s symptom self-management behaviors. Objective This article uses exemplars to describe how oncology nurses can apply a tested middle-range theory, the Theory of Symptom Self-Management, to clinical practice by incorporating interventions to increase a patient’s perceived self-efficacy to optimize patient outcomes. Methods The Theory of Symptom Self-Management provides a means to understand the dynamic aspects of symptom self-management and provides a tested framework for the development of efficacy enhancing interventions for use by oncology nurses in clinical practice. Results Exemplars based on the Theory of Symptom Self-Management that depict how oncology nursing can use perceived self-efficacy enhancing symptom self-management interventions to improve the functional status and quality of life of their patients. Conclusion Guided by a theoretical approach, oncology nurses can have a significant positive impact on the lives of their patients by reducing the symptom burden associated with cancer and its treatment. Implications for Practice Oncology nurses can partner with their patients to design tailored approaches to symptom self-management. These tailored approaches provide the ability to implement patient specific behaviors that recognize, prevent, relieve, or decrease the timing, intensity, distress, concurrence, and unpleasant quality of symptoms. PMID:22495550

Integrated multidisciplinary design optimization of rotorcraft

NASA Technical Reports Server (NTRS)

Adelman, Howard M.; Mantay, Wayne R.

1989-01-01

The NASA/Army research plan for developing the logic elements for helicopter rotor design optimization by integrating appropriate disciplines and accounting for important interactions among the disciplines is discussed. The paper describes the optimization formulation in terms of the objective function, design variables, and constraints. The analysis aspects are discussed, and an initial effort at defining the interdisciplinary coupling is summarized. Results are presented on the achievements made in the rotor aerodynamic performance optimization for minimum hover horsepower, rotor dynamic optimization for vibration reduction, rotor structural optimization for minimum weight, and integrated aerodynamic load/dynamics optimization for minimum vibration and weight.

Optimal management of colorectal liver metastases in older patients: a decision analysis

PubMed Central

Yang, Simon; Alibhai, Shabbir MH; Kennedy, Erin D; El-Sedfy, Abraham; Dixon, Matthew; Coburn, Natalie; Kiss, Alex; Law, Calvin HL

2014-01-01

Background Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients. Methods A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters. Results In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age. Conclusions HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values. PMID:24961482

Optimization of oncological {sup 18}F-FDG PET/CT imaging based on a multiparameter analysis

DOE Office of Scientific and Technical Information (OSTI.GOV)

Menezes, Vinicius O., E-mail: vinicius@radtec.com.br; Machado, Marcos A. D.; Queiroz, Cleiton C.

2016-02-15

Purpose: This paper describes a method to achieve consistent clinical image quality in {sup 18}F-FDG scans accounting for patient habitus, dose regimen, image acquisition, and processing techniques. Methods: Oncological PET/CT scan data for 58 subjects were evaluated retrospectively to derive analytical curves that predict image quality. Patient noise equivalent count rate and coefficient of variation (CV) were used as metrics in their analysis. Optimized acquisition protocols were identified and prospectively applied to 179 subjects. Results: The adoption of different schemes for three body mass ranges (<60 kg, 60–90 kg, >90 kg) allows improved image quality with both point spread functionmore » and ordered-subsets expectation maximization-3D reconstruction methods. The application of this methodology showed that CV improved significantly (p < 0.0001) in clinical practice. Conclusions: Consistent oncological PET/CT image quality on a high-performance scanner was achieved from an analysis of the relations existing between dose regimen, patient habitus, acquisition, and processing techniques. The proposed methodology may be used by PET/CT centers to develop protocols to standardize PET/CT imaging procedures and achieve better patient management and cost-effective operations.« less

Finding common ground to achieve a "good death": family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study.

PubMed

Tan, Amy; Manca, Donna

2013-01-22

Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a "bad death" experience for the patient and family. We aim to describe Canadian family physicians' experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients. Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged. Eleven family physicians with a range of 3 to 40 years in clinical practice participated.The family physicians expressed a desire to achieve a "good death" and described their role in positively influencing the experience of death.Finding Common Ground to Achieve a "Good Death" for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is described. A novel framework for developing

Optimized Hyper Beamforming of Linear Antenna Arrays Using Collective Animal Behaviour

PubMed Central

Ram, Gopi; Mandal, Durbadal; Kar, Rajib; Ghoshal, Sakti Prasad

2013-01-01

A novel optimization technique which is developed on mimicking the collective animal behaviour (CAB) is applied for the optimal design of hyper beamforming of linear antenna arrays. Hyper beamforming is based on sum and difference beam patterns of the array, each raised to the power of a hyperbeam exponent parameter. The optimized hyperbeam is achieved by optimization of current excitation weights and uniform interelement spacing. As compared to conventional hyper beamforming of linear antenna array, real coded genetic algorithm (RGA), particle swarm optimization (PSO), and differential evolution (DE) applied to the hyper beam of the same array can achieve reduction in sidelobe level (SLL) and same or less first null beam width (FNBW), keeping the same value of hyperbeam exponent. Again, further reductions of sidelobe level (SLL) and first null beam width (FNBW) have been achieved by the proposed collective animal behaviour (CAB) algorithm. CAB finds near global optimal solution unlike RGA, PSO, and DE in the present problem. The above comparative optimization is illustrated through 10-, 14-, and 20-element linear antenna arrays to establish the optimization efficacy of CAB. PMID:23970843

Numerical difficulties associated with using equality constraints to achieve multi-level decomposition in structural optimization

NASA Technical Reports Server (NTRS)

Thareja, R.; Haftka, R. T.

1986-01-01

There has been recent interest in multidisciplinary multilevel optimization applied to large engineering systems. The usual approach is to divide the system into a hierarchy of subsystems with ever increasing detail in the analysis focus. Equality constraints are usually placed on various design quantities at every successive level to ensure consistency between levels. In many previous applications these equality constraints were eliminated by reducing the number of design variables. In complex systems this may not be possible and these equality constraints may have to be retained in the optimization process. In this paper the impact of such a retention is examined for a simple portal frame problem. It is shown that the equality constraints introduce numerical difficulties, and that the numerical solution becomes very sensitive to optimization parameters for a wide range of optimization algorithms.

Optimized emission in nanorod arrays through quasi-aperiodic inverse design.

PubMed

Anderson, P Duke; Povinelli, Michelle L

2015-06-01

We investigate a new class of quasi-aperiodic nanorod structures for the enhancement of incoherent light emission. We identify one optimized structure using an inverse design algorithm and the finite-difference time-domain method. We carry out emission calculations on both the optimized structure as well as a simple periodic array. The optimized structure achieves nearly perfect light extraction while maintaining a high spontaneous emission rate. Overall, the optimized structure can achieve a 20%-42% increase in external quantum efficiency relative to a simple periodic design, depending on material quality.

Energy Requirements in Critically Ill Patients.

PubMed

Ndahimana, Didace; Kim, Eun-Kyung

2018-04-01

During the management of critical illness, optimal nutritional support is an important key for achieving positive clinical outcomes. Compared to healthy people, critically ill patients have higher energy expenditure, thereby their energy requirements and risk of malnutrition being increased. Assessing individual nutritional requirement is essential for a successful nutritional support, including the adequate energy supply. Methods to assess energy requirements include indirect calorimetry (IC) which is considered as a reference method, and the predictive equations which are commonly used due to the difficulty of using IC in certain conditions. In this study, a literature review was conducted on the energy metabolic changes in critically ill patients, and the implications for the estimation of energy requirements in this population. In addition, the issue of optimal caloric goal during nutrition support is discussed, as well as the accuracy of selected resting energy expenditure predictive equations, commonly used in critically ill patients.

Barriers to optimal diabetes care in Trinidad and Tobago: a health care Professionals' perspective.

PubMed

Roopnarinesingh, Nira; Brennan, Nancyellen; Khan, Claude; Ladenson, Paul W; Hill-Briggs, Felicia; Kalyani, Rita Rastogi

2015-09-19

The republic of Trinidad and Tobago (T&T) is a middle income country with a comparatively high prevalence of diabetes mellitus (DM) compared to others in the Caribbean. To date, there have been no studies on health care professionals' (HCP) perspectives regarding the barriers to achieving optimal care of patients with DM in this country and few previous studies in the Caribbean, yet such perspectives are imperative to develop strategies that reduce the global burden of this disease. An electronic invitation was sent to prospective HCP in T&T inviting them to attend a symposium on DM and cardiovascular disease. A total of 198 HCP participants attended of whom approximately 100 participants completed an Audience Response Survey at the completion of the conference. The Audience Response Survey included questions regarding access to resources, need for prevention and education, and coordination of care for to diabetes care in T&T. Responses were analyzed in aggregate. The 198 HCP participants attending the symposium included mostly nurses (40 %) and physicians (43 %). The most common specialty indicated by the 198 HCP participants was Internal and Family Medicine (28 %), followed by Anesthesiology (7 %), Emergency Medicine (6 %), Endocrinology and Diabetes (5 %) and Cardiology (3 %). Among the ~100 HCP who completed the Audience Response Survey, multiple barriers to achieving optimal care of patients with diabetes were reported such as: limited access to blood testing (75 %), ophthalmological evaluations (96 %), ECGs (69 %), and cardiac stress tests (92 %); inadequate time to screen and evaluate DM complications (95 %); poor access to consultants for referral of difficult cases (77 %); and lack of provider education regarding cardiovascular complications of DM (57 %). HCP agreed that nurses could potentially be considered to have a more active role in the care and prevention of cardiovascular disease and diabetes through leading patient education efforts (98

Acceleration of high resolution temperature based optimization for hyperthermia treatment planning using element grouping.

PubMed

Kok, H P; de Greef, M; Bel, A; Crezee, J

2009-08-01

In regional hyperthermia, optimization is useful to obtain adequate applicator settings. A speed-up of the previously published method for high resolution temperature based optimization is proposed. Element grouping as described in literature uses selected voxel sets instead of single voxels to reduce computation time. Elements which achieve their maximum heating potential for approximately the same phase/amplitude setting are grouped. To form groups, eigenvalues and eigenvectors of precomputed temperature matrices are used. At high resolution temperature matrices are unknown and temperatures are estimated using low resolution (1 cm) computations and the high resolution (2 mm) temperature distribution computed for low resolution optimized settings using zooming. This technique can be applied to estimate an upper bound for high resolution eigenvalues. The heating potential of elements was estimated using these upper bounds. Correlations between elements were estimated with low resolution eigenvalues and eigenvectors, since high resolution eigenvectors remain unknown. Four different grouping criteria were applied. Constraints were set to the average group temperatures. Element grouping was applied for five patients and optimal settings for the AMC-8 system were determined. Without element grouping the average computation times for five and ten runs were 7.1 and 14.4 h, respectively. Strict grouping criteria were necessary to prevent an unacceptable exceeding of the normal tissue constraints (up to approximately 2 degrees C), caused by constraining average instead of maximum temperatures. When strict criteria were applied, speed-up factors of 1.8-2.1 and 2.6-3.5 were achieved for five and ten runs, respectively, depending on the grouping criteria. When many runs are performed, the speed-up factor will converge to 4.3-8.5, which is the average reduction factor of the constraints and depends on the grouping criteria. Tumor temperatures were comparable. Maximum exceeding

Optimization of a shorter variable-acquisition time for legs to achieve true whole-body PET/CT images.

