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Sample records for achieve optimal patient

  1. Effectiveness of increasing the frequency of posaconazole syrup administration to achieve optimal plasma concentrations in patients with haematological malignancy.

    PubMed

    Park, Wan Beom; Cho, Joo-Youn; Park, Sang-In; Kim, Eun Jung; Yoon, Seonghae; Yoon, Seo Hyun; Lee, Jeong-Ok; Koh, Youngil; Song, Kyoung-Ho; Choe, Pyoeng Gyun; Yu, Kyung-Sang; Kim, Eu Suk; Bang, Su Mi; Kim, Nam Joong; Kim, Inho; Oh, Myoung-Don; Kim, Hong Bin; Song, Sang Hoon

    2016-07-01

    Few data are available on whether adjusting the dose of posaconazole syrup is effective in patients receiving anti-cancer chemotherapy. The aim of this prospective study was to analyse the impact of increasing the frequency of posaconazole administration on optimal plasma concentrations in adult patients with haematological malignancy. A total of 133 adult patients receiving chemotherapy for acute myeloid leukaemia or myelodysplastic syndrome who received posaconazole syrup 200 mg three times daily for fungal prophylaxis were enrolled in this study. Drug trough levels were measured by liquid chromatography-tandem mass spectrometry. In 20.2% of patients (23/114) the steady-state concentration of posaconazole was suboptimal (<500 ng/mL) on Day 8. In these patients, the frequency of posaconazole administration was increased to 200 mg four times daily. On Day 15, the median posaconazole concentration was significantly increased from 368 ng/mL [interquartile range (IQR), 247-403 ng/mL] to 548 ng/mL (IQR, 424-887 ng/mL) (P = 0.0003). The median increase in posaconazole concentration was 251 ng/mL (IQR, 93-517 ng/mL). Among the patients with initially suboptimal levels, 79% achieved the optimal level unless the steady-state level was <200 ng/mL. This study shows that increasing the administration frequency of posaconazole syrup is effective for achieving optimal levels in patients with haematological malignancy undergoing chemotherapy.

  2. Long-term management strategies to achieve optimal function in patients with bipolar disorder.

    PubMed

    Keck, Paul E

    2006-12-01

    Predictors of poor functional outcome in patients with bipolar disorder include psychiatric and medical comorbidity, interepisode subsyndromal symptoms, psychosis during manic or mixed episode, and low premorbid functioning. Cognitive dysfunction may also contribute to functional impairment. Psychosocial intervention has shown success in improving syndromal outcomes for people with bipolar disorder. Lithium, lamotrigine, olanzapine, and aripiprazole have all shown substantial improvements in relapse rates compared with placebo. Combination therapy with antipsychotics and antidepressants has also been shown to produce improvement in symptoms in people with bipolar disorder. However, limited evidence is available for the effects of these treatments on cognitive outcomes. This review discusses treatment strategies for the long-term management of bipolar disorder and functional outcome measures associated with these treatments.

  3. SU-E-T-387: Achieving Optimal Patient Setup Imaging and Treatment Workflow Configurations in Multi-Room Proton Centers

    SciTech Connect

    Zhang, H; Prado, K; Langen, K; Yi, B; Mehta, M; Regine, W; D'Souza, W

    2014-06-01

    Purpose: To simulate patient flow in proton treatment center under uncertainty and to explore the feasibility of treatment preparation rooms to improve patient throughput and cyclotron utilization. Methods: Three center layout scenarios were modeled: (S1: In-Tx room imaging) patient setup and imaging (planar/volumetric) performed in treatment room, (S2: Patient setup in preparation room) each treatment room was assigned with preparation room(s) that was equipped with lasers only for patient setup and gross patient alignment, and (S3: Patient setup and imaging in preparation room) preparation room(s) was equipped with laser and volumetric imaging for patient setup, gross and fine patient alignment. A 'snap' imaging was performed in treatment room. For each scenario, the number of treatment rooms and the number of preparation rooms serving each treatment room were varied. We examined our results (average of 100 16-hour (two shifts) working days) by evaluating patient throughput and cyclotron utilization. Results: When the number of treatment rooms increased ([from, to]) [1, 5], daily patient throughput increased [32, 161], [29, 184] and [27, 184] and cyclotron utilization increased [13%, 85%], [12%, 98%], and [11%, 98%] for scenarios S1, S2 and S3 respectively. However, both measures plateaued after 4 rooms. With the preparation rooms, the throughput and the cyclotron utilization increased by 14% and 15%, respectively. Three preparation rooms were optimal to serve 1-3 treatment rooms and two preparation rooms were optimal to serve 4 or 5 treatment rooms. Conclusion: Patient preparation rooms for patient setup may increase throughput and decrease the need for additional treatment rooms (cost effective). Optimal number of preparation rooms serving each gantry room varies as a function of treatment rooms and patient setup scenarios. A 5th treatment room may not be justified by throughput or utilization.

  4. Optimal and safe standard doses of midazolam and propofol to achieve patient and doctor satisfaction with dental treatment: A prospective cohort study

    PubMed Central

    Nonaka, Mutsumi; Nishimura, Akiko; Gotoh, Kinuko; Oka, Shuichirou; Iijima, Takehiko

    2017-01-01

    Background The incidences of morbidity and mortality caused by pharmacosedation for dental treatment have not yet reached zero. Adverse events are related to inappropriate respiratory management, mostly originating from an overdose of sedatives. Since sedation is utilized for the satisfaction of both the dentist and the patient, the optimal dose should be minimized to prevent adverse events. We attempted to define the optimal doses of midazolam and propofol required to achieve high levels of patient and dentist satisfaction. Methods One thousand dental patients, including those undergoing third molar extractions, were enrolled in this study. A dose of 1 mg of midazolam was administered at 1-minute intervals until adequate sedation was achieved. Propofol was then infused continuously to maintain the sedation level. Both the patients and the dentists were subsequently interviewed and asked to complete a questionnaire. A multivariate logistic regression analysis was used to examine the factors that contributed to patient and dentist satisfaction. Results The peak midazolam dose resulting in the highest percentage of patient satisfaction was 3 mg. Both a lower dose and a higher dose reduced patient satisfaction. Patient satisfaction increased with an increasing dosage of propofol up until 4 mg/kg/hr, reaching a peak of 78.6%. The peak midazolam dose resulting in the highest percentage of dentist satisfaction (78.8%) was 2 mg. Incremental propofol doses reduced dentist satisfaction, in contrast to their effect on patient satisfaction. The strongest independent predictors of patient satisfaction and dentist satisfaction were no intraoperative memory (OR, 5.073; 95% CI, 3.532–7.287; P<0.001) and unintentional movements by the patient (OR, 0.035; 95% CI, 0.012–0.104; P<0.001), respectively. No serious adverse events were reported. Conclusion We found that 3 mg of midazolam and 3 mg/kg/hr of propofol may be the optimal doses for maximizing both patient and dentist

  5. Achieving patient satisfaction: resolving patient complaints.

    PubMed

    Oxler, K F

    1997-07-01

    Patients demand to be active participants on and partners with the health care team to design their care regimen. Patients bring unique perceptions and expectations and use these to evaluate service quality and satisfaction. If customer satisfaction is not achieved and a patient complaint results, staff must have the skills to respond and launch a service recovery program. Service recovery, when done with style and panache, can retain loyal customers. Achieving patient satisfaction and resolving patient complaints require commitment from top leadership and commitment from providers to dedicate the time to understand their patients' needs.

  6. Low high-density lipoprotein cholesterol is a residual risk factor associated with long-term clinical outcomes in diabetic patients with stable coronary artery disease who achieve optimal control of low-density lipoprotein cholesterol.

    PubMed

    Ogita, Manabu; Miyauchi, Katsumi; Miyazaki, Tadashi; Naito, Ryo; Konishi, Hirokazu; Tsuboi, Shuta; Dohi, Tomotaka; Kasai, Takatoshi; Yokoyama, Takayuki; Okazaki, Shinya; Kurata, Takeshi; Daida, Hiroyuki

    2014-01-01

    Diabetes mellitus is recognized an independent risk factor for coronary artery disease (CAD) and mortality. Clinical trials have shown that statins significantly reduce cardiovascular events in diabetic patients. However, residual cardiovascular risk persists despite the achievement of target low-density lipoprotein cholesterol (LDL-C) levels with statin. High-density lipoprotein cholesterol (HDL-C) is an established coronary risk factor that is independent of LDL-C levels. We evaluated the impact of HDL-C on long-term mortality in diabetic patients with stable CAD who achieved optimal LDL-C. We enrolled 438 consecutive diabetic patients who were scheduled for percutaneous coronary intervention between 2004 and 2007 at our institution. We identified 165 patients who achieved target LDL-C <100 mg/dl. Patients were stratified into two groups according to HDL-C levels (low HDL-C group, baseline HDL-C <40 mg/dl; high HDL-C group, ≥40 mg/dl). Major adverse cardiac events (MACE) that included all-cause death, acute coronary syndrome, and target lesion revascularization were evaluated between the two groups. The median follow-up period was 946 days. The rate of MACE was significantly higher in diabetic patients with low-HDL-C who achieved optimal LDL-C (6.9 vs 17.9 %, log-rank P = 0.030). Multivariate Cox regression analysis showed that HDL-C is significantly associated with clinical outcomes (adjusted hazard ratio for MACE 1.33, 95 % confidence interval 1.01-1.75, P = 0.042). Low HDL-C is a residual risk factor that is significantly associated with long-term clinical outcomes among diabetic patients with stable CAD who achieve optimal LDL-C levels.

  7. Toward achieving optimal response: understanding and managing antidepressant side effects

    PubMed Central

    Kelly, Karen; Posternak, Michael; Jonathan, E. Alpert

    2008-01-01

    The safety and tolerability of antidepressants have improved considerably over the past two decades, Nevertheless, antidepressant side effects are still common and problematic. The majority of patients treated with contemporary agents experience one or more bothersome side effects. These side effects often create barriers to achieving depressive remission, as well as to preventing relapse and recurrence. Clinicians tend to underestimate the prevalence of side effects, and as many as one quarter of patients discontinue their antidepressants because of difficult-to-tolerate side effects; others may continue on antidepressant therapy but experience diminished quality of life related to troublesome side effects. This article reviews the prevalence of side effects, the impact of side effects on treatment adherence, and methodological issues including the challenge of distinguishing side effects from residual depressive symptoms, discontinuation effects, and general medical problems. In addition, we address the most common side effects such as sexual dysfunction, gastrointestinal problems, sleep disturbance, apathy, and fatigue, and offer strategies for management that may help patients achieve optimal response to pharmacotherapy. PMID:19170398

  8. 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

  9. 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

  10. 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

  11. Gout: optimizing treatment to achieve a disease cure.

    PubMed

    Bernal, José Antonio; Quilis, Neus; Andrés, Mariano; Sivera, Francisca; Pascual, Eliseo

    2016-03-01

    Gout is one of the most common inflammatory arthritides. The disease is due to the deposition of monosodium urate crystals. These deposits are reversible with proper treatment, suggesting that gout is a curable disease. The main aim in gout is to lower serum uric acid levels to a pre-established target; there are different urate-lowering drugs (xanthine oxidase inhibitors, uricosurics and uricases) through which this can be achieved. Proper treatment of gout also involves correct management of acute flares and their prevention. To ensure treatment adherence it is necessary to explain to the patient what the objectives are.

  12. Gout: optimizing treatment to achieve a disease cure

    PubMed Central

    Bernal, José Antonio; Quilis, Neus; Andrés, Mariano; Sivera, Francisca; Pascual, Eliseo

    2016-01-01

    Gout is one of the most common inflammatory arthritides. The disease is due to the deposition of monosodium urate crystals. These deposits are reversible with proper treatment, suggesting that gout is a curable disease. The main aim in gout is to lower serum uric acid levels to a pre-established target; there are different urate-lowering drugs (xanthine oxidase inhibitors, uricosurics and uricases) through which this can be achieved. Proper treatment of gout also involves correct management of acute flares and their prevention. To ensure treatment adherence it is necessary to explain to the patient what the objectives are. PMID:26977282

  13. 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.

  14. Standardization and optimization of CT protocols to achieve low dose.

    PubMed

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

    2014-03-01

    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, the authors summarize approaches to reduce dose, as discussed in lectures constituting the first session of the 2013 UCSF Virtual Symposium on Radiation Safety and 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.

  15. Optimal Vascular Access in the Elderly Patient

    PubMed Central

    Moist, Louise M.; Lok, Charmaine E.; Vachharajani, Tushar J.; Xi, Wang; AlJaishi, Ahmed; Polkinghorne, Kevan R; Lee, Timmy C.

    2014-01-01

    The optimal vascular access for elderly patients remains a challenge due to the difficulty balancing the benefits and risks in a population with increased comorbidity and decreased survival. Age is commonly associated with failure to mature in fistula and decreased rates of primary and secondary patency in both fistula and grafts. In the elderly, at 1 and 2-years, primary patency rates range from 43% to 74% and 29% to 67%, respectively. Secondary patency rates at 1 and 2-years range from 56% to 82% and 44% to 67% respectively. Cumulative fistula survival is no better than grafts survival when primary failures are included. Several observational studies consistently demonstrate a lower adjusted mortality among those using a fistula compared to a catheter (1–3)(1–3) however catheter use in the elderly is increasing in most countries with the exception of Japan. Both guidelines and quality initiatives do not acknowledge the trade-offs involved in managing the elderly patients with multiple chronic conditions and limited life expectancy or the value that patients place on achieving these outcomes(4)(4). The framework for choice of vascular access presented in this article considers: 1) likelihood of disease progression before death 2) patient life expectancy, 3) risks and benefits by vascular access type and 4) patient preference. Future studies evaluating the timing and type of vascular access with careful assessments of complications, functionality, cost benefit, and patients’ preference will provide relevant information to individualize and optimize care to improve morbidity, mortality, and quality of life in the elderly patient. PMID:23173892

  16. 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.

  17. 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.

  18. 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.

  19. Achieving optimal outcomes with all-zirconia crowns.

    PubMed

    Christensen, John Juel

    2014-01-01

    All-zirconia crowns are enjoying an unprecedented popularity. Dental laboratories are acquiring new equipment and adopting novel techniques, some of which require a learning curve. As a result, some crowns fabricated by computer-aided design/computer-aided manufacturing technology may come back to the dentist with unsatisfactory features. Dentists should carefully examine each crown under magnification prior to delivery to the patient. The dentist and dental laboratory should establish a close partnership with clear communication to yield the most favorable outcome for the patient.

  20. Concurrently adjusting interrelated control parameters to achieve optimal engine performance

    DOEpatents

    Jiang, Li; Lee, Donghoon; Yilmaz, Hakan; Stefanopoulou, Anna

    2015-12-01

    Methods and systems for real-time engine control optimization are provided. A value of an engine performance variable is determined, a value of a first operating condition and a value of a second operating condition of a vehicle engine are detected, and initial values for a first engine control parameter and a second engine control parameter are determined based on the detected first operating condition and the detected second operating condition. The initial values for the first engine control parameter and the second engine control parameter are adjusted based on the determined value of the engine performance variable to cause the engine performance variable to approach a target engine performance variable. In order to cause the engine performance variable to approach the target engine performance variable, adjusting the initial value for the first engine control parameter necessitates a corresponding adjustment of the initial value for the second engine control parameter.

  1. 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…

  2. A global study of the unmet need for glycemic control and predictor factors among patients with type 2 diabetes mellitus who have achieved optimal fasting plasma glucose control on basal insulin

    PubMed Central

    Chou, Engels; Colagiuri, Stephen; Gaàl, Zsolt; Lavalle, Fernando; Mkrtumyan, Ashot; Nikonova, Elena; Tentolouris, Nikolaos; Vidal, Josep; Davies, Melanie

    2016-01-01

    Abstract Background This study used data from different sources to identify the extent of the unmet need for postprandial glycemic control in patients with type 2 diabetes mellitus (T2DM) after the initiation of basal insulin therapy in Europe, Asia Pacific, the United States, and Latin America. Methods Different levels of evidence were used as available for each country/region, with data extracted from seven randomized controlled trials (RCTs), three clinical trial registries (CTRs), and three electronic medical record (EMR) databases. Glycemic status was categorized as “well controlled” (glycated hemoglobin [HbA1c] at target [<7%]), “residual hyperglycemia” (fasting plasma glucose [FPG] but not HbA1c at target [FPG <7.2/7.8 mmol/L, <130/140 mg/dL, depending on country‐specific recommendations]), or “uncontrolled” (both FPG and HbA1c above target). Predictor factors were identified from the RCT data set using logistic regression analysis. Results RCT data showed that 16.9% to 28.0%, 42.7% to 54.4%, and 16.9% to 38.1% of patients with T2DM had well‐controlled glycemia, residual hyperglycemia, and uncontrolled hyperglycemia, respectively. In CTRs, respective ranges were 21.8% to 33.6%, 31.5% to 35.6%, and 30.7% to 46.8%, and in EMR databases were 4.4% to 21.0%, 23.9% to 31.8%, and 53.6% to 63.8%. Significant predictor factors of residual hyperglycemia identified from RCT data included high baseline HbA1c (all countries/regions except Brazil), high baseline FPG (United Kingdom/Japan), longer duration of diabetes (Brazil), and female sex (Europe/Latin America). Conclusions Irrespective of intrinsic differences between data sources, 24% to 54% of patients with T2DM globally had residual hyperglycemia with HbA1c not at target, despite achieving FPG control, indicating a significant unmet need for postprandial glycemic control. PMID:27606888

  3. Multiphase Nano-Composite Coatings for Achieving Energy Optimization

    SciTech Connect

    Nainaparampil, Jose

    2012-03-26

    UES Inc. and ANL teamed in this work to develop novel coating systems for the protection of surfaces from thermal degradation mainly in two applications; Machining and Die casting. These coatings were specifically designed for the purpose by incorporating required material phases and the overall architecture, which led to reduce the energy usage and increase efficiency of the operations. Following the UES/ANL's feasibility work, the coatings were developed utilizing High power impulse magnetron sputtering (HiPMS) and Large area filtered arc deposition (LAFAD) techniques. Toughness, hardness and oxidation resistance: contrasting qualities have been mixed in the right proportion to attain the suitable material characteristic for the cause. Hafnium diboride (HfB2) based materials provided such a system and its properties were tamed to attain the right combination of toughness and hardness by working on the microstructure and architecture of coatings. An effective interfacing material (graded concentrations of topcoat) was also achieved in this work to provide the required adhesion between the substrate and the coating. Combination of an appropriate bond coat and a functional top coat provided the present thermal degradation resistant coating for cutting tools and die-casting applications. Laboratory level performance tests and industrial level application tests by partner companies (Beta Site Testing) were used for the development of these coatings.

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

    DTIC Science & Technology

    2015-06-01

    and pedigree possess additive implications toward the quality of the data utilized within the DSS. F. SUMMARY Decision - making theories such as...VISUALIZATIONS: A TOOL TO ACHIEVE OPTIMIZED OPERATIONAL DECISION MAKING AND DATA INTEGRATION by Paul C. Hudson Jeffrey A. Rzasa June 2015 Thesis...TOOL TO ACHIEVE OPTIMIZED OPERATIONAL DECISION MAKING AND DATA INTEGRATION 5. FUNDING NUMBERS 6. AUTHOR(S) Paul C. Hudson, and Jeffrey A. Rzasa

  5. The Effects of Academic Optimism on Student Academic Achievement in Alabama

    ERIC Educational Resources Information Center

    Bevel, Raymona King

    2010-01-01

    The purpose of the research was to determine the effects of academic optimism on student academic achievement through measuring the individual and collective effects of academic emphasis, collective efficacy, and faculty trust in clients. Data for this study were obtained from the School Academic Optimism Scale and the reading section of the…

  6. Collective Responsibility, Academic Optimism, and Student Achievement in Taiwan Elementary Schools

    ERIC Educational Resources Information Center

    Wu, Hsin-Chieh

    2012-01-01

    Previous research indicates that collective efficacy, faculty trust in students and parents, and academic emphasis together formed a single latent school construct, called academic optimism. In the U.S., academic optimism has been proven to be a powerful construct that could effectively predict student achievement even after controlling for…

  7. Optimal marker placement in photogrammetry patient positioning system.

    PubMed

    Liu, Haisong; Yu, Yan; Schell, M C; O'Dell, Walter G; Ruo, Russell; Okunieff, Paul

    2003-02-01

    A photogrammetry-based patient positioning system has been used instead of the conventional laser alignment technique for patient set-up in external beam radiotherapy. It tracks skin affixed reflective markers with multiple infrared cameras. The three-dimensional (3D) positions of the markers provide reference information to determine the treatment plan isocenter location and hence provide the ability to position the lesion at the isocenter of the treatment linear accelerator. However, in current clinical practice for lung or liver lesion treatments, fiducial markers are usually randomly affixed onto the patients' chest and abdomen, so that the actual target registration error (TRE) of the internal lesions inside the body may be large, depending on the fiducial registration error (FRE). There exists an optimal marker configuration that can minimize the TRE. In this paper, we developed methods to design the patient-specific optimal configurations of the surface makers to minimize the TRE, given the patient's surface contour, the lesion position and the FRE. Floating genetic algorithm (GA) optimization was used to optimize the positions of the skin markers. The surface curve of the patient body was determined by an automatic segmentation algorithm from the planning CT. The method was evaluated using a body phantom implanted with a metal ball (a simulated target). By registering two CT scans using the surface markers and measuring the displacement of the target, the TRE was measured. The TRE was also measured by taking two orthogonal portal films after positioning the phantom using the photogrammetry based patient positioning system. A 50% reduction in TRE has been achieved by using the optimal configuration compared to the random configuration. This result demonstrates that the optimization of a fiducial configuration can result in improved tumor targeting ability.

  8. Use of allopurinol with low-dose 6-mercaptopurine in inflammatory bowel disease to achieve optimal active metabolite levels: A review of four cases and the literature

    PubMed Central

    Witte, Todd N; Ginsberg, Allen L

    2008-01-01

    BACKGROUND: At least one-third of patients with inflammatory bowel disease do not respond or are intolerant to therapy with 6-mercaptopurine (6-MP). A subgroup fails to attain optimal levels of 6-thioguanine nucleotide (6-TGN) and instead shunts to 6-methylmercaptopurine nucleotide (6-MMPN). PATIENTS AND METHODS: A retrospective chart review was conducted, and four patients are described who had been previously unable to achieve optimal 6-TGN metabolite levels until allopurinol was added to their treatment. RESULTS: All four patients achieved optimal 6-TGN levels and undetectable 6-MMPN with a mean 6-MP dose of 0.49 mg/kg. Three achieved steroid-free clinical remission. Two of those three patients had normalization of liver enzymes; one patient had baseline normal liver enzymes despite an initial 6-MMPN level of 27,369 pmol/8×108 red blood cells. Two patients experienced reversible leukopenia. CONCLUSIONS: Combination allopurinol and low-dose 6-MP is an effective means to achieve optimal metabolite levels and steroid-free clinical remission in previously refractory patients. Caution is advised. PMID:18299738

  9. Restricted and Repetitive Behaviors in Individuals with a History of ASDs Who Have Achieved Optimal Outcomes

    ERIC Educational Resources Information Center

    Troyb, Eva; Orinstein, Alyssa; Tyson, Katherine; Eigsti, Inge-Marie; Naigles, Letitia; Fein, Deborah

    2014-01-01

    Studies of autism spectrum disorders (ASDs) suggest that restricted and repetitive behaviors (RRBs) are particularly difficult to remediate. We examined present and past RRBs in 34 individuals who achieved optimal outcomes (OOs; lost their ASD diagnosis), 45 high-functioning individuals with ASD (HFA) and 34 typically developing (TD) peers. The OO…

  10. Academic Optimism, Organizational Citizenship Behaviors, and Student Achievement at Charter Schools

    ERIC Educational Resources Information Center

    Guvercin, Mustafa

    2013-01-01

    The purpose of this study was to examine the relationship among academic optimism, Organizational Citizenship Behaviors (OCBs), and student achievement in college preparatory charter schools. A purposeful sample of elementary school teachers from college preparatory charter schools (N = 226) in southeast Texas was solicited to complete the…

  11. Preoperative Optimization of the Heart Failure Patient Undergoing Cardiac Surgery.

    PubMed

    Pichette, Maxime; Liszkowski, Mark; Ducharme, Anique

    2017-01-01

    Heart failure patients who undergo cardiac surgery are exposed to significant perioperative complications and high mortality. We herein review the literature concerning preoperative optimization of these patients. Salient findings are that end-organ dysfunction and medication should be optimized before surgery. Specifically: (1) reversible causes of anemia should be treated and a preoperative hemoglobin level of 100 g/L obtained; (2) renal function and volume status should be optimized; (3) liver function must be carefully evaluated; (4) nutritional status should be assessed and cachexia treated to achieve a preoperative albumin level of at least 30 g/L and a body mass index > 20; and (5) medication adjustments performed, such as withholding inhibitors of the renin-angiotensin-aldosterone system before surgery and continuing, but not starting, β-blockers. Levels of natriuretic peptides (brain natriuretic peptide [BNP] and N-terminal proBNP) provide additional prognostic value and therefore should be measured. In addition, individual patient's risk should be objectively assessed using standard formulas such as the EuroSCORE-II or Society of Thoracic Surgeons risk scores, which are simple and validated for various cardiac surgeries, including left ventricular assist device implantation. When patients are identified as high risk, preoperative hemodynamic optimization might be achieved with the insertion of a pulmonary artery catheter and hemodynamic-based tailored therapy. Finally, a prophylactic intra-aortic balloon pump might be considered in certain circumstances to decrease morbidity and even mortality, like in some high risk heart failure patients who undergo cardiac surgery, whereas routine preoperative inotropes are not recommended and should be reserved for patients in shock, except maybe for levosimendan.

  12. Use of a Batch Reactive Distillation with Dynamic Optimization Strategy to Achieve Industrial Grade Ethyl Acetate

    NASA Astrophysics Data System (ADS)

    Konakom, Kwantip; Saengchan, Aritsara; Kittisupakorn, Paisan; Mujtaba, Iqbal M.

    2011-08-01

    Industrial grade ethyl acetate is available with minimum purity of 85.0%. It is mostly produced by an ethanol esterification in a distillation process on both batch and continuous modes. However, researches on high purity production with short operating time are rarely achieved. Therefore, the objective in this work is to study an approach to produce ethyl acetate of 90.0% by 8 hours using a batch reactive distillation column. Based on open-loop simulations, the distillation with constant reflux ratio cannot achieve the product specification. Thus, the dynamic optimization strategy is proposed to handle this problem. For the process safety—preventing the dried column and fractured, a minimum reflux ratio must be determined in advance and then an optimal reflux profile is calculated to achieve optimal product yield. Simulation results show that the industrial grade ethyl acetate can be produced by the dynamic optimization programming with two or more time intervals. Besides, the increasing of time intervals can produce more distillate product.

  13. 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

  14. Results achieved in the treatment of patients with vestibular schwannoma.

    PubMed

    Freigang, Bernd; Rudolf, Jan

    2004-01-01

    Personal experience gathered with the treatment of 264 vestibular schwannoma (VS) at the Magdeburg University ENT Hospital is analysed. ABR Audiometry is useful as a screening, even though it yielded false-negative values in 12.7% (n = 33) for intrameatal VS and 16.9% for all VS, despite accurate evaluation. Latency increases of Waves I, III and V and their intraaural comparison exhibited a statistically significant difference for the VS levels proposed by TOS. The mean of intrameatal VS too was found to have longer latencies compared with the normal-hearing ears of the patients. In the individual case, with threshold hearing normal, anamnestic findings as well as otoneurological evidence provide an early indication for enhanced MRI, CISS imaging, or individual 3D reconstruction of the pontocerebellar cisterna. Adopting intraoperative monitoring of the facial nerve and the cochlea as well as the Pars acustica by means of far-field and near-field electrodes, a good facial 'mobility' was achieved in 95.3%, and a useful audition (AAO-HNS Types A and B) in 60%. Monitoring is beneficial as it enhances the reliability and improves the subtle preparation during surgery. The power of hearing improved postoperatively within six months and remained at a good level over two years. From our perspective, otorhinolaryngologists are the right specialists to attend to VS.