PubMed

Umeda, Takuro; Miwa, Kenta; Murata, Taisuke; Miyaji, Noriaki; Wagatsuma, Kei; Motegi, Kazuki; Terauchi, Takashi; Koizumi, Mitsuru

2017-12-01

The present study aimed to qualitatively and quantitatively evaluate PET images as a function of acquisition time for various leg sizes, and to optimize a shorter variable-acquisition time protocol for legs to achieve better qualitative and quantitative accuracy of true whole-body PET/CT images. The diameters of legs to be modeled as phantoms were defined based on data derived from 53 patients. This study analyzed PET images of a NEMA phantom and three plastic bottle phantoms (diameter, 5.68, 8.54 and 10.7 cm) that simulated the human body and legs, respectively. The phantoms comprised two spheres (diameters, 10 and 17 mm) containing fluorine-18 fluorodeoxyglucose solution with sphere-to-background ratios of 4 at a background radioactivity level of 2.65 kBq/mL. All PET data were reconstructed with acquisition times ranging from 10 to 180, and 1200 s. We visually evaluated image quality and determined the coefficient of variance (CV) of the background, contrast and the quantitative %error of the hot spheres, and then determined two shorter variable-acquisition protocols for legs. Lesion detectability and quantitative accuracy determined based on maximum standardized uptake values (SUV max ) in PET images of a patient using the proposed protocols were also evaluated. A larger phantom and a shorter acquisition time resulted in increased background noise on images and decreased the contrast in hot spheres. A visual score of ≥ 1.5 was obtained when the acquisition time was ≥ 30 s for three leg phantoms, and ≥ 120 s for the NEMA phantom. The quantitative %errors of the 10- and 17-mm spheres in the leg phantoms were ± 15 and ± 10%, respectively, in PET images with a high CV (scan < 30 s). The mean SUV max of three lesions using the current fixed-acquisition and two proposed variable-acquisition time protocols in the clinical study were 3.1, 3.1 and 3.2, respectively, which did not significantly differ. Leg acquisition time per bed position of

A continuous arc delivery optimization algorithm for CyberKnife m6.

PubMed

Kearney, Vasant; Descovich, Martina; Sudhyadhom, Atchar; Cheung, Joey P; McGuinness, Christopher; Solberg, Timothy D

2018-06-01

This study aims to reduce the delivery time of CyberKnife m6 treatments by allowing for noncoplanar continuous arc delivery. To achieve this, a novel noncoplanar continuous arc delivery optimization algorithm was developed for the CyberKnife m6 treatment system (CyberArc-m6). CyberArc-m6 uses a five-step overarching strategy, in which an initial set of beam geometries is determined, the robotic delivery path is calculated, direct aperture optimization is conducted, intermediate MLC configurations are extracted, and the final beam weights are computed for the continuous arc radiation source model. This algorithm was implemented on five prostate and three brain patients, previously planned using a conventional step-and-shoot CyberKnife m6 delivery technique. The dosimetric quality of the CyberArc-m6 plans was assessed using locally confined mutual information (LCMI), conformity index (CI), heterogeneity index (HI), and a variety of common clinical dosimetric objectives. Using conservative optimization tuning parameters, CyberArc-m6 plans were able to achieve an average CI difference of 0.036 ± 0.025, an average HI difference of 0.046 ± 0.038, and an average LCMI of 0.920 ± 0.030 compared with the original CyberKnife m6 plans. Including a 5 s per minute image alignment time and a 5-min setup time, conservative CyberArc-m6 plans achieved an average treatment delivery speed up of 1.545x ± 0.305x compared with step-and-shoot plans. The CyberArc-m6 algorithm was able to achieve dosimetrically similar plans compared to their step-and-shoot CyberKnife m6 counterparts, while simultaneously reducing treatment delivery times. © 2018 American Association of Physicists in Medicine.

SU-E-T-182: Feasibility of Dose Painting by Numbers in Proton Therapy with Contour-Driven Plan Optimization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Montero, A Barragan; Differding, S; Lee, J

Purpose: The work aims to 1) prove the feasibility of dose painting by numbers (DPBN) in proton therapy with usual contour-driven plan optimization and 2) compare the achieved plan quality to that of rotational IMRT. Methods: For two patients with head and neck cancers, voxel-by-voxel prescription to the target volume (PTV-PET) was calculated from {sup 18} FDG-PET images and converted to contour-based prescription by defining several sub-contours. Treatments were planned with RayStation (RaySearch Laboratories, Sweden) and proton pencil beam scanning modality. In order to determine the optimal plan parameters to approach the DPBN prescription, the effect of the number ofmore » fields, number of sub-contours and use of range shifter were tested separately on each patient. The number of sub-contours were increased from 3 to 11 while the number of fields were set to 3, 5, 7 and 9. Treatment plans were also optimized on two rotational IMRT systems (TomoTherapy and Varian RapidArc) using previously published guidelines. Results: For both patients, more than 99% of the PTV-PET received at least 95% of the prescribed dose while less than 1% of the PTV-PET received more than 105%, which demonstrates the feasibility of the treatment. Neither the use of a range shifter nor the increase of the number of fields had a significant influence on PTV coverage. Plan quality increased when increasing number of fields up to 7 or 9 and slightly decreased for a bigger number of sub-contours. Good OAR sparing is achieved while keeping high plan quality. Finally, proton therapy achieved significantly better plan quality than rotational IMRT. Conclusion: Voxel-by-voxel prescriptions can be approximated accurately in proton therapy using a contour-driven optimization. Target coverage is nearly insensitive to the number of fields and the use of a range shifter. Finally, plan quality assessment confirmed the superiority of proton therapy compared to rotational IMRT.« less

Febuxostat as a novel option to optimize thiopurines' metabolism in patients with inadequate metabolite levels.

PubMed

Doré, Maxime; Frenette, Anne Julie; Mansour, Anne-Marie; Troyanov, Yves; Bégin, Josiane

2014-05-01

To report the use of febuxostat in order to potentiate thiopurines' metabolism in a patient on azathioprine (AZA) therapy with low metabolite 6-thioguanine nucleotides (6-TGN) levels and elevated metabolite 6-methylmercaptopurine (6-MMP) levels. A 44-year-old woman with a history of anti-signal recognition particle necrotizing myopathy was treated with AZA-allopurinol combination therapy. When she developed an atypical drug-induced hypersensitivity syndrome, allopurinol was replaced by the new xanthine oxidase (XO) inhibitor febuxostat, at a daily dose of 40 mg. Febuxostat-AZA combination was successful with 6-TGN reaching therapeutic levels while 6-MMP levels remained low. After 5 months, she developed similar manifestations that she had presented on AZA-allopurinol combination. Febuxostat and AZA were then stopped. AZA and 6-MP are both inactive pro-drugs that undergo a complex metabolic transformation leading to active 6-TGN and potentially hepatotoxic 6-MMP. Some patients with unfavorable thiopurine metabolism might benefit from addition of XO inhibitor allopurinol in order to potentiate 6-TGN and reduce 6-MMP levels. It is likely that febuxostat, via its XO inhibition, would exhibit the same effect on thiopurines' metabolism. It has been shown that low dose of febuxostat was able to prevent hypermethylation and to potentiate 6-TGN levels in an AZA-treated patient. Thus, febuxostat could be useful in optimizing thiopurines' metabolism, but more data are needed before this practice can be recommended. The mechanisms by which febuxostat optimizes thiopurines' metabolism remain to be confirmed. Also, the optimal dose of febuxostat for this use remains to be determined.

Design of patient-specific gait modifications for knee osteoarthritis rehabilitation.

PubMed

Fregly, Benjamin J; Reinbolt, Jeffrey A; Rooney, Kelly L; Mitchell, Kim H; Chmielewski, Terese L

2007-09-01

Abstract-Gait modification is a nonsurgical approach for reducing the external knee adduction torque in patients with knee osteoarthritis (OA). The magnitude of the first adduction torque peak in particular is strongly associated with knee OA progression. While toeing out has been shown to reduce the second peak, no clinically realistic gait modifications have been identified that effectively reduce both peaks simultaneously. This study predicts novel patient-specific gait modifications that achieve this goal without changing the foot path. The modified gait motion was designed for a single patient with knee OA using dynamic optimization of a patient-specific, full-body gait model. The cost function minimized the knee adduction torque subject to constraints limiting how much the new gait motion could deviate from the patient's normal gait motion. The optimizations predicted a "medial-thrust" gait pattern that reduced the first adduction torque peak between 32% and 54% and the second peak between 34% and 56%. The new motion involved three synergistic kinematic changes: slightly decreased pelvis obliquity, slightly increased leg flexion, and slightly increased pelvis axial rotation. After gait retraining, the patient achieved adduction torque reductions of 39% to 50% in the first peak and 37% to 55% in the second one. These reductions are comparable to those reported after high tibial osteotomy surgery. The associated kinematic changes were consistent with the predictions except for pelvis obliquity, which showed little change. This study demonstrates that it is feasible to design novel patient-specific gait modifications with potential clinical benefit using dynamic optimization of patient-specific, full-body gait models. Further investigation is needed to assess the extent to which similar gait modifications may be effective for other patients with knee OA.

The DAS28-ESR cutoff value necessary to achieve remission under the new Boolean-based remission criteria in patients receiving tocilizumab.

PubMed

Hirabayashi, Yasuhiko; Ishii, Tomonori

2013-01-01

To seek the cutoff value of the 28-joint disease activity score using erythrocyte sedimentation rate (DAS28-ESR) that is necessary to achieve remission under the new Boolean-based criteria, we analyzed the data for 285 patients with rheumatoid arthritis registered between May 2008 and November 2009 by the Michinoku Tocilizumab Study Group and observed for 1 year after receiving tocilizumab (TCZ) in real clinical practice. Remission rates under the DAS28-ESR criteria and the Boolean criteria were assessed every 6 months after the first TCZ dose. The DAS28-ESR cutoff value necessary to achieve remission under the new criteria was analyzed by receiver operating characteristic (ROC) analysis. Data were analyzed using last observation carried forward. After 12 months of TCZ use, remission was achieved in 164 patients (57.5 %) by DAS28-ESR and 71 patients (24.9 %) under the new criteria for clinical trials. CRP levels scarcely affected remission rates, and the difference between remission rates defined by DAS28-ESR and by the new criteria was mainly due to patient global assessment (PGA). Improvement of PGA was inversely related to disease duration. ROC analysis revealed that the DAS28-ESR cutoff value necessary to predict remission under the new criteria for clinical trials was 1.54, with a sensitivity of 88.7 %, specificity of 85.5 %, positive predictive value of 67.0 %, and negative predictive value of 95.8 %. A DAS28-ESR cutoff value of 1.54 may be reasonable to predict achievement of remission under the new Boolean-based criteria for clinical trials in patients receiving TCZ.