  15. Robust, integrated computational control of NMR experiments to achieve optimal assignment by ADAPT-NMR.

    PubMed

    Bahrami, Arash; Tonelli, Marco; Sahu, Sarata C; Singarapu, Kiran K; Eghbalnia, Hamid R; Markley, John L

    2012-01-01

    ADAPT-NMR (Assignment-directed Data collection Algorithm utilizing a Probabilistic Toolkit in NMR) represents a groundbreaking prototype for automated protein structure determination by nuclear magnetic resonance (NMR) spectroscopy. With a [(13)C,(15)N]-labeled protein sample loaded into the NMR spectrometer, ADAPT-NMR delivers complete backbone resonance assignments and secondary structure in an optimal fashion without human intervention. ADAPT-NMR achieves this by implementing a strategy in which the goal of optimal assignment in each step determines the subsequent step by analyzing the current sum of available data. ADAPT-NMR is the first iterative and fully automated approach designed specifically for the optimal assignment of proteins with fast data collection as a byproduct of this goal. ADAPT-NMR evaluates the current spectral information, and uses a goal-directed objective function to select the optimal next data collection step(s) and then directs the NMR spectrometer to collect the selected data set. ADAPT-NMR extracts peak positions from the newly collected data and uses this information in updating the analysis resonance assignments and secondary structure. The goal-directed objective function then defines the next data collection step. The procedure continues until the collected data support comprehensive peak identification, resonance assignments at the desired level of completeness, and protein secondary structure. We present test cases in which ADAPT-NMR achieved results in two days or less that would have taken two months or more by manual approaches.

  16. Antibiotic dose optimization in critically ill patients.

    PubMed

    Cotta, M O; Roberts, J A; Lipman, J

    2015-12-01

    The judicious use of existing antibiotics is essential for preserving their activity against infections. In the era of multi-drug resistance, this is of particular importance in clinical areas characterized by high antibiotic use, such as the ICU. Antibiotic dose optimization in critically ill patients requires sound knowledge not only of the altered physiology in serious infections - including severe sepsis, septic shock and ventilator-associated pneumonia - but also of the pathogen-drug exposure relationship (i.e. pharmacokinetic/pharmacodynamic index). An important consideration is the fact that extreme shifts in organ function, such as those seen in hyperdynamic patients or those with multiple organ dysfunction syndrome, can have an impact upon drug exposure, and constant vigilance is required when reviewing antibiotic dosing regimens in the critically ill. The use of continuous renal replacement therapy and extracorporeal membrane oxygenation remain important interventions in these patients; however, both of these treatments can have a profound effect on antibiotic exposure. We suggest placing emphasis on the use of therapeutic drug monitoring and dose individualization when optimizing therapy in these settings.

  17. Brachytherapy for clinically localized prostate cancer: optimal patient selection.

    PubMed

    Kollmeier, Marisa A; Zelefsky, Michael J

    2011-10-01

    The objective of this review is to present an overview of each modality and delineate how to best select patients who are optimal candidates for these treatment approaches. Prostate brachytherapy as a curative modality for clinically localized prostate cancer has become increasingly utilized over the past decade; 25% of all early cancers are now treated this way in the United States (1). The popularity of this treatment strategy lies in the highly conformal nature of radiation dose, low morbidity, patient convenience, and high efficacy rates. Prostate brachytherapy can be delivered by either a permanent interstitial radioactive seed implantation (low dose rate [LDR]) or a temporary interstitial insertion of iridium-192 (Ir192) afterloading catheters. The objective of both of these techniques is to deliver a high dose of radiation to the prostate gland while exposing normal surrounding tissues to minimal radiation dose. Brachytherapy techniques are ideal to achieve this goal given the close proximity of the radiation source to tumor and sharp fall off of the radiation dose cloud proximate to the source. Brachytherapy provides a powerful means of delivering dose escalation above and beyond that achievable with intensity-modulated external beam radiotherapy alone. Careful selection of appropriate patients for these therapies, however, is critical for optimizing both disease-related outcomes and treatment-related toxicity.

  18. Achievements and challenges in automated parameter, shape and topology optimization for divertor design

    NASA Astrophysics Data System (ADS)

    Baelmans, M.; Blommaert, M.; Dekeyser, W.; Van Oevelen, T.

    2017-03-01

    Plasma edge transport codes play a key role in the design of future divertor concepts. Their long simulation times in combination with a large number of control parameters turn the design into a challenging task. In aerodynamics and structural mechanics, adjoint-based optimization techniques have proven successful to tackle similar design challenges. This paper provides an overview of achievements and remaining challenges with these techniques for complex divertor design. It is shown how these developments pave the way for fast sensitivity analysis and improved design from different perspectives.

  19. Achievements, challenges and unmet needs for haemophilia patients with inhibitors

    PubMed Central

    DARGAUD, Y.; PAVLOVA, A.; LACROIX-DESMAZES, S.; FISCHER, K.; SOUCIE, M.; CLAEYSSENS, S.; SCOTT, D.W.; d’OIRON, R.; LAVIGNE-LISSALDE, G.; KENET, G.; ETTINGSHAUSEN, C. ESCURIOLA; BOREL-DERLON, A.; LAMBERT, T.; PASTA, G.; NÉGRIER, C.

    2016-01-01

    Summary Over the past 20 years, there have been many advances in haemophilia treatment that have allowed patients to take greater control of their disease. However, the development of factor VIII (FVIII) inhibitors is the greatest complication of the disease and a challenge in the treatment of haemophilia making management of bleeding episodes difficult and surgical procedures very challenging. A meeting to discuss the unmet needs of haemophilia patients with inhibitors was held in Paris on 20 November 2014. Topics discussed were genetic and non-genetic risk factors for the development of inhibitors, immunological aspects of inhibitor development, FVIII products and inhibitor development, generation and functional properties of engineered antigen-specific T regulatory cells, suppression of immune responses to FVIII, prophylaxis in haemophilia patients with inhibitors, epitope mapping of FVIII inhibitors, current controversies in immune tolerance induction therapy, surgery in haemophilia patients with inhibitors and future perspectives for the treatment of haemophilia patients with inhibitors. A summary of the key points discussed is presented in this paper. PMID:26728503

  20. What can rehabilitation interventions achieve in patients with primary fibromyalgia?

    PubMed

    Sprott, Haiko

    2003-03-01

    Symptoms of primary fibromyalgia (FM) persist for years, independent of applied therapy. That is the sad reality we have to deal with. But is that really true? The following review is a scan of literature from September 1, 2001 to August 31, 2002, concerning rehabilitation interventions for patients with FM, to find progress in this field and to ascertain state-of-the-art treatment strategies for the disease. The main problem when treating patients with FM successfully is the heterogeneity of the patients' group. Several investigators determined subgroups within FM patients diagnosed by the 1990 American College of Rheumatology classification criteria of FM. Therefore, uniform recommendations for treatment cannot be given. Current treatment recommendations for FM include reassurance and explanation of the nature of the illness, evaluation and eradication of mechanical stressors as far as possible, symptomatic analgesic drug treatment, moderate individually adapted physical exercises, and adjuvant psychotherapeutic support in an interdisciplinary setting. Individually adapted measures are highly emphasized to differentially treat FM subgroups, as far as identified. This review will focus on these points on the one hand, and provide an overview about the current symptomatically-oriented therapy on the other hand. This all occurs against the background of an unknown etiology of the disease so far. Experimental approaches will be noted as well. The demonstration of a long-term effective intervention for managing the symptoms associated with FM is needed.

  1. 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

  2. Ethically optimal interventions with impaired patients.

    PubMed

    Howe, Edmund G

    2014-01-01

    It may be difficult to imagine having a severe impairment such as quadriplegia or being dependent on a respirator. There is evidence that when careproviders make treatment decisions for patients who are in these situations, we imagine the patients are worse-off than they report they are -- most patients with even very severe impairments report that they greatly value being alive. This misperception may cause us to make treatment decisions for patients with impairments that we might not make for other patients. In this article I describe how to provide better care for patients who have impairments. This includes not presupposing that the patients' quality of life is decreased, considering with patients how outside factors may be limiting their functioning, and seeking to help offset these factors, if we can, when they exist, to avoid allowing patients' impairments to result in their being truly "disabled".

  3. Optimal microelectromechanical systems (MEMS) device for achieving high pyroelectric response of AlN

    NASA Astrophysics Data System (ADS)

    Kebede, Bemnnet; Coutu, Ronald A.; Starman, LaVern

    2014-03-01

    This paper discusses research being conducted on aluminum nitride (AlN) as a pyroelectric material for use in detecting applications. AlN is being investigated because of its high pyroelectric coefficient, thermal stability, and high Curie temperature. In order to determine suitability of the pyroelectric properties of AlN for use as a detector, testing of several devices was conducted. These devices were fabricated using microelectromechanical systems (MEMS) fabrication processes; the devices were also designed to allow for voltage and current measurements. The deposited AlN films used were 150 nm - 300 nm in thickness. Thin-films were used to rapidly increase the temperature response after the thermal stimulus was applied to the pyroelectric material. This is important because the pyroelectric effect is directly proportional to the rate of temperature change. The design used was a face-electrode bridge that provides thermal isolation which minimizes heat loss to the substrate, thereby increasing operation frequency of the pyroelectric device. A thermal stimulus was applied to the pyroelectric material and the response was measured across the electrodes. A thermal imaging camera was used to monitor the changes in temperature. Throughout the testing process, the annealing temperatures, type of layers, and thicknesses were also varied. These changes resulted in improved MEMS designs, which were fabricated to obtain an optimal design configuration for achieving a high pyroelectric response. A pyroelectric voltage response of 38.9 mVp-p was measured without filtering, 12.45 mVp-p was measured in the infrared (IR) region using a Si filter, and 6.38 mVp-p was measured in the short wavelength IR region using a long pass filter. The results showed that AlN's pyroelectric properties can be used in detecting applications.

  4. 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.

  5. Achieving target hematocrit in dialysis patients: new concepts in iron management.

    PubMed

    Nissenson, A R

    1997-12-01

    The management of anemia in dialysis patients involves a comprehensive understanding of the role of erythropoietin deficiency and of the importance of adequate available iron. It is clear that iron and recombinant human erythropoietin (rHuEPO) in concert allow the clinician to achieve a given target hematocrit in dialysis patients. By first repleting and then maintaining iron stores, and with an appreciation of the concept of functional iron deficiency, the nephrologist can achieve target hematocrits with the lowest necessary dose of rHuEPO. Iron repletion and maintenance is difficult to achieve with oral iron, and parenteral iron is needed in most cases. New protocols for ongoing parenteral maintenance therapy with iron dextran or iron gluconate, a form of iron likely to be available soon in the United States, should lead to achievement of target hematocrits in a greater number of patients and be cost-effective in improving patient outcomes.

  6. Computer-aided optimal design of custom scoliosis braces considering clinical and patient evaluations.

    PubMed

    Visser, Daniel; Xue, Deyi; Ronsky, Janet L; Harder, James; Zernicke, Ronald F

    2012-09-01

    Scoliosis causes an abnormal three dimensional curvature of the spine that is often treated by an orthotic device called brace. The objective of this research was to develop a new approach to automatically identify the optimal design of custom-built brace, based on clinical and patient evaluations. In this approach, torso geometry of the scoliosis patient was achieved using a 3-D imaging system that generated a 3-D torso surface model, which was modified using a custom CAD system to design the 3-D brace surface model. Two design parameters, a translational correction factor and a rotational correction factor, were selected to design the brace geometry from the torso geometry. The 3-D digital brace was evaluated by three clinical evaluation measures (imbalance, rib hump and principal axis angle reduction) and one patient evaluation measure (discomfort). A multi-objective optimization method was employed to identify the optimal design parameters considering both clinical and patient evaluations.

  7. Scheduling Patients' Appointments: Allocation of Healthcare Service Using Simulation Optimization.

    PubMed

    Chenl, Ping-Shun; Robielos, Rex Aurelius C; Palaña, Philline Kate Vera C; Valencia, Pierre Lorenzo L; Chen, Gary Yu-Hsin

    2015-01-01

    In the service industry, scheduling medical procedures causes difficulties for both patients and management. Factors such as fluctuations in customer demand and service time affect the appointment scheduling systems' performance in terms of, for example, patients' waiting time, idle time of resources, and total cost/profits. This research implements four appointment scheduling policies, i.e., constant arrival, mixed patient arrival, three-section pattern arrival, and irregular arrival, in an ultrasound department of a hospital in Taiwan. By simulating the four implemented policies' optimization procedures, optimal or near-optimal solutions can be obtained for patients per arrival, patients' inter-arrival time, and the number of the time slots for arrived patients. Furthermore, three objective functions are tested, and the results are discussed. The managerial implications and discussions are summarized to demonstrate how outcomes can be useful for hospital managers seeking to allocate their healthcare service capacities.

  8. 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…

  9. 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…

  10. 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…

  11. 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

  12. 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…

  13. 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…

  14. [LDL cholesterol control in patients with very high cardiovascular risk. A simplified algorithm for achieving LDL cholesterol goals "in two steps"].

    PubMed

    Guijarro-Herraiz, Carlos; Masana-Marin, Luis; Galve, Enrique; Cordero-Fort, Alberto

    2014-01-01

    Reducing low density lipoprotein-cholesterol (LDL-c) is the main lipid goal of treatment for patients with very high cardiovascular risk. In these patients the therapeutic goal is to achieve a LDL-c lower than 70 mg/dL, as recommended by the guidelines for cardiovascular prevention commonly used in Spain and Europe. However, the degree of achieving these objectives in this group of patients is very low. This article describes the prevalence of the problem and the causes that motivate it. Recommendations and tools that can facilitate the design of an optimal treatment strategy for achieving the goals are also given. In addition, a new tool with a simple algorithm that can allow these very high risk patients to achieve the goals "in two-steps", i.e., with only two doctor check-ups, is presented.

  15. [Patient dose optimization in pediatric computerized tomography].

    PubMed

    Verdun, F R; Schnyder, P; Gutièrrez, D; Gudinchet, F

    2006-07-12

    The development of CT applications might become a public health problem if no effort is made on the justification and the optimisation of the examinations. This paper presents some hints to assure that the risk-benefit compromise remains in favour of the patient, especially when one deals with the examinations of young patients. In this context a particular attention has to be made on the justification of the examination. When performing the acquisition one needs to optimise the extension of the volume investigated together with the number of acquisition sequences used. Finally, the use of automatic exposure systems, now available on all the units, and the use of the Diagnostic Reference Levels (DRL) should allow help radiologists to control the exposure of their patients.

  16. Optimizing Exercise Programs for Arthritis Patients.

    ERIC Educational Resources Information Center

    Boulware, Dennis W.; Byrd, Shannon L.

    1993-01-01

    Exercise can help decrease pain and improve function in people with rheumatoid arthritis or osteoarthritis. Physicians must provide individualized, realistic, enjoyable exercise programs that help affected joints, build fitness, and maximize patient compliance. Physicians must also provide appropriate follow-up care, adjusting the exercise program…

  17. [CT imaging--towards patient- and indication-specific optimization].

    PubMed

    Kortesniemi, Mika; Lantto, Eila

    2015-01-01

    The same CT imaging program should not be applied to all patients, because the required image quality and dose of radiation vary according to the indications and regions. The programs should be optimized on the basis of indication, size of the patient and usage of intravenously administered iodine contrast agent. New technical options are available for reducing the radiation exposure. Additional means of optimization include proper definition of the region being imaged, avoidance of redundant series of images, selection of correct image quality, tube current and voltage, and new methods of calculating images. Patients' radiation exposure and clinical image quality should also be monitored.

  18. The service encounter in radiology: acing the "moments of truth" to achieve patient-centered care.

    PubMed

    Rosenkrantz, Andrew B; Pysarenko, Kristine

    2015-02-01

    Radiologists are increasingly recognizing their role as direct service providers to patients and seeking to offer an exceptional patient experience as part of high-quality service delivery. Patients' perceptions of service delivery are derived from the chain of numerous individual real-time encounters that occur throughout their visit. These so-called "moments of truth" define the overall experience and form the lasting impression of the given practice in their mind. Providing excellent service can be difficult to achieve in practice given its intangible nature as well as the heterogeneity and unpredictability of the large number of patients, frontline staff, and environmental circumstances that define the patient experience. Thus, broad commitment and team effort among all members of a radiology practice are required. This article explores important areas to be considered by a radiology practice to ensure positive and meaningful patient experiences. Specific ways in which every member within the practice, including schedulers, receptionists, technologists, nurses, and radiologists, can contribute to achieving high-quality patient service are discussed. Examples of patient-oriented language that may be useful in particular scenarios in radiology practice are given. The role of the practice's physical facility, including all aspects of its aesthetics and amenities, as well as of Internet services, in shaping the patient experience is also described. Throughout this work, a proactive approach to promoting a service-oriented organizational culture is provided. By improving the patient experience, these strategies may serve to enhance patients' perceptions of radiology and radiologists.

  19. Optimizing antimicrobial therapy in critically ill patients

    PubMed Central

    Vitrat, Virginie; Hautefeuille, Serge; Janssen, Cécile; Bougon, David; Sirodot, Michel; Pagani, Leonardo

    2014-01-01

    Critically ill patients with infection in the intensive care unit (ICU) would certainly benefit from timely bacterial identification and effective antimicrobial treatment. Diagnostic techniques have clearly improved in the last years and allow earlier identification of bacterial strains in some cases, but these techniques are still quite expensive and not readily available in all institutions. Moreover, the ever increasing rates of resistance to antimicrobials, especially in Gram-negative pathogens, are threatening the outcome for such patients because of the lack of effective medical treatment; ICU physicians are therefore resorting to combination therapies to overcome resistance, with the direct consequence of promoting further resistance. A more appropriate use of available antimicrobials in the ICU should be pursued, and adjustments in doses and dosing through pharmacokinetics and pharmacodynamics have recently shown promising results in improving outcomes and reducing antimicrobial resistance. The aim of multidisciplinary antimicrobial stewardship programs is to improve antimicrobial prescription, and in this review we analyze the available experiences of such programs carried out in ICUs, with emphasis on results, challenges, and pitfalls. Any effective intervention aimed at improving antibiotic usage in ICUs must be brought about at the present time; otherwise, we will face the challenge of intractable infections in critically ill patients in the near future. PMID:25349478

  20. Optimizing Enrollment of Patients into Nephrology Research Studies.

    PubMed

    Selewski, David T; Herreshoff, Emily G; Gipson, Debbie S

    2016-03-07

    Advances in medical care and biomedical research depend on the participation of human subjects. Poor patient enrollment in research has limited past clinical and translational research endeavors in nephrology. Simultaneously, patients and their caregivers are seeking better diagnostic, monitoring, and therapeutic approaches to improve or restore kidney and overall health. This manuscript will discuss a framework and strategies to optimize patient enrollment within nephrology research and provide examples of success from existing nephrology research programs.

  1. 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

  2. Post-laparoscopy predictive factors of achieving pregnancy in patients treated for infertility

    PubMed Central

    Wdowiak, Edyta; Stec, Magdalena; Bojar, Iwona

    2016-01-01

    Introduction Laparoscopy is a long-established diagnostic and therapeutic method for treating women suffering from infertility. The application of this method of treatment can help achieve pregnancy only if there is correct classification of patients and evaluation of their partner’s reproductive capacity. The main predictors of achieving pregnancy in a couple treated for infertility are the woman’s age, her ovarian reserve, tubal patency, the presence of endometriosis and quality of sperm parameters. Aim To evaluate the effect of endometriosis, ovarian reserve and selected parameters of semen on the effect of achieving pregnancy in patients undergoing laparoscopy. Material and methods The most significant predictor of pregnancy in patients undergoing laparoscopy due to infertility was found to be anti-Mullerian hormone (AMH) level after laparoscopy, and the main parameters of semen partners were density, motility and morphology. The number of achieved pregnancies after the laparoscopic treatment of infertility was lower in patients diagnosed with endometriosis, and depended on the severity of the condition. Results As a result of laparoscopic treatment of endometriosis, we found a decrease in ovarian reserve measured by means of AMH. Conclusions The most important predictors of pregnancy in patients who underwent laparoscopy due to infertility are post-laparoscopy AMH levels and the main parameters of the partner’s semen: density, motility and morphology. The number of pregnancies after laparoscopic treatment is lower in patients diagnosed with endometriosis, and depends on the severity of the conditio. PMID:28194245

  3. Optimal Experience and Reading Achievement in Virtual Environments among College Level Developmental Readers

    ERIC Educational Resources Information Center

    Burgess, Melissa L.

    2010-01-01

    In this mixed methods study the potential for developmental readers to experience optimal experience (flow) within the multi-user virtual environment, "Second Life," was examined. In an educational context, "Second Life" provided a space for constructivist learning, socialization, exploration, discovery and creativity. The communicative, social…

  4. Study of optimal extraction conditions for achieving high yield and antioxidant activity of tomato seed oil

    Technology Transfer Automated Retrieval System (TEKTRAN)

    Tomato seeds resulting from tomato processing by-product have not been effectively utilized as value-added products. This study investigated the kinetics of oil extraction from tomato seeds and sought to optimize the oil extraction conditions. The oil was extracted by using hexane as solvent for 0 t...

  5. 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.

  6. 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.

  7. 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.

  8. Allogeneic hematopoietic cell transplantation in patients with AML not achieving remission: potentially curative therapy.

    PubMed

    Gyurkocza, B; Lazarus, H M; Giralt, S

    2017-02-27

    Patients with acute myeloid leukemia (AML) who fail to achieve complete remission (CR) have a dismal prognosis. Although data suggest that durable remissions can be achieved in approximately 30% of patients with refractory or relapsed AML after allogeneic hematopoietic cell transplantation (HCT), only a small fraction of those patients are offered this therapeutic option. Importantly, patients with primary refractory AML have distinctly better outcomes following allogeneic HCT than those with refractory relapse. Access to suitable donors could be one of the main barriers in these situations. However, with recent developments in the field of allogeneic HCT, such as alternative donor sources, high-resolution HLA-typing, reduced intensity conditioning regimens and improvements in supportive care, this approach has the potential to offer long-term survival for patients with refractory and relapsed AML and should be considered as early after diagnosis as possible. Incorporating novel agents into the conditioning regimen or as post-transplant maintenance therapy could further improve outcomes and render older or medically infirm patients with refractory or relapsed AML eligible for allogeneic HCT. In this review, we summarize existing data on allogeneic HCT in patients with refractory or relapsed AML and explore novel approaches with the potential to improve outcomes in this patient population.Bone Marrow Transplantation advance online publication, 27 February 2017; doi:10.1038/bmt.2017.8.

  9. 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.

  10. Barriers to achieving optimal glycemic control in a multi-ethnic society: a US focus.

    PubMed

    Dagogo-Jack, Samuel; Funnell, Martha M; Davidson, Jaime

    2006-08-01

    The increasing prevalence of diabetes is particularly apparent in certain ethnic groups, such as African and Hispanic Americans. These groups generally also have poorer glycemic control and outcomes. To better understand the issues surrounding these problems and possible methods to overcome them we performed a literature review from the past 15 years on barriers to glycemic control with a focus on US data. The literature reveals that barriers may be inherent (eg, genetic, cultural, and language/communication) or acquired (eg, those associated with changes in lifestyle and socioeconomic factors). Healthcare interventions that take into consideration cultural and population-specific characteristics can reduce the prevalence and severity of diabetes and its resulting complications. Implementing such strategies will require suitable education for patients and providers, the availability of culturally-sensitive, patient-centered healthcare teams, the creation of collaborative relationships between providers and patients, better use of community resources, and assistance for patients to make informed decisions about available treatment options. There is also evidence suggesting that at the same level of glucose control Hispanics and African Americans have the same degree of complications as whites; therefore, good control is essential for the future well-being of all patients. Addressing these issues may help to decrease the ethnic disparities that currently exist in diabetes care.

  11. Optimized atomistic force fields for aqueous solutions of Magnesium and Calcium Chloride: Analysis, achievements and limitations

    NASA Astrophysics Data System (ADS)

    Elfgen, Roman; Hülsmann, Marco; Krämer, Andreas; Köddermann, Thorsten; Kirschner, Karl N.; Reith, Dirk

    2016-10-01

    Molecular simulations are an important tool in the study of aqueous salt solutions. To predict the physical properties accurately and reliably, the molecular models must be tailored to reproduce experimental data. In this work, a combination of recent global and local optimization tools is used to derive force fields for MgCl2 (aq) and CaCl2 (aq). The molecular models for the ions are based on a Lennard-Jones (LJ) potential with a superimposed point charge. The LJ parameters are adjusted to reproduce the bulk density and shear viscosity of the different solutions at 1 bar and temperatures of 293.15, 303.15, and 318.15 K. It is shown that the σ-value of chloride consistently has the strongest influence on the system properties. The optimized force field for MgCl2 (aq) provides both properties in good agreement with the experimental data over a wide range of salt concentrations. For CaCl2 (aq), a compromise was made between the bulk density and shear viscosity, since reproducing the two properties requires two different choices of the LJ parameters. This is demonstrated by studying metamodels of the simulated data, which are generated to visualize the correlation between the parameters and observables by using projection plots. Consequently, in order to derive a transferable force field, an error of ˜3% on the bulk density has to be tolerated to yield the shear viscosity in satisfactory agreement with experimental data.

  12. 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.

  13. Quality of Life and Optimism in Patients with Morphea.

    PubMed

    Szramka-Pawlak, Beata; Dańczak-Pazdrowska, Aleksandra; Rzepa, Teresa; Szewczyk, Aleksandra; Sadowska-Przytocka, Anna; Zaba, Ryszard

    2014-01-01

    Despite extensive knowledge about quality of life of people suffering from dermatological diseases, data on patients with morphea are scarce. The aim of our study was to compare the quality of life of healthy controls and morphea patients, as well as to determine the correlation of this variable with the level of dispositional optimism. The study included 47 patients with morphea and 47 healthy controls, matched for gender and age. Cantril's Ladder and Life Orientation Test-Revised were used to assess the levels of life satisfaction and dispositional optimism, respectively. LoSSI was used for the objective assessment. The anticipated level of life quality and the level of dispositional optimism were statistically significantly lower in morphea patients (p = 0.032 and p = 0.014, respectively) when compared to controls. There were no differences in the assessment of current (p = 0.168) and past (p = 0.318) levels of life quality. Also, we proved that type of morphea did not differentiate the current (p = 0.175), past (p = 0.620) and future (p = 0.356) assessment of the quality of life. In the group of morphea patients there was a statistically significant correlation between the level of dispositional optimism and current (p = 0.002, r = 0.43), as well as anticipated (p < 0.001, r = 0.57) levels of life quality. Current level of life quality of healthy controls and morphea patients is comparable, whereas the latter anticipate their future life situation to be significantly worse than the former. Higher level of life satisfaction correlates with higher level of optimism.

  14. Metal-binding sites are designed to achieve optimal mechanical and signaling properties

    PubMed Central

    Dutta, Anindita; Bahar, Ivet

    2010-01-01

    Many proteins require bound metals to achieve their function. We take advantage of increasing structural data on metal-binding proteins to elucidate three properties: the involvement of metal-binding sites in the global dynamics of the protein, predicted by elastic network models, their exposure/burial to solvent, and their signal-processing properties indicated by Markovian stochastics analysis. Systematic analysis of a dataset of 145 structures reveals that the residues that coordinate metal ions enjoy remarkably efficient and precise signal transduction properties. These properties are rationalized in terms of their physical properties: participation in hinge sites that control the softest modes collectively accessible to the protein and occupancy of central positions minimally exposed to solvent. Our observations suggest that metal-binding sites may have been evolutionary selected to achieve optimum allosteric communication. They also provide insights into basic principles for designing metal-binding sites, which are verified to be met by recently designed de novo metal-binding proteins. PMID:20826340

  15. 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.