Multimodality Monitoring for Cerebral Perfusion Pressure Optimization in Comatose Patients with Intracerebral Hemorrhage

PubMed Central

Ko, Sang-Bae; Choi, H. Alex; Parikh, Gunjan; Helbok, Raimund; Schmidt, J. Michael; Lee, Kiwon; Badjatia, Neeraj; Claassen, Jan; Connolly, E. Sander; Mayer, Stephan A.

2011-01-01

Background and Purpose Limited data exists to recommend specific cerebral perfusion pressure (CPP) targets in patients with intracerebral hemorrhage (ICH). We sought to determine the feasibility of brain multimodality monitoring (MMM) for optimizing CPP and potentially reducing secondary brain injury after ICH. Methods We retrospectively analyzed brain MMM data targeted at perihematomal brain tissue in 18 comatose ICH patients (median monitoring: 164 hours). Physiological measures were averaged over one-hour intervals corresponding to each microdialysis sample. Metabolic crisis (MC) was defined as a lactate/pyruvate ratio (LPR) >40 with a brain glucose concentration <0.7 mmol/L. Brain tissue hypoxia (BTH) was defined as PbtO2 <15 mm Hg. Pressure reactivity index (PRx) and oxygen reactivity index (ORx) were calculated. Results Median age was 59 years, median GCS score 6, and median ICH volume was 37.5 ml. The risk of BTH, and to a lesser extent MC, increased with lower CPP values. Multivariable analyses showed that CPP <80 mm Hg was associated with a greater risk of BTH (OR 1.5, 95% CI 1.1–2.1, P=0.01) compared to CPP >100 mm Hg as a reference range. Six patients died (33%). Survivors had significantly higher CPP and PbtO2 and lower ICP values starting on post-bleed day 4, whereas LPR and PRx values were lower, indicating preservation of aerobic metabolism and pressure autoregulation. Conclusions PbtO2 monitoring can be used to identify CPP targets for optimal brain tissue oxygenation. In patients who do not undergo MMM, maintaining CPP >80 mm Hg may reduce the risk of BTH. PMID:21852615

Comparison of evolutionary algorithms for LPDA antenna optimization

NASA Astrophysics Data System (ADS)

Lazaridis, Pavlos I.; Tziris, Emmanouil N.; Zaharis, Zaharias D.; Xenos, Thomas D.; Cosmas, John P.; Gallion, Philippe B.; Holmes, Violeta; Glover, Ian A.

2016-08-01

A novel approach to broadband log-periodic antenna design is presented, where some of the most powerful evolutionary algorithms are applied and compared for the optimal design of wire log-periodic dipole arrays (LPDA) using Numerical Electromagnetics Code. The target is to achieve an optimal antenna design with respect to maximum gain, gain flatness, front-to-rear ratio (F/R) and standing wave ratio. The parameters of the LPDA optimized are the dipole lengths, the spacing between the dipoles, and the dipole wire diameters. The evolutionary algorithms compared are the Differential Evolution (DE), Particle Swarm (PSO), Taguchi, Invasive Weed (IWO), and Adaptive Invasive Weed Optimization (ADIWO). Superior performance is achieved by the IWO (best results) and PSO (fast convergence) algorithms.

Estimation of tissue stiffness, reflex activity, optimal muscle length and slack length in stroke patients using an electromyography driven antagonistic wrist model.

PubMed

de Gooijer-van de Groep, Karin L; de Vlugt, Erwin; van der Krogt, Hanneke J; Helgadóttir, Áróra; Arendzen, J Hans; Meskers, Carel G M; de Groot, Jurriaan H

2016-06-01

About half of all chronic stroke patients experience loss of arm function coinciding with increased stiffness, reduced range of motion and a flexed wrist due to a change in neural and/or structural tissue properties. Quantitative assessment of these changes is of clinical importance, yet not trivial. The goal of this study was to quantify the neural and structural properties contributing to wrist joint stiffness and to compare these properties between healthy subjects and stroke patients. Stroke patients (n=32) and healthy volunteers (n=14) were measured using ramp-and-hold rotations applied to the wrist joint by a haptic manipulator. Neural (reflexive torque) and structural (connective tissue stiffness and slack lengths and (contractile) optimal muscle lengths) parameters were estimated using an electromyography driven antagonistic wrist model. Kruskal-Wallis analysis with multiple comparisons was used to compare results between healthy subjects, stroke patients with modified Ashworth score of zero and stroke patients with modified Ashworth score of one or more. Stroke patients with modified Ashworth score of one or more differed from healthy controls (P<0.05) by increased tissue stiffness, increased reflexive torque, decreased optimal muscle length and decreased slack length of connective tissue of the flexor muscles. Non-invasive quantitative analysis, including estimation of optimal muscle lengths, enables to identify neural and non-neural changes in chronic stroke patients. Monitoring these changes in time is important to understand the recovery process and to optimize treatment. Copyright © 2016 Elsevier Ltd. All rights reserved.

Inverse 4D conformal planning for lung SBRT using particle swarm optimization

NASA Astrophysics Data System (ADS)

Modiri, A.; Gu, X.; Hagan, A.; Bland, R.; Iyengar, P.; Timmerman, R.; Sawant, A.

2016-08-01

A critical aspect of highly potent regimens such as lung stereotactic body radiation therapy (SBRT) is to avoid collateral toxicity while achieving planning target volume (PTV) coverage. In this work, we describe four dimensional conformal radiotherapy using a highly parallelizable swarm intelligence-based stochastic optimization technique. Conventional lung CRT-SBRT uses a 4DCT to create an internal target volume and then, using forward-planning, generates a 3D conformal plan. In contrast, we investigate an inverse-planning strategy that uses 4DCT data to create a 4D conformal plan, which is optimized across the three spatial dimensions (3D) as well as time, as represented by the respiratory phase. The key idea is to use respiratory motion as an additional degree of freedom. We iteratively adjust fluence weights for all beam apertures across all respiratory phases considering OAR sparing, PTV coverage and delivery efficiency. To demonstrate proof-of-concept, five non-small-cell lung cancer SBRT patients were retrospectively studied. The 4D optimized plans achieved PTV coverage comparable to the corresponding clinically delivered plans while showing significantly superior OAR sparing ranging from 26% to 83% for D max heart, 10%-41% for D max esophagus, 31%-68% for D max spinal cord and 7%-32% for V 13 lung.

Ethnic Differences in Achievement of Cholesterol Treatment Goals

PubMed Central

Clark, Luther T; Maki, Kevin C; Galant, Ron; Maron, David J; Pearson, Thomas A; Davidson, Michael H

2006-01-01

BACKGROUND African Americans (AA) have the highest coronary heart disease mortality rate of any ethnic group in the United States. Data from the National Cholesterol Education Program Evaluation ProjecT Utilizing Novel E-Technology (NEPTUNE) II survey were used to assess ethnic differences in low-density lipoprotein cholesterol (LDL-C) goal achievement. METHODS NEPTUNE II surveyed patients with treated dyslipidemia to assess achievement of treatment goals established by the Adult Treatment Panel III of the National Cholesterol Education Program. United States physicians working in primary care or relevant subspecialties enrolled 10 to 20 consecutive patients (May to September 2003), and patient data were recorded in Personal Digital Assistants and uploaded to a central database via the internet. RESULTS Among 4,885 patients receiving treatment for dyslipidemia, 79.7% were non-Hispanic white (NHW) and 8.4% were AA. Non-Hispanic white and AA patients had significantly different frequencies of treatment success, with 69.0% and 53.7%, respectively, having achieved their LDL-C goal (P <.001). African-American patients were more likely to be in the highest risk category, and less likely to be using lipid drug therapy, taking high-efficacy statins, and receiving care from a subspecialist, but the difference in goal achievement remained significant (P <.001) after adjustment for these and other predictors of treatment success. CONCLUSIONS The frequency of treatment success in dyslipidemia management was significantly lower in AA than NHW patients. Additional research is needed to elucidate reasons for this disparity and to evaluate strategies for improving goal achievement among AA patients receiving therapy for dyslipidemia. PMID:16686806

How are metabolic control targets of patients with Type 1 diabetes mellitus achieved in daily practice in the area with high diabetes prevalence?

PubMed

Kekäläinen, Päivi; Tirkkonen, Hilkka; Laatikainen, Tiina

2016-05-01

We assessed the prevalence of Type 1 diabetes mellitus and determined how the targets established in the guidelines for patients with Type 1 diabetes mellitus were achieved in clinical practice in North Karelia, Finland. All adult Type 1 diabetes mellitus patients (n=1075) were identified from the regional electronic patient database. The data for HbA1c and LDL cholesterol measurements during the years 2013 and 2014 were obtained from medical records. The prevalence of Type 1 diabetes mellitus in the adult population in North Karelia was 0.8%, which is among the highest worldwide. HbA1c and LDL cholesterol were measured in 93% and 90% of participants, respectively. Nineteen percent of patients reached the HbA1c target of <7.0% (53mmol/mol) and 45% attained LDL cholesterol <2.5mmol/l. Overall, 26% of patients over 60 years old with diabetes achieved glycaemic control targets compared with 13-16% of younger patients with diabetes. Glycaemic control was in line with the recommendations in only one-fifth of Type 1 diabetes mellitus patients and less than half of them had LDL cholesterol levels within the target range. Interestingly, older Type 1 diabetes mellitus patients met the glycaemic control target more often than younger patients with diabetes. The targets established for patients with Type 1 diabetes mellitus are not achieved satisfactorily in daily practice. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Modeling hospital surgical delivery process design using system simulation: optimizing patient flow and bed capacity as an illustration.

PubMed

Kumar, Sameer

2011-01-01

It is increasingly recognized that hospital operation is an intricate system with limited resources and many interacting sources of both positive and negative feedback. The purpose of this study is to design a surgical delivery process in a county hospital in the U.S where patient flow through a surgical ward is optimized. The system simulation modeling is used to address questions of capacity planning, throughput management and interacting resources which constitute the constantly changing complexity that characterizes designing a contemporary surgical delivery process in a hospital. The steps in building a system simulation model is demonstrated using an example of building a county hospital in a small city in the US. It is used to illustrate a modular system simulation modeling of patient surgery process flows. The system simulation model development will enable planners and designers how they can build in overall efficiencies in a healthcare facility through optimal bed capacity for peak patient flow of emergency and routine patients.