  16. Achieving high lipid productivity of a thermotolerant microalga Desmodesmus sp. F2 by optimizing environmental factors and nutrient conditions.

    PubMed

    Ho, Shih-Hsin; Chang, Jo-Shu; Lai, Yen-Ying; Chen, Ching-Nen Nathan

    2014-03-01

    The optimal conditions for cultivating the thermotolerant lipid-rich microalga Desmodesmus sp. F2 to achieve maximal lipid productivity were determined in this study. The conditions were light intensity, 700μmol/m(2)s; temperature, 35°C; cultivation nitrogen source, nitrate; initial nitrogen level, 6.6mM nitrogen. Carbon dioxide (2.5%, 0.2 vvm) was pumped into the cultures continuously. In the pre-optimized conditions, the maximal lipid productivity of this microalga was 113mg/L/d, which was raised to 263mg/L/d in the optimized conditions. This level of lipid productivity of microalgae is the highest ever reported in the literature. Fatty acid composition of the lipid produced by Desmodesmus sp. F2 in the optimal conditions was determined, in which C16 and C18 species accounted for 95% of the fatty acids. Saturated, monounsaturated and polyunsaturated fatty acids accounted for 38.9%, 33.1% and 22.6%, respectively. Based on the analysis, this lipid quality makes it a good feedstock for biodiesel production.

  17. High direct drive illumination uniformity achieved by multi-parameter optimization approach: a case study of Shenguang III laser facility.

    PubMed

    Tian, Chao; Chen, Jia; Zhang, Bo; Shan, Lianqiang; Zhou, Weimin; Liu, Dongxiao; Bi, Bi; Zhang, Feng; Wang, Weiwu; Zhang, Baohan; Gu, Yuqiu

    2015-05-04

    The uniformity of the compression driver is of fundamental importance for inertial confinement fusion (ICF). In this paper, the illumination uniformity on a spherical capsule during the initial imprinting phase directly driven by laser beams has been considered. We aim to explore methods to achieve high direct drive illumination uniformity on laser facilities designed for indirect drive ICF. There are many parameters that would affect the irradiation uniformity, such as Polar Direct Drive displacement quantity, capsule radius, laser spot size and intensity distribution within a laser beam. A novel approach to reduce the root mean square illumination non-uniformity based on multi-parameter optimizing approach (particle swarm optimization) is proposed, which enables us to obtain a set of optimal parameters over a large parameter space. Finally, this method is applied to improve the direct drive illumination uniformity provided by Shenguang III laser facility and the illumination non-uniformity is reduced from 5.62% to 0.23% for perfectly balanced beams. Moreover, beam errors (power imbalance and pointing error) are taken into account to provide a more practical solution and results show that this multi-parameter optimization approach is effective.

  18. Optimization of Oxidation Temperature for Commercially Pure Titanium to Achieve Improved Corrosion Resistance

    NASA Astrophysics Data System (ADS)

    Bansal, Rajesh; Singh, J. K.; Singh, Vakil; Singh, D. D. N.; Das, Parimal

    2017-03-01

    Thermal oxidation of commercially pure titanium (cp-Ti) was carried out at different temperatures, ranging from 200 to 900 °C to achieve optimum corrosion resistance of the thermally treated surface in simulated body fluid. Scanning electron microscopy, x-ray diffraction, Raman spectroscopy and electrochemical impedance spectroscopy techniques were used to characterize the oxides and assess their protective properties exposed in the test electrolyte. Maximum resistance toward corrosion was observed for samples oxidized at 500 °C. This was attributed to the formation of a composite layer of oxides at this temperature comprising Ti2O3 (titanium sesquioxide), anatase and rutile phases of TiO2 on the surface of cp-Ti. Formation of an intact and pore-free oxide-substrate interface also improved its corrosion resistance.

  19. Optimization of Oxidation Temperature for Commercially Pure Titanium to Achieve Improved Corrosion Resistance

    NASA Astrophysics Data System (ADS)

    Bansal, Rajesh; Singh, J. K.; Singh, Vakil; Singh, D. D. N.; Das, Parimal

    2017-02-01

    Thermal oxidation of commercially pure titanium (cp-Ti) was carried out at different temperatures, ranging from 200 to 900 °C to achieve optimum corrosion resistance of the thermally treated surface in simulated body fluid. Scanning electron microscopy, x-ray diffraction, Raman spectroscopy and electrochemical impedance spectroscopy techniques were used to characterize the oxides and assess their protective properties exposed in the test electrolyte. Maximum resistance toward corrosion was observed for samples oxidized at 500 °C. This was attributed to the formation of a composite layer of oxides at this temperature comprising Ti2O3 (titanium sesquioxide), anatase and rutile phases of TiO2 on the surface of cp-Ti. Formation of an intact and pore-free oxide-substrate interface also improved its corrosion resistance.

  20. Behaviour and school achievement in patients with early and continuously treated phenylketonuria.

    PubMed

    Stemerdink, B A; Kalverboer, A F; van der Meere, J J; van der Molen, M W; Huisman, J; de Jong, L W; Slijper, F M; Verkerk, P H; van Spronsen, F J

    2000-09-01

    Thirty patients with early and continuously treated phenylketonuria (PKU) between 8 and 20 years of age were compared with 30 controls, matched individually for age, sex, and educational level of both parents, on behaviour rating scales for parents and teachers as well as a school achievement scale. PKU patients, as a group, demonstrated more problems in task-oriented behaviour and average academic performance than did matched controls. Interestingly, whereas male PKU patients were rated significantly lower on introversion by their teachers, female patients were rated significantly higher on introversion and lower on extraversion than matched controls. This sex difference was also reflected in the relationship between measures of dietary control and the behaviour clusters, suggesting that male and female patients respond differently to elevated Phe levels or the stress associated with PKU. The teacher rating on average academic performance of the PKU patients was associated with recent level of dietary control, which suggests that it might be improved by more strict adherence to the diet. In addition, academic performance correlated negatively with the behaviour cluster negative task orientation. Further studies are recommended to obtain a more complete evaluation of this relationship and to replicate the current findings on larger samples. Over the years a number of studies have examined behaviour and school achievement in patients with early treated phenylketonuria (PKU; McKusick 261600). In general, these studies have found that despite early treatment with a phenylalanine (Phe)-restricted diet, PKU patients demonstrate more behavioural and school problems than do healthy controls. The behaviour problems include both internalizing symptoms (e.g. solitary, unresponsive, anxious, depressed mood: Pietz et al 1997; Smith et al 1988; Weglage et al 1992) and externalizing symptoms (e.g. hyperactive, talkative, impulsive, restless: Hendrikx et al 1994; Kalverboer et al

  1. Achieving optimal essential fatty acid status in vegetarians: current knowledge and practical implications.

    PubMed

    Davis, Brenda C; Kris-Etherton, Penny M

    2003-09-01

    Although vegetarian diets are generally lower in total fat, saturated fat, and cholesterol than are nonvegetarian diets, they provide comparable levels of essential fatty acids. Vegetarian, especially vegan, diets are relatively low in alpha-linolenic acid (ALA) compared with linoleic acid (LA) and provide little, if any, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). Clinical studies suggest that tissue levels of long-chain n-3 fatty acids are depressed in vegetarians, particularly in vegans. n-3 Fatty acids have numerous physiologic benefits, including potent cardioprotective effects. These effects have been demonstrated for ALA as well as EPA and DHA, although the response is generally less for ALA than for EPA and DHA. Conversion of ALA by the body to the more active longer-chain metabolites is inefficient: < 5-10% for EPA and 2-5% for DHA. Thus, total n-3 requirements may be higher for vegetarians than for nonvegetarians, as vegetarians must rely on conversion of ALA to EPA and DHA. Because of the beneficial effects of n-3 fatty acids, it is recommended that vegetarians make dietary changes to optimize n-3 fatty acid status.

  2. Patient optimization for surgery relating to Crohn's disease.

    PubMed

    Patel, Kamal V; Darakhshan, Amir A; Griffin, Nyree; Williams, Andrew B; Sanderson, Jeremy D; Irving, Peter M

    2016-12-01

    The majority of patients with Crohn's disease require abdominal surgery during their lifetime, some of whom will require multiple operations. Postoperative complications are seen more frequently in patients requiring abdominal surgery for Crohn's disease than in patients requiring abdominal surgery for other conditions. In this article, we review the evidence supporting preoperative optimization, discussing strategies that potentially improve surgical outcomes and reduce perioperative morbidity and mortality. We discuss the roles of adequate cross-sectional imaging, nutritional optimization, appropriate adjustments of medical therapy, management of preoperative abscesses and phlegmons, smoking cessation and thromboembolic prophylaxis. We also review operation-related factors, and discuss their potential implications with respect to postoperative complications. Overall, the literature suggests that preoperative management has a major effect on postoperative outcomes.

  3. Isometric Scaling in Developing Long Bones Is Achieved by an Optimal Epiphyseal Growth Balance.

    PubMed

    Stern, Tomer; Aviram, Rona; Rot, Chagai; Galili, Tal; Sharir, Amnon; Kalish Achrai, Noga; Keller, Yosi; Shahar, Ron; Zelzer, Elazar

    2015-08-01

    One of the major challenges that developing organs face is scaling, that is, the adjustment of physical proportions during the massive increase in size. Although organ scaling is fundamental for development and function, little is known about the mechanisms that regulate it. Bone superstructures are projections that typically serve for tendon and ligament insertion or articulation and, therefore, their position along the bone is crucial for musculoskeletal functionality. As bones are rigid structures that elongate only from their ends, it is unclear how superstructure positions are regulated during growth to end up in the right locations. Here, we document the process of longitudinal scaling in developing mouse long bones and uncover the mechanism that regulates it. To that end, we performed a computational analysis of hundreds of three-dimensional micro-CT images, using a newly developed method for recovering the morphogenetic sequence of developing bones. Strikingly, analysis revealed that the relative position of all superstructures along the bone is highly preserved during more than a 5-fold increase in length, indicating isometric scaling. It has been suggested that during development, bone superstructures are continuously reconstructed and relocated along the shaft, a process known as drift. Surprisingly, our results showed that most superstructures did not drift at all. Instead, we identified a novel mechanism for bone scaling, whereby each bone exhibits a specific and unique balance between proximal and distal growth rates, which accurately maintains the relative position of its superstructures. Moreover, we show mathematically that this mechanism minimizes the cumulative drift of all superstructures, thereby optimizing the scaling process. Our study reveals a general mechanism for the scaling of developing bones. More broadly, these findings suggest an evolutionary mechanism that facilitates variability in bone morphology by controlling the activity of

  4. Identification and Treatment of Pathophysiological Comorbidities of Autism Spectrum Disorder to Achieve Optimal Outcomes

    PubMed Central

    Frye, Richard E.; Rossignol, Daniel A.

    2016-01-01

    the optimal treatments for these abnormalities. PMID:27330338

  5. Pregnancy in end-stage renal disease patients on dialysis: how to achieve a successful delivery.

    PubMed

    Manisco, Gianfranco; Potì', Marcello; Maggiulli, Giuseppe; Di Tullio, Massimo; Losappio, Vincenzo; Vernaglione, Luigi

    2015-06-01

    Pregnancy in women with chronic kidney disease has always been considered as a challenging event both for the mother and the fetus. Over the years, several improvements have been achieved in the outcome of pregnant chronic renal patients with increasing rates of successful deliveries. To date, evidence suggests that the stage of renal failure is the main predictive factor of worsening residual kidney function and complications in pregnant women. Moreover, the possibility of success of the pregnancy depends on adequate depurative and pharmacological strategies in patients with end-stage renal disease. In this paper, we propose a review of the current literature about this topic presenting our experience as well.

  6. Pregnancy in end-stage renal disease patients on dialysis: how to achieve a successful delivery

    PubMed Central

    Manisco, Gianfranco; Potì’, Marcello; Maggiulli, Giuseppe; Di Tullio, Massimo; Losappio, Vincenzo; Vernaglione, Luigi

    2015-01-01

    Pregnancy in women with chronic kidney disease has always been considered as a challenging event both for the mother and the fetus. Over the years, several improvements have been achieved in the outcome of pregnant chronic renal patients with increasing rates of successful deliveries. To date, evidence suggests that the stage of renal failure is the main predictive factor of worsening residual kidney function and complications in pregnant women. Moreover, the possibility of success of the pregnancy depends on adequate depurative and pharmacological strategies in patients with end-stage renal disease. In this paper, we propose a review of the current literature about this topic presenting our experience as well. PMID:26034591

  7. 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.

  8. 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.

  9. Pharmacodynamic effects of cangrelor and clopidogrel: the platelet function substudy from the cangrelor versus standard therapy to achieve optimal management of platelet inhibition (CHAMPION) trials.