Shared Decision Making and Motivational Interviewing: Achieving Patient-Centered Care Across the Spectrum of Health Care Problems

PubMed Central

Elwyn, Glyn; Dehlendorf, Christine; Epstein, Ronald M.; Marrin, Katy; White, James; Frosch, Dominick L.

2014-01-01

Patient-centered care requires different approaches depending on the clinical situation. Motivational interviewing and shared decision making provide practical and well-described methods to accomplish patient-centered care in the context of situations where medical evidence supports specific behavior changes and the most appropriate action is dependent on the patient’s preferences. Many clinical consultations may require elements of both approaches, however. This article describes these 2 approaches—one to address ambivalence to medically indicated behavior change and the other to support patients in making health care decisions in cases where there is more than one reasonable option—and discusses how clinicians can draw on these approaches alone and in combination to achieve patient-centered care across the range of health care problems. PMID:24821899

The Impact of a Standalone, Patient-centered Communication Course Series on Student Achievement, Preparedness, and Attitudes.

PubMed

Trujillo, Jennifer M; McNair, Chelsea D; Linnebur, Sunny A; Valdez, Connie; Trujillo, Toby C

2016-12-25

Objective. To evaluate the impact of a standalone, patient-centered communication (PCC) course series on student achievement of and perceived preparedness for PCC skills and to assess student attitudes regarding learning methods used. Design. During curriculum renewal, a standalone PCC course series that integrated horizontally and vertically within the curriculum was developed. Student achievement of outcomes was evaluated by aggregate performance on simulated evaluations. Students who completed the PCC series were surveyed to assess preparedness and attitudes. Students in the prior curriculum were also surveyed. Assessment. The majority of students who completed the PCC series met or exceeded expectations for the simulated evaluations. Preparedness responses were more positive from students who completed the PCC series than from those who completed the prior curriculum. Student attitudes about the learning methods use in the courses also were more positive. Conclusion. The standalone PCC course series effectively achieved PCC outcomes and improved student preparedness for communication-based activities.

Barriers, Facilitators, and Solutions to Optimal Patient Portal and Personal Health Record Use: A Systematic Review of the Literature

PubMed Central

Zhao, Jane Y.; Song, Buer; Anand, Edwin; Schwartz, Diane; Panesar, Mandip; Jackson, Gretchen P.; Elkin, Peter L.

2017-01-01

Patient portal and personal health record adoption and usage rates have been suboptimal. A systematic review of the literature was performed to capture all published studies that specifically addressed barriers, facilitators, and solutions to optimal patient portal and personal health record enrollment and use. Consistent themes emerged from the review. Patient attitudes were critical as either barrier or facilitator. Institutional buy-in, information technology support, and aggressive tailored marketing were important facilitators. Interface redesign was a popular solution. Quantitative studies identified many barriers to optimal patient portal and personal health record enrollment and use, and qualitative and mixed methods research revealed thoughtful explanations for why they existed. Our study demonstrated the value of qualitative and mixed research methodologies in understanding the adoption of consumer health technologies. Results from the systematic review should be used to guide the design and implementation of future patient portals and personal health records, and ultimately, close the digital divide. PMID:29854263

Dithiothreitol-Regulated Coverage of Oligonucleotide-Modified Gold Nanoparticles To Achieve Optimized Biosensor Performance.

PubMed

Liang, Pingping; Canoura, Juan; Yu, Haixiang; Alkhamis, Obtin; Xiao, Yi

2018-01-31

DNA-modified gold nanoparticles (AuNPs) are useful signal-reporters for detecting diverse molecules through various hybridization- and enzyme-based assays. However, their performance is heavily dependent on the probe DNA surface coverage, which can influence both target binding and enzymatic processing of the bound probes. Current methods used to adjust the surface coverage of DNA-modified AuNPs require the production of multiple batches of AuNPs under different conditions, which is costly and laborious. We here develop a single-step assay utilizing dithiothreitol (DTT) to fine-tune the surface coverage of DNA-modified AuNPs. DTT is superior to the commonly used surface diluent, mercaptohexanol, as it is less volatile, allowing for the rapid and reproducible controlling of surface coverage on AuNPs with only micromolar concentrations of DTT. Upon adsorption, DTT forms a dense monolayer on gold surfaces, which provides antifouling capabilities. Furthermore, surface-bound DTT adopts a cyclic conformation, which reorients DNA probes into an upright position and provides ample space to promote DNA hybridization, aptamer assembly, and nuclease digestion. We demonstrate the effects of surface coverage on AuNP-based sensors using DTT-regulated DNA-modified AuNPs. We then use these AuNPs to visually detect DNA and cocaine in colorimetric assays based on enzyme-mediated AuNP aggregation. We determine that DTT-regulated AuNPs with lower surface coverage achieve shorter reaction times and lower detection limits relative to those for assays using untreated AuNPs or DTT-regulated AuNPs with high surface coverage. Additionally, we demonstrate that our DTT-regulated AuNPs can perform cocaine detection in 50% urine without any significant matrix effects. We believe that DTT regulation of surface coverage can be broadly employed for optimizing DNA-modified AuNP performance for use in biosensors as well as drug delivery and therapeutic applications.

Optimization of Medication Use at Accountable Care Organizations.

PubMed

Wilks, Chrisanne; Krisle, Erik; Westrich, Kimberly; Lunner, Kristina; Muhlestein, David; Dubois, Robert

2017-10-01

Optimized medication use involves the effective use of medications for better outcomes, improved patient experience, and lower costs. Few studies systematically gather data on the actions accountable care organizations (ACOs) have taken to optimize medication use. To (a) assess how ACOs optimize medication use; (b) establish an association between efforts to optimize medication use and achievement on financial and quality metrics; (c) identify organizational factors that correlate with optimized medication use; and (d) identify barriers to optimized medication use. This cross-sectional study consisted of a survey and interviews that gathered information on the perceptions of ACO leadership. The survey contained a medication practices inventory (MPI) composed of 38 capabilities across 6 functional domains related to optimizing medication use. ACOs completed self-assessments that included rating each component of the MPI on a scale of 1 to 10. Fisher's exact tests, 2-proportions tests, t-tests, and logistic regression were used to test for associations between ACO scores on the MPI and performance on financial and quality metrics, and on ACO descriptive characteristics. Of the 847 ACOs that were contacted, 49 provided usable survey data. These ACOs rated their own system's ability to manage the quality and costs of optimizing medication use, providing a 64% and 31% affirmative response, respectively. Three ACOs achieved an overall MPI score of 8 or higher, 45 scored between 4 and 7.9, and 1 scored between 0 and 3.9. Using the 3 score groups, the study did not identify a relationship between MPI scores and achievement on financial or quality benchmarks, ACO provider type, member volume, date of ACO creation, or the presence of a pharmacist in a leadership position. Barriers to optimizing medication use relate to reimbursement for pharmacist integration, lack of health information technology interoperability, lack of data, feasibility issues, and physician buy

Treatment-naïve Gaucher disease patients achieve therapeutic goals and normalization with velaglucerase alfa by 4years in phase 3 trials.

PubMed

Zimran, Ari; Elstein, Deborah; Gonzalez, Derlis E; Lukina, Elena A; Qin, Yulin; Dinh, Quinn; Turkia, Hadhami Ben

2018-02-01

Gaucher disease is an inherited metabolic disease characterized by β-glucocerebrosidase deficiency and commonly treated with enzyme replacement therapy (ERT). The efficacy of ERT with velaglucerase alfa was assessed based on the achievement of published therapeutic goals and the normalization of disease parameters in 39 treatment-naïve patients with type 1 Gaucher disease, 6 to 62years of age, enrolled in phase 3 clinical trials. After 4years of ERT, therapeutic goals for thrombocytopenia and splenomegaly had been achieved in 100% of patients; goals for anemia and hepatomegaly had been achieved in 95% and 94% of patients, respectively. Consistent with the goal for bone mineral density, lumbar spine bone density improved in 87% of patients ≥18years of age. At year 4, compared with clinical ranges for healthy individuals, 86% of patients with a low baseline hemoglobin concentration had normalized, 60% with a low baseline platelet count had normalized, 67% with baseline splenomegaly had normalized, 58% with hepatomegaly had normalized, and lumbar spine bone density had normalized in 53% of adults. The decade-old therapeutic goals do not reflect the potential for normalization of clinical parameters in ERT-treated patients. Goals consistent with normalization or near-normalization should be considered. ClinicalTrials.gov identifiers: NCT00430625, NCT00553631, NCT00635427. Copyright © 2016 Shire Human Genetic Therapies, Inc. Published by Elsevier Inc. All rights reserved.

Optimizing human factors in dentistry

PubMed Central

Gupta, Arpit; Ankola, Anil V.; Hebbal, Mamata

2013-01-01

Occupational health hazards among dental professionals are on a continuous rise and they have a significant negative overall impact on daily life. This review is intended to provide the information regarding risk factors and to highlight the prevention strategies for optimizing human factors in dentistry. Risk factors among dentists are multifactorial, which can be categorized into biomechanical and psychosocial. To achieve a realistic target of safety and health at work, prevention is clearly the best approach; therefore, musculoskeletal disorders can be reduced through proper positioning of dental worker and patient, regular rest breaks, general good health, using ergonomic equipment, and exercises designed to counteract the particular risk factors for the dental occupation. However, substantial evidences are still required to elucidate the potential risk factors and to formulate effective prevention programs. PMID:23946745

Optimizing human factors in dentistry.

PubMed

Gupta, Arpit; Ankola, Anil V; Hebbal, Mamata

2013-03-01

Occupational health hazards among dental professionals are on a continuous rise and they have a significant negative overall impact on daily life. This review is intended to provide the information regarding risk factors and to highlight the prevention strategies for optimizing human factors in dentistry. Risk factors among dentists are multifactorial, which can be categorized into biomechanical and psychosocial. To achieve a realistic target of safety and health at work, prevention is clearly the best approach; therefore, musculoskeletal disorders can be reduced through proper positioning of dental worker and patient, regular rest breaks, general good health, using ergonomic equipment, and exercises designed to counteract the particular risk factors for the dental occupation. However, substantial evidences are still required to elucidate the potential risk factors and to formulate effective prevention programs.

Treatment Optimization Using Computed Tomography-Delineated Targets Should be Used for Supraclavicular Irradiation for Breast Cancer

DOE Office of Scientific and Technical Information (OSTI.GOV)

Liengsawangwong, Raweewan; Yu, T.-K.; Sun, T.-L.