    PubMed

    Angiolillo, Dominick J; Schneider, David J; Bhatt, Deepak L; French, William J; Price, Matthew J; Saucedo, Jorge F; Shaburishvili, Tamaz; Huber, Kurt; Prats, Jayne; Liu, Tiepu; Harrington, Robert A; Becker, Richard C

    2012-07-01

    Cangrelor is an intravenous antagonist of the P2Y(12) receptor characterized by rapid, potent, predictable, and reversible platelet inhibition. However, cangrelor was not superior to clopidogrel in reducing the incidence of ischemic events in the cangrelor versus standard therapy to achieve optimal management of platelet inhibition (CHAMPION) trials. A prospectively designed platelet function substudy was performed in a selected cohort of patients to provide insight into the pharmacodynamic effects of cangrelor, particularly in regard to whether cangrelor therapy may interfere with the inhibitory effects of clopidogrel. This pre-defined substudy was conducted in a subset of patients from the CHAMPION-PCI trial (n = 230) comparing cangrelor with 600 mg of clopidogrel administered before percutaneous coronary intervention (PCI) and from the CHAMPION-PLATFORM trial (n = 4) comparing cangrelor at the time of PCI and 600 mg clopidogrel given after the PCI. Pharmacodynamic measures included P2Y12 reaction units (PRU) assessed by VerifyNow P2Y12 testing (primary endpoint marker), platelet aggregation by light transmittance aggregometry following 5 and 20 μmol/L adenosine diphosphate stimuli, and markers of platelet activation determined by flow cytometry. The primary endpoint was the percentage of patients who achieved <20 % change in PRU between baseline and >10 h after PCI. The main trial was stopped early limiting enrollment in the platelet substudy. A total of 167 patients had valid pharmacodynamic assessments for the primary endpoint. The percent of individuals achieving <20 % change in PRU between baseline and >10 h after PCI was higher with cangrelor + clopidogrel (32/84, 38.1 %) compared with placebo + clopidogrel (21/83, 25.3 %), but this was not statistically significant (difference:12.79 %, 95 % CI: -1.18 %, 26.77 %;p = 0.076). All pharmacodynamic markers as well as the prevalence of patients with high on-treatment platelet reactivity were significantly lower

  10. Optimal serum phenylalanine for adult patients with phenylketonuria.

    PubMed

    Okano, Yoshiyuki; Nagasaka, Hironori

    2013-12-01

    High serum phenylalanine in adult patients with phenylketonuria (PKU) causes neuropsychological and psychosocial problems that can be resolved by phenylalanine-restricted diet. Therefore, PKU patients must continue to adhere to phenylalanine-restricted diet for life, although the optimal serum phenylalanine level in later life has yet to be established. The purpose of this review was to establish the optimal serum phenylalanine level in later life of PKU patients. We evaluated oxidative stress status, nitric oxide metabolism, cholesterol-derived oxysterols, vitamin D and bone status, and magnetic resonance imaging (MRI) in adult PKU patients according to serum phenylalanine level. Oxidative stress increased markedly at serum phenylalanine of 700-800 μmol/L. Serum phenylalanine higher than 700-850 μmol/L correlated with the disturbance of nitric oxide regulatory system. Adult PKU patients had poor vitamin D status and exhibited predominance of bone resorption over bone formation. In the brain, the levels of 24S-hydroxycholesterol, a marker of brain cholesterol elimination, were low at serum phenylalanine levels exceeding 650 μmol/L. MRI studies showed high signal intensity in deep white matter on T2-weighted and FLAIR images of PKU patients with serum phenylalanine greater than 500 μmol/L, with decreased apparent diffusion coefficients. Changes in most parameters covering the entire body organs in adult PKU were almost acceptable below 700-800 μmol/L of phenylalanine level. However, the optimal serum phenylalanine level should be 500 μmol/L or less in later life for the brain to be safe.

  11. The Stories Clinicians Tell: Achieving High Reliability and Improving Patient Safety

    PubMed Central

    Cohen, Daniel L; Stewart, Kevin O

    2016-01-01

    The patient safety movement has been deeply affected by the stories patients have shared that have identified numerous opportunities for improvements in safety. These stories have identified system and/or human inefficiencies or dysfunctions, possibly even failures, often resulting in patient harm. Although patients’ stories tell us much, less commonly heard are the stories of clinicians and how their personal observations regarding the environments they work in and the circumstances and pressures under which they work may degrade patient safety and lead to harm. If the health care industry is to function like a high-reliability industry, to improve its processes and achieve the outcomes that patients rightly deserve, then leaders and managers must seek and value input from those on the front lines—both clinicians and patients. Stories from clinicians provided in this article address themes that include incident identification, disclosure and transparency, just culture, the impact of clinical workload pressures, human factors liabilities, clinicians as secondary victims, the impact of disruptive and punitive behaviors, factors affecting professional morale, and personal failings. PMID:26580146

  12. Does achieving the best practice tariff improve outcomes in hip fracture patients? An observational cohort study

    PubMed Central

    Oakley, B; Nightingale, J; Moran, CG; Moppett, IK

    2017-01-01

    Objectives To determine if the introduction of the best practice tariff (BPT) has improved survival of the elderly hip fracture population, or if achieving BPT results in improved survival for an individual. Setting A single university-affiliated teaching hospital. Participants 2541 patients aged over 60 admitted with a neck of femur fracture between 2008 and 2010 and from 2012 to 2014 were included, to create two cohorts of patients, before and after the introduction of BPT. The post-BPT cohort was divided into two groups, those who achieved the criteria and those who did not. Primary and secondary outcome measures Primary outcomes of interest were differences in mortality across cohorts. Secondary analysis was performed to identify associations between individual BPT criteria and mortality. Results The introduction of BPT did not significantly alter overall 30-mortality in the hip fracture population (8.3% pre-BPT vs 10.0% post-BPT; p=0.128). Neither was there a significant reduction in length of stay (15 days (IQR 9–21) pre-BPT vs 14 days (IQR 11–22); p=0.236). However, the introduction of BPT was associated with a reduction in the time from admission to theatre (median 44 hours pre-BPT (IQR 24–44) vs 23 hours post-BPT (IQR 17–30); p<0.005). 30-day mortality in those who achieved BPT was significantly lower (6.0% vs 21.0% in those who did not achieve-BPT; p<0.005). There was a survival benefit at 1 year for those who achieved BPT (28.6% vs 42.0% did not achieve-BPT; p<0.005). Multivariate logistic regression revealed that of the BPT criteria, AMT monitoring and expedited surgery were the only BPT criteria that significantly influenced survival. Conclusions The introduction of the BPT has not led to a demonstrable improvement in outcomes at organisational level, though other factors may have confounded any benefits. However, patients where BPT criteria are met appear to have improved outcomes. PMID:28167748

  13. Is there an optimal resting velopharyngeal gap in operated cleft palate patients?

    PubMed Central

    Yellinedi, Rajesh; Damalacheruvu, Mukunda Reddy

    2013-01-01

    Context: Videofluoroscopy in operated cleft palate patients. Aims: To determine the existence of an optimal resting velopharyngeal (VP) gap in operated cleft palate patients Settings and Design: A retrospective analysis of lateral view videofluoroscopy of operated cleft palate patients. Materials and Methods: A total of 117 cases of operated cleft palate underwent videofluoroscopy between 2006 and 2011. The lateral view of videofluoroscopy was utilised in the study. A retrospective analysis of the lateral view of videofluoroscopy of these 117 patients was performed to analyse the resting VP gap and its relationship to VP closure. Statistical analysis used: None. Results: Of the 117 cases, 35 had a resting gap of less than 6 mm, 34 had a resting gap between 6 and 10 mm and 48 patients had a resting gap of more than 10 mm. Conclusions: The conclusive finding was that almost all the patients with a resting gap of <6 mm (group C) achieved radiological closure of the velopharynx with speech; thus, they had the least chance of VP insufficiency (VPI). Those patients with a resting gap of >10 mm (group A) did not achieve VP closure on phonation, thus having full-blown VPI. Therefore, it can be concluded that the ideal resting VP gap is approximately 6 mm so as to get the maximal chance of VP closure and thus prevent VPI. PMID:23960311

  14. 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.

  15. Optimization of scheduling patient appointments in clinics using a novel modelling technique of patient arrival.

    PubMed

    Tai, Guangfu; Williams, Peter

    2012-11-01

    This paper re-visits the question of mapping a probability distribution to patient unpunctuality in appointment-driven outpatient clinics, with reference to published empirical arrival data. This data indicates the possibility of interesting aberrations such as local modes and near-modes, asymmetry and peakedness. We examine the form of some published data on patient unpunctuality, and propose a mixed distribution which we call "F3" to provide a richer representation of shape such as in the shoulders of the distribution. The adequacy of this model is assessed in a worked example referencing a classical study, where a comparison is made of F3 against the normal and Pearson VII distributions with reference to summary statistics, graphical probability plots (P-P and Q-Q), a range of goodness of fitness criteria. Under this patient arrival setting, 2P method is proposed for optimal patient interval setting to minimize waiting time of both patient and the doctor and this 2P method is validated with a tentative simulation example. This study argues that frequency distribution of patient unpunctuality shows asymmetry in shape which is resulted from various types of arrival behaviours. Consequently optimal appointment intervals of scheduled patients, which minimize the total waiting time of patients and the doctor is highly related to patient unpunctuality patterns and this makes the optimal appointment intervals for various patient unpunctualities predictable.

  16. Optimal study design for pioglitazone in septic pediatric patients.

    PubMed

    Sherwin, Catherine M T; Ding, Lili; Kaplan, Jennifer; Spigarelli, Michael G; Vinks, Alexander A

    2011-08-01

    The objective was to demonstrate the methodology and process of optimal sparse sampling pharmacokinetics (PK). This utilized a single daily dose of pioglitazone for pediatric patients with severe sepsis and septic shock based upon adult and minimal adolescent data. Pioglitazone pharmacokinetics were modeled using non-compartment analysis WinNonlin Pro (version 5.1) and population kinetics using NONMEM (version 7.1) with first order conditional estimation method (FOCE) with interaction. The initial model was generated from single- and multiple-dose pioglitazone PK data (15 mg, 30 mg, and 45 mg) in 36 adolescents with diabetes. PK models were simulated and overlaid upon original data to provide a comparison best described by a single compartment, first order model. The optimal design was based on the simulated oral administration of pioglitazone to three groups of pediatric patients, age 3.8 (2-6 years), weight 14.4 (7-28 kg); age 9.6 (6.1-11.9 years), weight 36.5 (28.1-48 kg) and age 15.5 (12-17 years,) weight 61.6 (48.1-80 kg). PFIM (version 3.2) was used to evaluate sample study size. Datasets were compiled using simulation for each dose (15, 30 and 45 mg) for the potential age/weight groups. A target dose of 15 mg daily in the youngest and middle groups was considered appropriate with area under the curve exposure levels (AUC) comparable to studies in adolescents. The final optimal design suggested time points of 0.5, 2, 6 and 21 h for 24 h dosing. This methodology provides a robust method of utilizing adult and limited adolescent data to simulate allometrically scaled, pediatric data sets that allow the optimal design of a pediatric trial. The pharmacokinetics of pioglitazone were described adequately and simulated data estimates were comparable to literature values. The optimal design provided clinically attainable sample times and windows.

  17. Hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery.

    PubMed

    Najafi, Mahdi; Faraoni, David

    2015-07-26

    Although red blood cells (RBCs) transfusion is sometimes associated with adverse reactions, anemia could also lead to increased morbidity and mortality in high-risk patients. For these reasons, the definition of perioperative strategies that aims to detect and treat preoperative anemia, prevent excessive blood loss, and define "optimal" transfusion algorithms is crucial. Although the treatment with preoperative iron and erythropoietin has been recommended in some specific conditions, several controversies exist regarding the benefit-to-risk balance associated with these treatments. Further studies are needed to better define the indications, dosage, and route of administration for preoperative iron with or without erythropoietin supplementation. Although restrictive transfusion strategies in patients undergoing cardiac surgery have been shown to effectively reduce the incidence and the amount of RBCs transfusion without increase in side effects, some high-risk patients (e.g., symptomatic acute coronary syndrome) could benefit from higher hemoglobin concentrations. Despite all efforts made last decade, a significant amount of work remains to be done to improve hemoglobin optimization and transfusion strategies in patients undergoing cardiac surgery.

  18. Optimal parameters for clinical implementation of breast cancer patient setup using Varian DTS software.

    PubMed

    Ng, Sook Kien; Zygmanski, Piotr; Jeung, Andrew; Mostafavi, Hassan; Hesser, Juergen; Bellon, Jennifer R; Wong, Julia S; Lyatskaya, Yulia

    2012-05-10

    Digital tomosynthesis (DTS) was evaluated as an alternative to cone-beam computed tomography (CBCT) for patient setup. DTS is preferable when there are constraints with setup time, gantry-couch clearance, and imaging dose using CBCT. This study characterizes DTS data acquisition and registration parameters for the setup of breast cancer patients using nonclinical Varian DTS software. DTS images were reconstructed from CBCT projections acquired on phantoms and patients with surgical clips in the target volume. A shift-and-add algorithm was used for DTS volume reconstructions, while automated cross-correlation matches were performed within Varian DTS software. Triangulation on two short DTS arcs separated by various angular spread was done to improve 3D registration accuracy. Software performance was evaluated on two phantoms and ten breast cancer patients using the registration result as an accuracy measure; investigated parameters included arc lengths, arc orientations, angular separation between two arcs, reconstruction slice spacing, and number of arcs. The shifts determined from DTS-to-CT registration were compared to the shifts based on CBCT-to-CT registration. The difference between these shifts was used to evaluate the software accuracy. After findings were quantified, optimal parameters for the clinical use of DTS technique were determined. It was determined that at least two arcs were necessary for accurate 3D registration for patient setup. Registration accuracy of 2 mm was achieved when the reconstruction arc length was > 5° for clips with HU ≥ 1000; larger arc length (≥ 8°) was required for very low HU clips. An optimal arc separation was found to be ≥ 20° and optimal arc length was 10°. Registration accuracy did not depend on DTS slice spacing. DTS image reconstruction took 10-30 seconds and registration took less than 20 seconds. The performance of Varian DTS software was found suitable for the accurate setup of breast cancer patients

  19. 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.

  20. Optimal control based seizure abatement using patient derived connectivity

    PubMed Central

    Taylor, Peter N.; Thomas, Jijju; Sinha, Nishant; Dauwels, Justin; Kaiser, Marcus; Thesen, Thomas; Ruths, Justin

    2015-01-01

    Epilepsy is a neurological disorder in which patients have recurrent seizures. Seizures occur in conjunction with abnormal electrical brain activity which can be recorded by the electroencephalogram (EEG). Often, this abnormal brain activity consists of high amplitude regular spike-wave oscillations as opposed to low amplitude irregular oscillations in the non-seizure state. Active brain stimulation has been proposed as a method to terminate seizures prematurely, however, a general and widely-applicable approach to optimal stimulation protocols is still lacking. In this study we use a computational model of epileptic spike-wave dynamics to evaluate the effectiveness of a pseudospectral method to simulated seizure abatement. We incorporate brain connectivity derived from magnetic resonance imaging of a subject with idiopathic generalized epilepsy. We find that the pseudospectral method can successfully generate time-varying stimuli that abate simulated seizures, even when including heterogeneous patient specific brain connectivity. The strength of the stimulus required varies in different brain areas. Our results suggest that seizure abatement, modeled as an optimal control problem and solved with the pseudospectral method, offers an attractive approach to treatment for in vivo stimulation techniques. Further, if optimal brain stimulation protocols are to be experimentally successful, then the heterogeneity of cortical connectivity should be accounted for in the development of those protocols and thus more spatially localized solutions may be preferable. PMID:26089775

  1. 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.

  2. Optimization of the radiological protection of patients undergoing digital radiography.

    PubMed

    Zhang, Menglong; Chu, Cunkun

    2012-02-01

    Because of a much higher dynamic range of flat panel detectors, patient dose can vary without change of image quality being perceived by radiologists. This condition makes optimization (OT) of radiation protection undergoing digital radiography (DR) more complex, while a chance to reduced patient dose also exists. In this study, we evaluated the difference of patient radiation and image rejection before and after OT to identify if it is necessary to carry out an OT procedure in a routine task with DR. The study consisted of a measurement of the dose area product (DAP) and entrance surface dose (ESD) received by a reference group of patients for eight common radiographic procedures using the DR system before and after OT. Meanwhile image rejection data during two 2-month periods were collected and sorted according to reason. For every radiographic procedure, t tests showed significant difference in average ESD and DAP before and after OT (p < 0.005). The ESDs from most examinations before OT were three times higher than that after OT. For DAPs, the difference is more significant. Image rejection rate after OT is significantly lower than that before OT (χ (2) = 36.5, p < 0.005). The substantial reductions of dose after OT resulted from appropriate mAs and exposure field. For DR patient dose, less than recommended diagnostic reference level can meet quality criteria and clinic diagnosis.

  3. Adalimumab induction and maintenance therapy achieve clinical remission and response in Chinese patients with Crohn's disease

    PubMed Central

    Ran, Zhi Hua; Gao, Xiang; Chen, Minhu; Zhong, Jie; Sheng, Jian-Qiu; Kamm, Michael A; Travis, Simon; Wallace, Kori; Mostafa, Nael M; Shapiro, Marisa; Li, Yao; Thakkar, Roopal B; Robinson, Anne M

    2016-01-01

    Background/Aims This was a Phase 2 study (NCT02015793) to evaluate the pharmacokinetics, safety, and efficacy of adalimumab in Chinese patients with Crohn's disease (CD). Methods Thirty, adult Chinese patients with CD (CD Activity Index [CDAI] 220–450; high-sensitivity [hs]-C-reactive protein [CRP] ≥3 mg/L) received double-blind adalimumab 160/80 mg or 80/40 mg at weeks 0/2, followed by 40 mg at weeks 4 and 6. An open-label extension period occurred from weeks 8–26; patients received 40 mg adalimumab every other week. Serum adalimumab concentration and change from baseline in fecal calprotectin (FC) were measured during the double-blind period. Clinical remission (CDAI <150), response (decrease in CDAI ≥70 points from baseline), and change from baseline in hs-CRP were assessed through week 26. Nonresponder imputation was used for missing categorical data and last observation carried forward for missing hs-CRP/FC values. No formal hypothesis was tested. Adverse events were monitored. Results Mean adalimumab serum concentrations during the induction phase were 13.9–18.1 µg/mL (160/80 mg group) and 7.5−9.5 µg/mL (80/40 mg group). During the double-blind period, higher remission/response rates and greater reductions from baseline in hs-CRP and FC were observed with adalimumab 160/80 mg compared to that with 80/40 mg. Adverse event rates were similar among all treatment groups. Conclusions Adalimumab serum concentrations in Chinese patients with CD were comparable to those observed previously in Western and Japanese patients. Clinically meaningful remission rates and improvement in inflammatory markers were achieved with both dosing regimens; changes occurred rapidly with adalimumab 160/80 mg induction therapy. No new safety signals were reported. PMID:27175116

  4. Optimal management of cytomegalovirus retinitis in patients with AIDS

    PubMed Central

    Stewart, Michael W

    2010-01-01

    Cytomegalovirus (CMV) retinitis is the most common cause of vision loss in patients with acquired immunodeficiency syndrome (AIDS). CMV retinitis afflicted 25% to 42% of AIDS patients in the pre-highly active antiretroviral therapy (HAART) era, with most vision loss due to macula-involving retinitis or retinal detachment. The introduction of HAART significantly decreased the incidence and severity of CMV retinitis. Optimal treatment of CMV retinitis requires a thorough evaluation of the patient’s immune status and an accurate classification of the retinal lesions. When retinitis is diagnosed, HAART therapy should be started or improved, and anti-CMV therapy with oral valganciclovir, intravenous ganciclovir, foscarnet, or cidofovir should be administered. Selected patients, especially those with zone 1 retinitis, may receive intravitreal drug injections or surgical implantation of a sustained-release ganciclovir reservoir. Effective anti-CMV therapy coupled with HAART significantly decreases the incidence of vision loss and improves patient survival. Immune recovery uveitis and retinal detachments are important causes of moderate to severe loss of vision. Compared with the early years of the AIDS epidemic, the treatment emphasis in the post- HAART era has changed from short-term control of retinitis to long-term preservation of vision. Developing countries face shortages of health care professionals and inadequate supplies of anti-CMV and anti-HIV medications. Intravitreal ganciclovir injections may be the most cost effective strategy to treat CMV retinitis in these areas. PMID:20463796

  5. [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.

  6. Lipid Encapsulation Provides Insufficient Total-Tract Digestibility to Achieve an Optimal Transfer Efficiency of Fatty Acids to Milk Fat

    PubMed Central

    Bainbridge, Melissa; Kraft, Jana

    2016-01-01

    Transfer efficiencies of rumen-protected n-3 fatty acids (FA) to milk are low, thus we hypothesized that rumen-protection technologies allow for biohydrogenation and excretion of n-3 FA. The objectives of this study were to i) investigate the ruminal protection and post-ruminal release of the FA derived from the lipid-encapsulated echium oil (EEO), and ii) assess the bioavailability and metabolism of the EEO-derived FA through measuring the FA content in plasma lipid fractions, feces, and milk. The EEO was tested for rumen stability using the in situ nylon bag technique, then the apparent total-tract digestibility was assessed in vivo using six Holstein dairy cattle. Diets consisted of a control (no EEO); 1.5% of dry matter (DM) as EEO and 1.5% DM as encapsulation matrix; and 3% DM as EEO. The EEO was rumen-stable and had no effect on animal production. EEO-derived FA were incorporated into all plasma lipid fractions, with the highest proportion of n-3 FA observed in cholesterol esters. Fecal excretion of EEO-derived FA ranged from 7–14%. Biohydrogenation products increased in milk, plasma, and feces with EEO supplementation. In conclusion, lipid-encapsulation provides inadequate digestibility to achieve an optimal transfer efficiency of n-3 FA to milk. PMID:27741299

  7. Impact of achievement of complete cytogenetic response on outcome in patients with myelodysplastic syndromes treated with hypomethylating agents.

    PubMed

    Jabbour, Elias; Strati, Paolo; Cabrero, Monica; O'Brien, Susan; Ravandi, Farhad; Bueso-Ramos, Carlos; Wei, Qiao; Hu, Jianhua; Abi Aad, Simon; Short, Nicholas J; Dinardo, Courtney; Daver, Naval; Kadia, Tapan; Wierda, William; Wei, Yue; Colla, Simona; Borthakur, Gautam; Cortes, Jorge; Estrov, Zeev; Kantarjian, Hagop; Garcia-Manero, Guillermo

    2017-04-01

    Two hundred and sixteen consecutive patients with MDS and abnormal karyotype treated with hypomethylating agents between 4/04 and 10/12 were reviewed. Median follow-up was 17 months. Using IWG criteria, best responses were complete response (CR) in 79 patients (37%), partial response (PR) in 4 (2%), and hematologic improvement (HI) in 10 (5%). Cytogenetic response (CyR) was achieved in 78 patients (36%): complete (CCyR) in 62 (29%) and partial in 16 (7%). CyR was achieved in 48 of 79 patients (61%) with CR, 1 of 14 (7%) with PR/HI, and in 29 of the 123 (24%) with no morphologic response. Median overall survival (OS) and leukemia-free survival (LFS) for patients with and without CCyR were 21 and 13 months (P = .007), and 16 and 9 months (P = .001), respectively. By multivariate analysis, the achievement of CCyR was predictive for better OS (HR = 2.1; P < .001). In conclusion, CyR occurs at a rate of 36% (complete in 29%) in patients with MDS treated with HMA and is not always associated with morphological response. The achievement of CCyR is associated with survival improvement and constitutes a major predictive factor for outcome particularly in patients without morphologic response. Therefore, the achievement of CCyR should be considered a milestone in the management of patients with MDS.

  8. How to successfully achieve salt restriction in dialysis patients? What are the outcomes?

    PubMed

    Ok, Ercan

    2010-01-01

    Despite the fact that dietary salt restriction is the most logical measure to prevent accumulation of salt and water in patients without renal function, it is not applied in most dialysis centers. In this review, the reasons for this unlucky development are analyzed. First, it appears that many dialysis patients are slightly overhydrated, but this is often not noticed and, if so, the deleterious effects in the long run are not appreciated. These consist not only of 'drug-resistant' hypertension, but also dilatation of the cardiac compartments leading to preventable cardiovascular events. Second, there are practical reasons why salt restriction is neglected. It is very difficult to buy salt-poor food. Salt consumption is an addiction, which can be overcome, but time and efforts are needed to achieve that. Suggestions are made how to reach that goal. Finally, examples are given how cardiac damage (often considered irreversible) can be improved or even cured by a 'volume control' strategy, whose crucial part is serious salt restriction.

  9. [Complete response achieved after rituximab plus CHOP therapy in a patient with rapidly progressing Waldenstrom's macroglobulinemia].

    PubMed

    Ise, Mikiko; Sakai, Chikara; Kumagai, Kyoya

    2009-01-01

    A 62-year-old man presented with lymphocytosis, anemia, thrombocytopenia, abdominal lymphadenopathies, and gross splenomegaly. He had a high serum immunoglobulin M (IgM) of 1,150 mg/dl and IgM-kappa type monoclonal protein was detected. Bone marrow examination demonstrated massive infiltration of CD19+CD20+CD5-CD10-CD23-lymphoplasmacytic cells, and the diagnosis of Waldenstrom's macroglobulinemia (WM) was made. The serum levels of soluble interleukin-2 receptor and beta2-microglobulin were also elevated to 14,300 U/ml and 6.2 mg/l, respectively. The high tumor burden and aggressive clinical features prompted the initiation of CHOP therapy. After three courses of CHOP, the patient recovered from anemia and the serum IgM level decreased to 615 mg/dl. Then we administered rituximab in combination with CHOP (R-CHOP therapy). After an additional five courses of R-CHOP, bone marrow tumor cells, splenomegaly and lymphadenopathies entirely disappeared and IgM-type monoclonal protein also became negative on immunofixation studies. Thus, a complete response (CR) was achieved and the patient has remained in CR for 12 months. Although new therapeutic options for WM including combination chemotherapy have recently been explored, complete response rates defined by immunofixation remain low. Our case indicates that R-CHOP therapy is fully effective and tolerable for aggressive type WM.

  10. 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.

  11. A quality improvement model for optimizing care of the diabetic end-stage renal disease patient.

    PubMed

    Mahnensmith, Rex L; Zorzanello, Mary; Hsu, Yueh-Han; Williams, Mark E

    2010-01-01

    Persons with diabetes mellitus whose kidney disease progresses to end-stage requiring dialysis have poorer outcomes compared to nondiabetic patients who commence maintenance dialysis. In the diabetic patient without renal failure, sustained strict glycemic, lipid, and blood pressure (BP) control can retard or thwart diabetic complications such as retinopathy, neuropathy, coronary disease, and peripheral vascular disease. Achieving these outcomes requires multidisciplinary collaborative care. Best care of the diabetic person requires a dedicated clinician who knows the patient well, who closely follows the course of clinical problems, who provides frequent assessments and interventions, and who also directs care to other agencies, clinics, and specialized clinicians who provide expert focused evaluations and interventions aimed at specific clinical concerns. Diabetic patients who reach end-stage renal disease (ESRD) have even greater clinical need of a dedicated principal care clinician than the diabetic patient who has minimal or moderate kidney disease. The diabetic patient with ESRD exhibits greater fluctuations in glucose and BP due to dialysis-related diet patterns and fluid balances and has more active cardiovascular problems due to the combined influences of calcium, phosphorus, and lipid imbalances. These problems warrant exceptional care that includes frequent surveillance and monitoring with timely interventions if patient outcomes are to be improved. We present here a quality improvement model for optimizing care of the diabetic dialysis patient that relies on a dedicated practitioner who can evaluate and intervene on the multiple variables within and beyond the dialysis clinic that impact the patient's health. We present three detailed clinical care pathways that the dedicated clinician can follow. We believe that patient outcomes can be improved with this approach that provides customized problem-focused care, collaborates with the dialysis

  12. Prediction of the optimum surface orientation angles to achieve maximum solar radiation using Particle Swarm Optimization in Sabha City Libya

    NASA Astrophysics Data System (ADS)

    Mansour, F. A.; Nizam, M.; Anwar, M.

    2017-02-01

    This research aims to predict the optimum surface orientation angles in solar panel installation to achieve maximum solar radiation. Incident solar radiation is calculated using koronakis mathematical model. Particle Swarm Optimization (PSO) is used as computational method to find optimum angle orientation for solar panel installation in order to get maximum solar radiation. A series of simulation has been carried out to calculate solar radiation based on monthly, seasonally, semi-yearly and yearly period. South-facing was calculated also as comparison of proposed method. South-facing considers azimuth of 0°. Proposed method attains higher incident predictions than South-facing that recorded 2511.03 kWh/m2for monthly. It were about 2486.49 kWh/m2, 2482.13 kWh/m2and 2367.68 kWh/m2 for seasonally, semi-yearly and yearly. South-facing predicted approximately 2496.89 kWh/m2, 2472.40 kWh/m2, 2468.96 kWh/m2, 2356.09 kWh/m2for monthly, seasonally, semi-yearly and yearly periods respectively. Semi-yearly is the best choice because it needs twice adjustments of solar panel in a year. Yet it considers inefficient to adjust solar panel position in every season or monthly with no significant solar radiation increase than semi-yearly and solar tracking device still considers costly in solar energy system. PSO was able to predict accurately with simple concept, easy and computationally efficient. It has been proven by finding the best fitness faster.