2007-11-01

Background: The purpose of this study was to determine whether the use of optimized CT treatment planning offered better coverage of axillary level III (LIII)/supraclavicular (SC) targets than the empirically derived dose prescription that are commonly used. Materials/Methods: Thirty-two consecutive breast cancer patients who underwent CT treatment planning of a SC field were evaluated. Each patient was categorized according to body mass index (BMI) classes: normal, overweight, or obese. The SC and LIII nodal beds were contoured, and four treatment plans for each patient were generated. Three of the plans used empiric dose prescriptions, and these were compared with amore » CT-optimized plan. Each plan was evaluated by two criteria: whether 98% of target volume receive >90% of prescribed dose and whether < 5% of the irradiated volume received 105% of prescribed dose. Results: The mean depth of SC and LIII were 3.2 cm (range, 1.4-6.7 cm) and 3.1 (range, 1.7-5.8 cm). The depth of these targets varied according across BMI classes (p = 0.01). Among the four sets of plans, the CT-optimized plans were the most successful at achieving both of the dosimetry objectives for every BMI class (normal BMI, p = .003; overweight BMI, p < .0001; obese BMI, p < .001). Conclusions: Across all BMI classes, routine radiation prescriptions did not optimally cover intended targets for every patient. Optimized CT-based treatment planning generated the most successful plans; therefore, we recommend the use of routine CT simulation and treatment planning of SC fields in breast cancer.« less

Finding common ground to achieve a “good death”: family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study

PubMed Central

2013-01-01

Background Substitute decision-makers are integral to the care of dying patients and make many healthcare decisions for patients. Unfortunately, conflict between physicians and surrogate decision-makers is not uncommon in end-of-life care and this could contribute to a “bad death” experience for the patient and family. We aim to describe Canadian family physicians’ experiences of conflict with substitute decision-makers of dying patients to identify factors that may facilitate or hinder the end-of-life decision-making process. This insight will help determine how to best manage these complex situations, ultimately improving the overall care of dying patients. Methods Grounded Theory methodology was used with semi-structured interviews of family physicians in Edmonton, Canada, who experienced conflict with substitute decision-makers of dying patients. Purposeful sampling included maximum variation and theoretical sampling strategies. Interviews were audio-taped, and transcribed verbatim. Transcripts, field notes and memos were coded using the constant-comparative method to identify key concepts until saturation was achieved and a theoretical framework emerged. Results Eleven family physicians with a range of 3 to 40 years in clinical practice participated. The family physicians expressed a desire to achieve a “good death” and described their role in positively influencing the experience of death. Finding Common Ground to Achieve a “Good Death” for the Patient emerged as an important process which includes 1) Building Mutual Trust and Rapport through identifying key players and delivering manageable amounts of information, 2) Understanding One Another through active listening and ultimately, and 3) Making Informed, Shared Decisions. Facilitators and barriers to achieving Common Ground were identified. Barriers were linked to conflict. The inability to resolve an overt conflict may lead to an impasse at any point. A process for Resolving an Impasse is

Optimization of Composite Material System and Lay-up to Achieve Minimum Weight Pressure Vessel

NASA Astrophysics Data System (ADS)

Mian, Haris Hameed; Wang, Gang; Dar, Uzair Ahmed; Zhang, Weihong

2013-10-01

The use of composite pressure vessels particularly in the aerospace industry is escalating rapidly because of their superiority in directional strength and colossal weight advantage. The present work elucidates the procedure to optimize the lay-up for composite pressure vessel using finite element analysis and calculate the relative weight saving compared with the reference metallic pressure vessel. The determination of proper fiber orientation and laminate thickness is very important to decrease manufacturing difficulties and increase structural efficiency. In the present work different lay-up sequences for laminates including, cross-ply [ 0 m /90 n ] s , angle-ply [ ±θ] ns , [ 90/±θ] ns and [ 0/±θ] ns , are analyzed. The lay-up sequence, orientation and laminate thickness (number of layers) are optimized for three candidate composite materials S-glass/epoxy, Kevlar/epoxy and Carbon/epoxy. Finite element analysis of composite pressure vessel is performed by using commercial finite element code ANSYS and utilizing the capabilities of ANSYS Parametric Design Language and Design Optimization module to automate the process of optimization. For verification, a code is developed in MATLAB based on classical lamination theory; incorporating Tsai-Wu failure criterion for first-ply failure (FPF). The results of the MATLAB code shows its effectiveness in theoretical prediction of first-ply failure strengths of laminated composite pressure vessels and close agreement with the FEA results. The optimization results shows that for all the composite material systems considered, the angle-ply [ ±θ] ns is the optimum lay-up. For given fixed ply thickness the total thickness of laminate is obtained resulting in factor of safety slightly higher than two. Both Carbon/epoxy and Kevlar/Epoxy resulted in approximately same laminate thickness and considerable percentage of weight saving, but S-glass/epoxy resulted in weight increment.

Patient Navigators: Agents of Creating Community-Nested Patient-Centered Medical Homes for Cancer Care

PubMed Central

Simon, Melissa A.; Samaras, Athena T.; Nonzee, Narissa J.; Hajjar, Nadia; Frankovich, Carmi; Bularzik, Charito; Murphy, Kara; Endress, Richard; Tom, Laura S.; Dong, XinQi

2016-01-01

Patient navigation is an internationally utilized, culturally grounded, and multifaceted strategy to optimize patients’ interface with the health-care team and system. The DuPage County Patient Navigation Collaborative (DPNC) is a campus–community partnership designed to improve access to care among uninsured breast and cervical cancer patients in DuPage County, IL. Importantly, the DPNC connects community-based social service delivery with the patient-centered medical home to achieve a community-nested patient-centered medical home model for cancer care. While the patient navigator experience has been qualitatively documented, the literature pertaining to patient navigation has largely focused on efficacy outcomes and program cost effectiveness. Here, we uniquely highlight stories of women enrolled in the DPNC, told from the perspective of patient navigators, to shed light on the myriad barriers that DPNC patients faced and document the strategies DPNC patient navigators implemented. PMID:27594792

Optimizing fluid management in patients with acute decompensated heart failure (ADHF): the emerging role of combined measurement of body hydration status and brain natriuretic peptide (BNP) levels.

PubMed

Valle, Roberto; Aspromonte, Nadia; Milani, Loredano; Peacock, Frank W; Maisel, Alan S; Santini, Massimo; Ronco, Claudio

2011-11-01

The study tests the hypothesis that in patients admitted with acutely decompensated heart failure (ADHF), achievement of adequate body hydration status with intensive medical therapy, modulated by combined bioelectrical vectorial impedance analysis (BIVA) and B-type natriuretic peptide (BNP) measurement, may contribute to optimize the timing of patient's discharge and to improve clinical outcomes. Three hundred patients admitted for ADHF underwent serial BIVA and BNP measurement. Therapy was titrated to reach a BNP value of <250 pg/ml, whenever possible. Patients were categorized as early responders (rapid BNP fall below 250 pg/ml); late responders (slow BNP fall below 250 pg/ml, after aggressive therapy); and non-responders (BNP persistently >250 pg/ml). Worsening of renal function (WRF) was evaluated during hospitalization. Death and rehospitalization were monitored with a 6-month follow-up. BNP value on discharge of ≤250 pg/ml led to a 25% event rate within 6 months (Group A: 17.4%; Group B: 21%, Chi2; n.s.), whereas a value >250 pg/ml (Group C) was associated with a far higher percentage (37%). At discharge, body hydration was 73.8 ± 3.2% in the total population and 73.2 ± 2.1, 73.5 ± 2.8, 74.1 ± 3.6% in the three groups, respectively. WRF was observed in 22.3% of the total. WRF occurred in 22% in Group A, 32% in Group B, and 20% in Group C (P = n.s.). Our study confirms the hypothesis that combined BNP/BIVA sequential measurements help to achieve adequate fluid balance status in patients with ADHF and can be used to drive a "tailored therapy," allowing clinicians to identify high-risk patients and possibly to reduce the incidence of complications secondary to fluid management strategies.

Organizational transformation: a model for joint optimization of culture change and evidence-based design.

PubMed

Hamilton, D Kirk; Orr, Robin Diane; Raboin, W Ellen

2008-01-01

Healthcare organizations face continuous and accelerating external change and thus must be prepared to manage their own change initiatives proactively. Given that many believe that the U.S. healthcare system is broken and most healthcare organizations are dealing with pervasive problems, some organizations may choose to seek transformational change to achieve the six aims identified by the Institute of Medicine: healthcare that is safe, effective, patient-centered, timely, efficient, and equitable. Transformational change will almost certainly involve organizational culture. Culture change may be most effective when linked to other organizational change initiatives such as organizational strategy, structure, policies, procedures, and recruiting. Significant organizational change often requires accompanying facility change. There is an interdependent relationship between facility design and organizational culture. They affect each other and both impact organizational performance. Sociotechnical theory promotes joint optimization of the social (culture) and technical (facilities) aspects of an organization to achieve sustained positive change. To achieve organizational transformation and to sustain positive change, organizations must be prepared to adopt collaborative efforts in culture change and facility design. The authors propose a model for accomplishing joint optimization of culture change and evidence-based facility design.

Configuration optimization and experimental accuracy evaluation of a bone-attached, parallel robot for skull surgery.

PubMed

Kobler, Jan-Philipp; Nuelle, Kathrin; Lexow, G Jakob; Rau, Thomas S; Majdani, Omid; Kahrs, Lueder A; Kotlarski, Jens; Ortmaier, Tobias

2016-03-01

Minimally invasive cochlear implantation is a novel surgical technique which requires highly accurate guidance of a drilling tool along a trajectory from the mastoid surface toward the basal turn of the cochlea. The authors propose a passive, reconfigurable, parallel robot which can be directly attached to bone anchors implanted in a patient's skull, avoiding the need for surgical tracking systems. Prior to clinical trials, methods are necessary to patient specifically optimize the configuration of the mechanism with respect to accuracy and stability. Furthermore, the achievable accuracy has to be determined experimentally. A comprehensive error model of the proposed mechanism is established, taking into account all relevant error sources identified in previous studies. Two optimization criteria to exploit the given task redundancy and reconfigurability of the passive robot are derived from the model. The achievable accuracy of the optimized robot configurations is first estimated with the help of a Monte Carlo simulation approach and finally evaluated in drilling experiments using synthetic temporal bone specimen. Experimental results demonstrate that the bone-attached mechanism exhibits a mean targeting accuracy of [Formula: see text] mm under realistic conditions. A systematic targeting error is observed, which indicates that accurate identification of the passive robot's kinematic parameters could further reduce deviations from planned drill trajectories. The accuracy of the proposed mechanism demonstrates its suitability for minimally invasive cochlear implantation. Future work will focus on further evaluation experiments on temporal bone specimen.

Patients' Perceptions of the Causes of Their Success and Lack of Success in Achieving Their Potential in Spinal Cord Rehabilitation

ERIC Educational Resources Information Center

Belciug, Marian P.

2012-01-01

The objective of this study was to examine the patients' perception of the causes of their success and lack of success in achieving their potential in rehabilitation and their emotional reactions to the outcome of their rehabilitation. Thirty-five patients with spinal cord injury who were participating in the Rehabilitation Program at Hamilton…

Blast optimization for improved dragline productivity

DOE Office of Scientific and Technical Information (OSTI.GOV)

Humphreys, M.; Baldwin, G.

1994-12-31

A project aimed at blast optimization for large open pit coal mines is utilizing blast monitoring and analysis techniques, advanced dragline monitoring equipment, and blast simulation software, to assess the major controlling factors affecting both blast performance and subsequent dragline productivity. This has involved collaborative work between the explosives supplier, mine operator, monitoring equipment manufacturer, and a mining research organization. The results from trial blasts and subsequently monitored dragline production have yielded promising results and continuing studies are being conducted as part of a blast optimization program. It should be stressed that the optimization of blasting practices for improved draglinemore » productivity is a site specific task, achieved through controlled and closely monitored procedures. The benefits achieved at one location can not be simply transferred to another minesite unless similar improvement strategies are first implemented.« less

Optimized Orthovoltage Stereotactic Radiosurgery

NASA Astrophysics Data System (ADS)

Fagerstrom, Jessica M.

Because of its ability to treat intracranial targets effectively and noninvasively, stereotactic radiosurgery (SRS) is a prevalent treatment modality in modern radiation therapy. This work focused on SRS delivering rectangular function dose distributions, which are desirable for some targets such as those with functional tissue included within the target volume. In order to achieve such distributions, this work used fluence modulation and energies lower than those utilized in conventional SRS. In this work, the relationship between prescription isodose and dose gradients was examined for standard, unmodulated orthovoltage SRS dose distributions. Monte Carlo-generated energy deposition kernels were used to calculate 4pi, isocentric dose distributions for a polyenergetic orthovoltage spectrum, as well as monoenergetic orthovoltage beams. The relationship between dose gradients and prescription isodose was found to be field size and energy dependent, and values were found for prescription isodose that optimize dose gradients. Next, a pencil-beam model was used with a Genetic Algorithm search heuristic to optimize the spatial distribution of added tungsten filtration within apertures of cone collimators in a moderately filtered 250 kVp beam. Four cone sizes at three depths were examined with a Monte Carlo model to determine the effects of the optimized modulation compared to open cones, and the simulations found that the optimized cones were able to achieve both improved penumbra and flatness statistics at depth compared to the open cones. Prototypes of the filter designs calculated using mathematical optimization techniques and Monte Carlo simulations were then manufactured and inserted into custom built orthovoltage SRS cone collimators. A positioning system built in-house was used to place the collimator and filter assemblies temporarily in the 250 kVp beam line. Measurements were performed in water using radiochromic film scanned with both a standard white light

Optimal correction and design parameter search by modern methods of rigorous global optimization

NASA Astrophysics Data System (ADS)

Makino, K.; Berz, M.

2011-07-01

Frequently the design of schemes for correction of aberrations or the determination of possible operating ranges for beamlines and cells in synchrotrons exhibit multitudes of possibilities for their correction, usually appearing in disconnected regions of parameter space which cannot be directly qualified by analytical means. In such cases, frequently an abundance of optimization runs are carried out, each of which determines a local minimum depending on the specific chosen initial conditions. Practical solutions are then obtained through an often extended interplay of experienced manual adjustment of certain suitable parameters and local searches by varying other parameters. However, in a formal sense this problem can be viewed as a global optimization problem, i.e. the determination of all solutions within a certain range of parameters that lead to a specific optimum. For example, it may be of interest to find all possible settings of multiple quadrupoles that can achieve imaging; or to find ahead of time all possible settings that achieve a particular tune; or to find all possible manners to adjust nonlinear parameters to achieve correction of high order aberrations. These tasks can easily be phrased in terms of such an optimization problem; but while mathematically this formulation is often straightforward, it has been common belief that it is of limited practical value since the resulting optimization problem cannot usually be solved. However, recent significant advances in modern methods of rigorous global optimization make these methods feasible for optics design for the first time. The key ideas of the method lie in an interplay of rigorous local underestimators of the objective functions, and by using the underestimators to rigorously iteratively eliminate regions that lie above already known upper bounds of the minima, in what is commonly known as a branch-and-bound approach. Recent enhancements of the Differential Algebraic methods used in particle

HIV-infected patients receiving lopinavir/ritonavir-based antiretroviral therapy achieve high rates of virologic suppression despite adherence rates less than 95%.

PubMed

Shuter, Jonathan; Sarlo, Julie A; Kanmaz, Tina J; Rode, Richard A; Zingman, Barry S

2007-05-01

The observation that extremely high levels of medication adherence are required to achieve complete virologic suppression is based largely on studies of treatment-experienced patients receiving HIV protease inhibitor (PI)-based therapy without ritonavir boosting. This study aims to define the level of adherence needed to achieve virologic suppression in patients receiving boosted PI-based highly active antiretroviral therapy (HAART) with lopinavir/ritonavir. HIV-infected adults receiving a regimen containing lopinavir/ritonavir were recruited into a prospective, observational study of the relation between adherence to lopinavir/ritonavir and virologic outcomes. Adherence was measured using the Medication Event Monitoring System (MEMS; Aardex, Union City, CA). HIV-1 viral load (VL) was measured at week 24. The final study population contained 64 subjects. Eighty percent had AIDS, 97% received lopinavir/ritonavir before enrollment, and most had more than 7 years of HAART experience. Mean adherence overall was 73%. Eighty percent and 59% achieved a VL <400 copies/mL and a VL <75 copies/mL, respectively. Mean adherence was 75% in those achieving a VL <75 copies/mL. High rates of virologic suppression were observed in all adherence quartiles, including the lowest quartile (range of adherence: 23.5%-53.3%). Moderate levels of adherence can lead to virologic suppression in most patients taking lopinavir/ritonavir-based HAART.

Achieving health care cost containment through provider payment reform that engages patients and providers.

PubMed

Ginsburg, Paul B

2013-05-01

The best opportunity to pursue cost containment in the next five to ten years is through reforming provider payment to gradually diminish the role of fee-for-service reimbursement. Public and private payers have launched many promising payment reform pilots aimed at blending fee-for-service with payment approaches based on broader units of care, such as an episode or patients' total needs over a period of time, a crucial first step. But meaningful cost containment from payment reform will not be achieved until Medicare and Medicaid establish stronger incentives for providers to contract in this way, with discouragement of nonparticipation increasing over time. In addition, the models need to evolve to engage beneficiaries, perhaps through incentives for patients to enroll in an accountable care organization and to seek care within that organization's network of providers.

Design and methodology of the COACH-2 (Comparative study on guideline adherence and patient compliance in heart failure patients) study: HF clinics versus primary care in stable patients on optimal therapy.

PubMed

Luttik, M L A; Brons, M; Jaarsma, T; Hillege, H L; Hoes, A; de Jong, R; Linssen, G; Lok, D J; Berger, M; van Veldhuisen, D J

2012-08-01

Since the number of heart failure (HF) patients is still growing and long-term treatment of HF patients is necessary, it is important to initiate effective ways for structural involvement of primary care services in HF management programs. However, evidence on whether and when patients can be referred back to be managed in primary care is lacking. To determine whether long-term patient management in primary care, after initial optimisation of pharmacological and non-pharmacological treatment in a specialised HF clinic, is equally effective as long-term management in a specialised HF clinic in terms of guideline adherence and patient compliance. The study is designed as a randomised, controlled, non-inferiority trial. Two-hundred patients will be randomly assigned to be managed and followed in primary care or in a HFclinic. Patients are eligible to participate if they are (1) clinically stable, (2) optimally up-titrated on medication (according to ESC guidelines) and, (3) have received optimal education and counselling on pre-specified issues regarding HF and its treatment. Furthermore, close cooperation between secondary and primary care in terms of back referral to or consultation of the HF clinic will be provided.The primary outcome will be prescriber adherence and patient compliance with medication after 12 months. Secondary outcomes measures will be readmission rate, mortality, quality of life and patient compliance with other lifestyle changes. The results of the study will add to the understanding of the role of primary care and HF clinics in the long-term follow-up of HF patients.

Improving Rural Cancer Patients' Outcomes: A Group-Randomized Trial

ERIC Educational Resources Information Center

Elliott, Thomas E.; Elliott, Barbara A.; Regal, Ronald R.; Renier, Colleen M.; Haller, Irina V.; Crouse, Byron J.; Witrak, Martha T.; Jensen, Patricia B.

2004-01-01

Significant barriers exist in the delivery of state-of-the-art cancer care to rural populations. Rural providers' knowledge and practices, their rural health care delivery systems, and linkages to cancer specialists are not optimal; therefore, rural cancer patient outcomes are less than achievable. Purpose: To test the effects of a strategy…

Optimal reconstruction interval in dual source CT coronary angiography: a single-center experience in 285 patients

PubMed Central

Akgöz, Ayça; Akata, Deniz; Hazırolan, Tuncay; Karçaaltıncaba, Muşturay

2014-01-01

PURPOSE We aimed to evaluate the visibility of coronary arteries and bypass-grafts in patients who underwent dual source computed tomography (DSCT) angiography without heart rate (HR) control and to determine optimal intervals for image reconstruction. MATERIALS AND METHODS A total of 285 consecutive cases who underwent coronary (n=255) and bypass-graft (n=30) DSCT angiography at our institution were identified retrospectively. Patients with atrial fibrillation were excluded. Ten datasets in 10% increments were reconstructed in all patients. On each dataset, the visibility of coronary arteries was evaluated using the 15-segment American Heart Association classification by two radiologists in consensus. RESULTS Mean HR was 76±16.3 bpm, (range, 46–127 bpm). All coronary segments could be visualized in 277 patients (97.19%). On a segment-basis, 4265 of 4275 (99.77%) coronary artery segments were visible. All segments of 56 bypass-grafts in 30 patients were visible (100%). Total mean segment visibility scores of all coronary arteries were highest at 70%, 40%, and 30% intervals for all HRs. The optimal reconstruction intervals to visualize the segments of all three coronary arteries in descending order were 70%, 60%, 80%, and 30% intervals in patients with a mean HR <70 bpm; 40%, 70%, and 30% intervals in patients with a mean HR 70–100 bpm; and 40%, 50%, and 30% in patients with a mean HR >100 bpm. CONCLUSION Without beta-blocker administration, DSCT coronary angiography offers excellent visibility of vascular segments using both end-systolic and mid-late diastolic reconstructions at HRs up to 100 bpm, and only end-systolic reconstructions at HRs over 100 bpm. PMID:24834490

The Medication Optimization Value Proposition: Aligning Teams and Education to Improve Care.

PubMed

Easter, Jon C; DeWalt, Darren A

2017-01-01

United States health care lags behind other countries in quality and cost. The present health care system is unsustainable, and there is now a quick movement toward value-based care. This article lays out essential care delivery elements, and makes the case for medication optimization to enable new value-based models. Success factors include enhancing team-based care and interdisciplinary education to achieve patient-centered care. ©2017 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.

Strategy to Achieve Highly Porous/Biocompatible Macroscale Cell Blocks, Using a Collagen/Genipin-bioink and an Optimal 3D Printing Process.

PubMed

Kim, Yong Bok; Lee, Hyeongjin; Kim, Geun Hyung

2016-11-30

Recently, a three-dimensional (3D) bioprinting process for obtaining a cell-laden structure has been widely applied because of its ability to fabricate biomimetic complex structures embedded with and without cells. To successfully obtain a cell-laden porous block, the cell-delivering vehicle, bioink, is one of the significant factors. Until now, various biocompatible hydrogels (synthetic and natural biopolymers) have been utilized in the cell-printing process, but a bioink satisfying both biocompatibility and print-ability requirements to achieve a porous structure with reasonable mechanical strength has not been issued. Here, we propose a printing strategy with optimal conditions including a safe cross-linking procedure for obtaining a 3D porous cell block composed of a biocompatible collagen-bioink and genipin, a cross-linking agent. To obtain the optimal processing conditions, we modified the 3D printing machine and selected an optimal cross-linking condition (∼1 mM and 1 h) of genipin solution. To show the feasibility of the process, 3D pore-interconnected cell-laden constructs were manufactured using osteoblast-like cells (MG63) and human adipose stem cells (hASCs). Under these processing conditions, a macroscale 3D collagen-based cell block of 21 × 21 × 12 mm 3 and over 95% cell viability was obtained. In vitro biological testing of the cell-laden 3D porous structure showed that the embedded cells were sufficiently viable, and their proliferation was significantly higher; the cells also exhibited increased osteogenic activities compared to the conventional alginate-based bioink (control). The results indicated the fabrication process using the collagen-bioink would be an innovative platform to design highly biocompatible and mechanically stable cell blocks.

Optimization of a Tube Hydroforming Process

NASA Astrophysics Data System (ADS)

Abedrabbo, Nader; Zafar, Naeem; Averill, Ron; Pourboghrat, Farhang; Sidhu, Ranny

2004-06-01

An approach is presented to optimize a tube hydroforming process using a Genetic Algorithm (GA) search method. The goal of the study is to maximize formability by identifying the optimal internal hydraulic pressure and feed rate while satisfying the forming limit diagram (FLD). The optimization software HEEDS is used in combination with the nonlinear structural finite element code LS-DYNA to carry out the investigation. In particular, a sub-region of a circular tube blank is formed into a square die. Compared to the best results of a manual optimization procedure, a 55% increase in expansion was achieved when using the pressure and feed profiles identified by the automated optimization procedure.

Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project.

PubMed

De Smedt, Delphine; Kotseva, Kornelia; De Bacquer, Dirk; Wood, David; De Backer, Guy; Dallongeville, Jean; Seppo, Lehto; Pajak, Andrzej; Reiner, Zeljko; Vanuzzo, Diego; Georgiev, Borislav; Gotcheva, Nina; Annemans, Lieven

2012-11-01

The EUROASPIRE III survey indicated that the guidelines on cardiovascular disease prevention are poorly implemented in patients with established coronary heart disease (CHD). The purpose of this health economic project was to assess the potential clinical effectiveness and cost-effectiveness of optimizing cardiovascular prevention in eight EUROASPIRE III countries (Belgium, Bulgaria, Croatia, Finland, France, Italy, Poland, and the U.K.). METHODS AND RESULTS The individual risk for subsequent cardiovascular events was estimated, based on published Framingham equations. Based on the EUROASPIRE III data, the type of suboptimal prevention, if any, was identified for each individual, and the effects of optimized tailored prevention (smoking cessation, diet and exercise, better management of elevated blood pressure and/or LDL-cholesterol) were estimated. Costs of prevention and savings of avoided events were based on country-specific data. A willingness to pay threshold of €30,000/quality-adjusted life year (QALY) was used. The robustness of the results was validated by sensitivity analyses. Overall, the cost-effectiveness analyses for the eight countries showed mainly favourable results with an average incremental cost-effectiveness ratio (ICER) of €12,484 per QALY. Only in the minority of patients at the lowest risk for recurrent events, intensifying preventive therapy seems not cost-effective. Also, the single impact of intensified cholesterol control seems less cost-effective, possibly because their initial 2-year risk was already fairly low, hence the room for improvement is rather limited. These results underscore the societal value of optimizing prevention in most patients with established CHD, but also highlight the need for setting priorities towards patients more at risk and the need for more studies comparing intensified prevention with usual care in these patients.

The Optimal Dose of Nicardipine for Enhancement of Indirect Portography

DOE Office of Scientific and Technical Information (OSTI.GOV)

Inoue, Yutaka; Nakamura, Hironobu; Akaji, Hideyo

1998-01-15

Purpose: To determine the optimal dose of nicardipine (NCR) for enhancement of indirect portography. Methods: Forty-eight patients underwent conventional film indirect portography via the superior mesenteric artery (SMA) first without and then with preinjection of 1/64-2 mg of NCR into the SMA. Results: NCR (1/8-2 mg) shortened the arterial phase to 50% and the portal appearance time to 60% of control without reflux of contrast medium into the aorta. Portal enhancement was excellent at doses of 1/32 mg or more. Blood pressures and pulse rate showed no significant change at 1/4 mg or less. Conclusion: NCR (1/8-1/4 mg) into themore » SMA is the optimal dose for achieving sufficient contrast enhancement on indirect portography while reducing the transit time of contrast medium and minimizing effects on the systemic circulation.« less

Penile fracture: preoperative evaluation and surgical technique for optimal patient outcome.

PubMed

Kamdar, Ciamack; Mooppan, Unni M M; Kim, Hong; Gulmi, Frederick A

2008-12-01

To review the preoperative diagnostic evaluation and surgical treatment of penile fracture, as the condition is a urological emergency that requires immediate surgical exploration and repair. Between January 2003 and October 2007 eight patients presented to the emergency department with penile fracture after sexual intercourse. The clinical presentation, preoperative evaluation and imaging, surgical technique, and postoperative care were assessed to determine the optimal patient outcome. Seven of the eight patients were treated surgically and one refused surgical intervention. Four cases involved unilateral corporal injury, two involved unilateral corporal injury with an associated urethral injury, and one involved bilateral corporal injury with an associated urethral injury. Although retrograde urethrogram were taken of all three urethral injuries, none of them revealed the injury. Diagnostic cavernosography or magnetic resonance imaging were not used in any of the patients. No complications occurred in the patients treated surgically. Preoperative imaging should not delay surgical repair. If an associated urethral injury is suspected, flexible cystoscopy is recommended in the operating room, as opposed to a retrograde urethrogram. A subcoronal circumcising incision is recommended to deglove the entire penile shaft and have complete access to all three corporal bodies, as well as the neurovascular bundle. Saline mixed with indigo carmine can be injected both into the corpora cavernosum or corpus spongiosum via the glans penis, after a tourniquet is placed at the base of the penis, to evaluate the surgical repair and to determine if there are any missed injuries.

Improving scanner wafer alignment performance by target optimization

NASA Astrophysics Data System (ADS)

Leray, Philippe; Jehoul, Christiane; Socha, Robert; Menchtchikov, Boris; Raghunathan, Sudhar; Kent, Eric; Schoonewelle, Hielke; Tinnemans, Patrick; Tuffy, Paul; Belen, Jun; Wise, Rich

2016-03-01

In the process nodes of 10nm and below, the patterning complexity along with the processing and materials required has resulted in a need to optimize alignment targets in order to achieve the required precision, accuracy and throughput performance. Recent industry publications on the metrology target optimization process have shown a move from the expensive and time consuming empirical methodologies, towards a faster computational approach. ASML's Design for Control (D4C) application, which is currently used to optimize YieldStar diffraction based overlay (DBO) metrology targets, has been extended to support the optimization of scanner wafer alignment targets. This allows the necessary process information and design methodology, used for DBO target designs, to be leveraged for the optimization of alignment targets. In this paper, we show how we applied this computational approach to wafer alignment target design. We verify the correlation between predictions and measurements for the key alignment performance metrics and finally show the potential alignment and overlay performance improvements that an optimized alignment target could achieve.

[Knowing the patient's representations in order to optimize the educational project].

PubMed

Robin-Quach, Patricia

2009-09-01

To determine if this educational care meets the needs of the patients. To show that to know the representations made by the patient on his disease, his health and on his educational needs allows to define with him a programme of adapted accompaniment and to reduce the risk of ineffective care of his therapeutic programme. 7 interviews of patients were carried out before their integration in an educational process, in three different medico-surgical specialities, with the condition that the latter offer to the patients a formalized educational process. An interview of each of the 3 people in charge or referent of the educational unit was also carried out to understand the educational care proposed to the patients. The grid of interview of the patient used original techniques of expression, and aimed at investigating the representations of the patient on his disease, his health and his educational needs. The 3 services in which the interviews of the patients took place present 3 different educational structures of care: the first one has a profile of "psycho-pedagogical" educational care, the second, a profile of "psychological" type and the third, a profile of "educational" type. They thus propose different tools of educational care. The exploration of the representations of the patients shows that the latter have a groundless vision of the disease and of health within our hospitals which are "health promoters" today. Their educational needs are finally very far from their pathology, and thus from the medical field. They both take root in their personality and in society. Consequently, the 3 aforesaid educational structures are only very partially adapted to the needs of the patients. The educational optimal care of the patient can only be realized "tailor-made" to every patient, in a relation of collaboration between the health professionals and the patients. Finally, it must come largely outside the hospital. The educational care of the patient turns out much

Educational achievement in Swiss childhood cancer survivors compared with the general population.

PubMed

Kuehni, Claudia E; Strippoli, Marie-Pierre F; Rueegg, Corina S; Rebholz, Cornelia E; Bergstraesser, Eva; Grotzer, Michael; von der Weid, Nicolas X; Michel, Gisela

2012-03-01

The objective of this study was to describe educational achievements of childhood cancer survivors in Switzerland compared with the general population. In particular, the authors investigated educational problems during childhood, final educational achievement in adulthood, and its predictors. Childhood cancer survivors who were aged <16 years at diagnosis from 1976 to 2003 who had survived for ≥5 years and were currently ages 20 to 40 years received a postal questionnaire during 2007 to 2009. Controls were respondents of the Swiss Health Survey ages 20 to 40 years. Educational achievement included compulsory schooling, vocational training, upper secondary schooling, and university degree. The analysis was weighted to optimize comparability of the populations. The authors analyzed the association between demographic and clinical predictors and educational achievement using multivariable logistic regression. Subgroup analyses focused on survivors aged ≥27 years. One-third of survivors encountered educational problems during schooling (30% repeated 1 year, and 35% received supportive tutoring). In the total sample, more survivors than controls achieved compulsory schooling only (8.7% vs 5.2%) and fewer acquired a university degree (7.3% vs 11%), but more survivors than controls achieved an upper secondary education (36.1 vs 24.1%). In those aged ≥27 years, differences in compulsory schooling and university education largely disappeared. In survivors and controls, sex, nationality, language region, and migration background were strong predictors of achievement. Survivors of central nervous system tumors or those who had a relapse had poorer outcomes (P < .05). Childhood cancer survivors encountered problems during schooling and completed professional education with some delay. However, with the exception of patients who had central nervous system tumors and those who experienced a relapse, the final educational achievement in survivors of child cancer was

Pain in children--are we accomplishing the optimal pain treatment?

PubMed

Lundeberg, Stefan

2015-01-01

Morphine, paracetamol and local anesthetics have for a long time been the foremost used analgesics in the pediatric patient by tradition but not always enough effective and associated with side effects. The purpose with this article is to propose alternative approaches in pain management, not always supported up by substantial scientific work but from a combination of science and clinical experience in the field. The scientific literature has been reviewed in parts regarding different aspects of pain assessment and analgesics used for treatment of diverse pain conditions with focus on procedural and acute pain. Clinical experience has been added to form the suggested improvements in accomplishing an improved pain management in pediatric patients. The aim with pain management in children should be a tailored analgesic medication with an individual acceptable pain level and optimal degree of mobilization with as little side effects as possible. Simple techniques of pain control are as effective as and complex techniques in pediatrics but the technique used is not of the highest importance in achieving a good pain management. Increased interest and improved education of the doctors prescribing analgesics is important in accomplishing a better pain management. The optimal treatment with analgesics is depending on the analysis of pain origin and analgesics used should be adjusted thereafter. A multimodal treatment regime is advocated for optimal analgesic effect. © 2014 John Wiley & Sons Ltd.

Aerodynamic design and optimization in one shot

NASA Technical Reports Server (NTRS)

Ta'asan, Shlomo; Kuruvila, G.; Salas, M. D.

1992-01-01

This paper describes an efficient numerical approach for the design and optimization of aerodynamic bodies. As in classical optimal control methods, the present approach introduces a cost function and a costate variable (Lagrange multiplier) in order to achieve a minimum. High efficiency is achieved by using a multigrid technique to solve for all the unknowns simultaneously, but restricting work on a design variable only to grids on which their changes produce nonsmooth perturbations. Thus, the effort required to evaluate design variables that have nonlocal effects on the solution is confined to the coarse grids. However, if a variable has a nonsmooth local effect on the solution in some neighborhood, it is relaxed in that neighborhood on finer grids. The cost of solving the optimal control problem is shown to be approximately two to three times the cost of the equivalent analysis problem. Examples are presented to illustrate the application of the method to aerodynamic design and constraint optimization.

Optimization of pelvic heating rate distributions with electromagnetic phased arrays.

PubMed

Paulsen, K D; Geimer, S; Tang, J; Boyse, W E

1999-01-01

Deep heating of pelvic tumours with electromagnetic phased arrays has recently been reported to improve local tumour control when combined with radiotherapy in a randomized clinical trial despite the fact that rather modest elevations in tumour temperatures were achieved. It is reasonable to surmise that improvements in temperature elevation could lead to even better tumour response rates, motivating studies which attempt to explore the parameter space associated with heating rate delivery in the pelvis. Computational models which are based on detailed three-dimensional patient anatomy are readily available and lend themselves to this type of investigation. In this paper, volume average SAR is optimized in a predefined target volume subject to a maximum allowable volume average SAR outside this zone. Variables under study include the position of the target zone, the number and distribution of radiators and the applicator operating frequency. The results show a clear preference for increasing frequency beyond 100 MHz, which is typically applied clinically, especially as the number of antennae increases. Increasing both the number of antennae per circumferential distance around the patient, as well as the number of independently functioning antenna bands along the patient length, is important in this regard, although improvements were found to be more significant with increasing circumferential antenna density. However, there is considerable site specific variation and cases occur where lower numbers of antennae spread out over multiple longitudinal bands are more advantageous. The results presented here have been normalized relative to an optimized set of antenna array amplitudes and phases operating at 100 MHz which is a common clinical configuration. The intent is to provide some indications of avenues for improving the heating rate distributions achievable with current technology.

Optimal control of complex atomic quantum systems

PubMed Central

van Frank, S.; Bonneau, M.; Schmiedmayer, J.; Hild, S.; Gross, C.; Cheneau, M.; Bloch, I.; Pichler, T.; Negretti, A.; Calarco, T.; Montangero, S.

2016-01-01

Quantum technologies will ultimately require manipulating many-body quantum systems with high precision. Cold atom experiments represent a stepping stone in that direction: a high degree of control has been achieved on systems of increasing complexity. However, this control is still sub-optimal. In many scenarios, achieving a fast transformation is crucial to fight against decoherence and imperfection effects. Optimal control theory is believed to be the ideal candidate to bridge the gap between early stage proof-of-principle demonstrations and experimental protocols suitable for practical applications. Indeed, it can engineer protocols at the quantum speed limit – the fastest achievable timescale of the transformation. Here, we demonstrate such potential by computing theoretically and verifying experimentally the optimal transformations in two very different interacting systems: the coherent manipulation of motional states of an atomic Bose-Einstein condensate and the crossing of a quantum phase transition in small systems of cold atoms in optical lattices. We also show that such processes are robust with respect to perturbations, including temperature and atom number fluctuations. PMID:27725688

Optimal control of complex atomic quantum systems.

PubMed

van Frank, S; Bonneau, M; Schmiedmayer, J; Hild, S; Gross, C; Cheneau, M; Bloch, I; Pichler, T; Negretti, A; Calarco, T; Montangero, S

2016-10-11

Quantum technologies will ultimately require manipulating many-body quantum systems with high precision. Cold atom experiments represent a stepping stone in that direction: a high degree of control has been achieved on systems of increasing complexity. However, this control is still sub-optimal. In many scenarios, achieving a fast transformation is crucial to fight against decoherence and imperfection effects. Optimal control theory is believed to be the ideal candidate to bridge the gap between early stage proof-of-principle demonstrations and experimental protocols suitable for practical applications. Indeed, it can engineer protocols at the quantum speed limit - the fastest achievable timescale of the transformation. Here, we demonstrate such potential by computing theoretically and verifying experimentally the optimal transformations in two very different interacting systems: the coherent manipulation of motional states of an atomic Bose-Einstein condensate and the crossing of a quantum phase transition in small systems of cold atoms in optical lattices. We also show that such processes are robust with respect to perturbations, including temperature and atom number fluctuations.

Taking It to the Top: A Lesson in Search Engine Optimization

ERIC Educational Resources Information Center

Frydenberg, Mark; Miko, John S.

2011-01-01

Search engine optimization (SEO), the promoting of a Web site so it achieves optimal position with a search engine's rankings, is an important strategy for organizations and individuals in order to promote their brands online. Techniques for achieving SEO are relevant to students of marketing, computing, media arts, and other disciplines, and many…

Patients with History of Colonoscopy Are Less Likely to Achieve High Quality Preparation After Implementing Split-Dose Bowel Preparation.

PubMed

Madhoun, M F; Bitar, H; Parava, P; Bashir, M H; Zia, H

2017-01-01

Anecdotally, we observed that patients who had previous colonoscopies were less likely to follow newly implemented split-dose bowel preparation (SDBP) instructions. We investigated whether the indication for colonoscopy is an independent factor for achieving high quality bowel preparation among patients asked to follow SDBP. We performed a retrospective study of data from 1478 patients who received outpatient colonoscopies in 2014 (the year of SDBP implementation) at our Veterans Affairs Medical Center. We collected information related to demographics and factors known to affect bowel preparations. Reasons for colonoscopy were dichotomized into surveillance (previous colonoscopy) vs. non-surveillance (positive occult blood test or screening). Bowel preparation quality was scored using the Boston Bowel Preparation Scale (BBPS), and was categorized as either excellent vs. not excellent (BBPS≥7 vs. BBPS<7), or adequate vs. inadequate (BBPS≥6 vs. BBPS<6). Bowel preparation quality was excellent in 60% of colonoscopies and adequate in 84% of colonoscopies. Thirty-six percent (535) were surveillance colonoscopies. In multivariate logistic regression analysis, more patients in the non-surveillance group achieved excellent (OR 0.8 ; 95% CI [0.7-0.8], P <0.0001) and adequate (OR 0.8 ; 95% CI [0.7-0.9], P <0.006) bowel preparation than did patients in the surveillance group. Patients with a prior colonoscopy might not follow the split-dose bowel preparation instructions. Educational interventions emphasizing the benefits of SDBP in this group of patients may help ensure compliance and prevent the habitual use of day-before preparations. © Acta Gastro-Enterologica Belgica.

Updated recommendations on the management of gastrointestinal disturbances during iron chelation therapy with Deferasirox in transfusion dependent patients with myelodysplastic syndrome - Emphasis on optimized dosing schedules and new formulations.

PubMed

Nolte, Florian; Angelucci, Emanuele; Breccia, Massimo; Gattermann, Norbert; Santini, Valeria; Vey, Norbert; Hofmann, Wolf-Karsten

2015-10-01

Myelodysplastic syndromes (MDS) are oligoclonal hematopoietic disorders characterized by peripheral cytopenias with anemias being the most prevalent feature. The majority of patients will depend on regular transfusions of packed red blood cells (PRBC) during the course of the disease. Particularly patients with MDS and low risk for transformation into acute myeloid leukemia and low risk of early death will receive PRBC transfusions on a regular basis, which puts them at high risk for transfusional iron overload. Transfusion dependence has been associated with negative impact on organ function and reduced life expectancy. Recently, several retrospective but also some prospective studies have indicated, that transfusion dependent patients with MDS might benefit from consequent iron chelation with regard to morbidity and mortality. However, low treatment adherence due to adverse events mainly gastrointestinal in nature is an important obstacle in achieving sufficient iron chelation in MDS patients. Here, we will summarize and discuss the existing data on Deferasirox in low risk MDS published so far and provide recommendations for optimal management of gastrointestinal adverse events during iron chelation aiming at improving treatment compliance and, hence, sufficiently removing excess iron from the patients. Copyright © 2015. Published by Elsevier Ltd.