  13. 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…

  14. Long-term management strategies to achieve optimal function in patients with bipolar disorder.

    PubMed

    Keck, Paul E

    2006-01-01

    Functional impairment is a problem for people with bipolar disorder. Predictors of poor functional outcome are psychiatric and medical comorbidity, interepisode subsyndromal symptoms, psychosis during a manic or mixed episode, and low premorbid functioning. Cognitive dysfunction may also be a contributory factor in functional impairment. Several psychosocial interventions designed for people with bipolar disorder have demonstrated success in improving syndromal outcomes, but the effects of psychosocial interventions on functioning and cognition have not been examined. Among pharmacologic interventions available for long-term treatment of bipolar disorder, there is a strong clinical trend away from monotherapy and toward combination therapy. Lithium, lamotrigine, olanzapine, and aripiprazole have all shown substantial improvements in relapse rates compared with placebo. Although some of these medications show superior results compared with the others in preventing the recurrence of either depressive or manic episodes, only anecdotal evidence exists regarding their effect on cognition. Combination therapy with antipsychotics or antidepressants has also been shown to produce better syndromal outcomes in people with bipolar disorder, but inadequate evidence is available on cognitive outcomes. Substantial information is needed regarding the prevalence and causes of cognitive dysfunction in bipolar disorder, the effects of existing treatments on cognition, and long-term treatments to improve cognition and functioning.

  15. Optimizing CT radiation dose based on patient size and image quality: the size-specific dose estimate method.

    PubMed

    Larson, David B

    2014-10-01

    The principle of ALARA (dose as low as reasonably achievable) calls for dose optimization rather than dose reduction, per se. Optimization of CT radiation dose is accomplished by producing images of acceptable diagnostic image quality using the lowest dose method available. Because it is image quality that constrains the dose, CT dose optimization is primarily a problem of image quality rather than radiation dose. Therefore, the primary focus in CT radiation dose optimization should be on image quality. However, no reliable direct measure of image quality has been developed for routine clinical practice. Until such measures become available, size-specific dose estimates (SSDE) can be used as a reasonable image-quality estimate. The SSDE method of radiation dose optimization for CT abdomen and pelvis consists of plotting SSDE for a sample of examinations as a function of patient size, establishing an SSDE threshold curve based on radiologists' assessment of image quality, and modifying protocols to consistently produce doses that are slightly above the threshold SSDE curve. Challenges in operationalizing CT radiation dose optimization include data gathering and monitoring, managing the complexities of the numerous protocols, scanners and operators, and understanding the relationship of the automated tube current modulation (ATCM) parameters to image quality. Because CT manufacturers currently maintain their ATCM algorithms as secret for proprietary reasons, prospective modeling of SSDE for patient populations is not possible without reverse engineering the ATCM algorithm and, hence, optimization by this method requires a trial-and-error approach.

  16. Optimal control of ICU patient discharge: from theory to implementation.

    PubMed

    Mallor, Fermín; Azcárate, Cristina; Barado, Julio

    2015-09-01

    This paper deals with the management of scarce health care resources. We consider a control problem in which the objective is to minimize the rate of patient rejection due to service saturation. The scope of decisions is limited, in terms both of the amount of resources to be used, which are supposed to be fixed, and of the patient arrival pattern, which is assumed to be uncontrollable. This means that the only potential areas of control are speed or completeness of service. By means of queuing theory and optimization techniques, we provide a theoretical solution expressed in terms of service rates. In order to make this theoretical analysis useful for the effective control of the healthcare system, however, further steps in the analysis of the solution are required: physicians need flexible and medically-meaningful operative rules for shortening patient length of service to the degree needed to give the service rates dictated by the theoretical analysis. The main contribution of this paper is to discuss how the theoretical solutions can be transformed into effective management rules to guide doctors' decisions. The study examines three types of rules based on intuitive interpretations of the theoretical solution. Rules are evaluated through implementation in a simulation model. We compare the service rates provided by the different policies with those dictated by the theoretical solution. Probabilistic analysis is also included to support rule validity. An Intensive Care Unit is used to illustrate this control problem. The study focuses on the Markovian case before moving on to consider more realistic LoS distributions (Weibull, Lognormal and Phase-type distribution).

  17. Optimizing sedation in patients with acute brain injury.

    PubMed

    Oddo, Mauro; Crippa, Ilaria Alice; Mehta, Sangeeta; Menon, David; Payen, Jean-Francois; Taccone, Fabio Silvio; Citerio, Giuseppe

    2016-05-05

    Daily interruption of sedative therapy and limitation of deep sedation have been shown in several randomized trials to reduce the duration of mechanical ventilation and hospital length of stay, and to improve the outcome of critically ill patients. However, patients with severe acute brain injury (ABI; including subjects with coma after traumatic brain injury, ischaemic/haemorrhagic stroke, cardiac arrest, status epilepticus) were excluded from these studies. Therefore, whether the new paradigm of minimal sedation can be translated to the neuro-ICU (NICU) is unclear. In patients with ABI, sedation has 'general' indications (control of anxiety, pain, discomfort, agitation, facilitation of mechanical ventilation) and 'neuro-specific' indications (reduction of cerebral metabolic demand, improved brain tolerance to ischaemia). Sedation also is an essential therapeutic component of intracranial pressure therapy, targeted temperature management and seizure control. Given the lack of large trials which have evaluated clinically relevant endpoints, sedative selection depends on the effect of each agent on cerebral and systemic haemodynamics. Titration and withdrawal of sedation in the NICU setting has to be balanced between the risk that interrupting sedation might exacerbate brain injury (e.g. intracranial pressure elevation) and the potential benefits of enhanced neurological function and reduced complications. In this review, we provide a concise summary of cerebral physiologic effects of sedatives and analgesics, the advantages/disadvantages of each agent, the comparative effects of standard sedatives (propofol and midazolam) and the emerging role of alternative drugs (ketamine). We suggest a pragmatic approach for the use of sedation-analgesia in the NICU, focusing on some practical aspects, including optimal titration and management of sedation withdrawal according to ABI severity.

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

    PubMed Central

    Sangsawang, Tamon; Sriwijitkamol, Apiradee

    2015-01-01

    Background 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. Objective 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. Methods 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. Results 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/m2; 60% had CKD stage 3 with an estimated glomerular filtration rate of 34±12 mL/min/1.73 m2, 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. Conclusion 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. PMID:26604773

  19. Clinical Outcomes according to the Achievement of Target Low Density Lipoprotein-Cholesterol in Patients with Acute Myocardial Infarction

    PubMed Central

    Ahn, Taehoon; Lee, Kyounghoon; Kang, Woong Chol; Han, Seung Hwan; Ahn, Youngkeun; Jeong, Myung Ho

    2017-01-01

    Background and Objectives The clinical outcome of patient with an acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI), with or without achievement of target low density lipoprotein-cholesterol (LDL-C), has little known information. This study investigated if target LDL-C level (below 70 mg/dL) achievements in patients with AMI showed better clinical outcomes or not. Subjects and Methods Between May 2008 and September 2012, this study enrolled 13473 AMI patients in a large-scale, prospective, multicenter Korean Myocardial Infarction (KorMI) registry. 12720 patients survived and 6746 patients completed a 1-year clinical follow up. Among them 3315 patients received serial lipid profile follow-ups. Propensity score matching was applied to adjust for differences in clinical baseline and angiographic characteristics, producing a total of 1292 patients (646 target LDL-C achievers vs. 646 non-achievers). The primary end point was the composite of a 1-year major adverse cardiac event (MACE) including cardiac death, recurrent myocardial infarction (MI), target lesion revascularization (TLR) and coronary artery bypass grafting. Results After propensity score matching, baseline clinical and angiographic characteristics were similar between the two groups. Clinical outcomes of the propensity score matched patients who showed no significant differences in cardiac death (0.5% vs. 0.5%, p=1.000), recurrent MI (1.1% vs. 0.8%, p=0.562), TLR (5.0% vs. 4.5%, p=0.649), MACEs (6.5% vs. 5.9%, p=0.644) and stent thrombosis (2.5% vs. 1.9%, p=0.560). Conclusion In this propensity-matched comparison, AMI patients undergoing PCI with a target LDL-C (below 70 mg/dL) achievement did not show better clinical outcomes. PMID:28154588

  20. Optimal delivery of colorectal cancer follow-up care: improving patient outcomes

    PubMed Central

    Jorgensen, Mikaela L; Young, Jane M; Solomon, Michael J

    2015-01-01

    patients achieves optimal outcomes. PMID:26056501

  1. Primary care of patients with high cardiovascular risk : Blood pressure, lipid and diabetic target levels and their achievement in Hungary.

    PubMed

    Szigethy, Endre; Jancsó, Zoltán; Móczár, Csaba; Ilyés, István; Kovács, Eszter; Róbert Kolozsvári, László; Rurik, Imre

    2013-07-01

    Cardiovascular diseases are responsible for the majority of premature deaths in Hungary as well. Most of them could be prevented with healthy lifestyle of patients and adequate drug prescription of primary care physicians. Earlier European surveys found wide differences between the practices and achievements of different countries in this field. The study was based on and designed according to the framework of previous European Action on Secondary and Primary Prevention by Intervention to Reduce Events (EUROASPIRE) studies and aimed presenting Hungarian results and comparing with the achievements of other countries and previous Hungarian surveys. Among rural and urban settings, 679 patients under continuous care (236 diabetics, 218 with dyslipidaemia, and 225 with hypertension) were consecutively selected by 20 experienced general practitioners. The mean age of patients was 60.3 years (men) and 64.0 years (women). Among diabetics, less than 7 % of glycated hemoglobin (HbA1c) values were found in 42.5 % patients, while only 11.4 % patients had fasting plasma sugar less than 6.0 mmol/L. Of the patients treated for dyslipidaemia, the target level of triglyceride was reached by 40.6 %, recommended total cholesterol by 14.2 % and the HDL-cholesterol by 71.8 %. The therapeutic control of total and HDL-cholesterol was better in men, although women had better triglyceride values. The achievement among patients with hypertension was 42.0 %. Significantly higher blood pressure was measured by patients who were treated with not recommended combinations of antihypertensive medication. A remarkable improvement could be observed in Hungary in the field of secondary prevention. It was greater among patients with hypertension and dyslipidaemia and smaller in diabetes care. Compared to the results of published European surveys, Hungary occupies a good position, but further improvement is still required.

  2. 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

  3. Language and Verbal Memory in Individuals with a History of Autism Spectrum Disorders Who Have Achieved Optimal Outcomes

    ERIC Educational Resources Information Center

    Tyson, Katherine; Kelley, Elizabeth; Fein, Deborah; Orinstein, Alyssa; Troyb, Eva; Barton, Marianne; Eigsti, Inge-Marie; Naigles, Letitia; Schultz, Robert T.; Stevens, Michael; Helt, Molly; Rosenthal, Michael

    2014-01-01

    Some individuals who lose their autism spectrum disorder diagnosis may continue to display subtle weaknesses in language. We examined language and verbal memory in 44 individuals with high-functioning autism (HFA), 34 individuals with "optimal outcomes" (OO) and 34 individuals with typical development (TD). The OO group scored in the…

  4. Exquisite Moments: Achieving Optimal Flow in Three Activity-Based Groups Regardless of Early-Childhood Adversity

    ERIC Educational Resources Information Center

    Thomson, Paula; Jaque, S. Victoria

    2016-01-01

    Flow experiences (also known as optimal performance) occur when people engage in activities they enjoy. The authors discuss such events in their study that examined a number of healthy, active individuals (performing artists, athletes, and others engaged in a range of recreational activities) and divided these into three groups based on adverse…

  5. Achieving quality and fiscal outcomes in patient care: the clinical mentor care delivery model.

    PubMed

    Burritt, Joan E; Wallace, Patricia; Steckel, Cynthia; Hunter, Anita

    2007-12-01

    Contemporary patient care requires sophisticated clinical judgment and reasoning in all nurses. However, the level of development regarding these abilities varies within a staff. Traditional care models lack the structure and process to close the expertise gap creating potential patient safety risks. In an innovative model, senior, experienced nurses were relieved of direct patient care assignments to oversee nursing care delivery. Evaluation of the model showed significant impact on quality and fiscal outcomes.

  6. The genetic and genomic background of multiple myeloma patients achieving complete response after induction therapy with bortezomib, thalidomide and dexamethasone (VTD)

    PubMed Central

    Terragna, Carolina; Remondini, Daniel; Martello, Marina; Zamagni, Elena; Pantani, Lucia; Patriarca, Francesca; Pezzi, Annalisa; Levi, Giuseppe; Offidani, Massimo; Proserpio, Ilaria; De Sabbata, Giovanni; Tacchetti, Paola; Cangialosi, Clotilde; Ciambelli, Fabrizio; Viganò, Clara Virginia; Dico, Flores Angela; Santacroce, Barbara; Borsi, Enrica; Brioli, Annamaria; Marzocchi, Giulia; Castellani, Gastone; Martinelli, Giovanni; Palumbo, Antonio; Cavo, Michele

    2016-01-01

    The prime focus of the current therapeutic strategy for Multiple Myeloma (MM) is to obtain an early and deep tumour burden reduction, up to the level of complete response (CR). To date, no description of the characteristics of the plasma cells (PC) prone to achieve CR has been reported. This study aimed at the molecular characterization of PC obtained at baseline from MM patients in CR after bortezomib-thalidomide-dexamethasone (VTD) first line therapy. One hundred and eighteen MM primary tumours obtained from homogeneously treated patients were profiled both for gene expression and for single nucleotide polymorphism genotype. Genomic results were used to obtain a predictor of sensitivity to VTD induction therapy, as well as to describe both the transcription and the genomic profile of PC derived from MM with subsequent optimal response to primary induction therapy. By analysing the gene profiles of CR patients, we identified a 5-gene signature predicting CR with an overall median accuracy of 75% (range: 72%–85%). In addition, we highlighted the differential expression of a series of genes, whose deregulation might explain patients' sensitivity to VTD therapy. We also showed that a small copy number loss, covering 606Kb on chromosome 1p22.1 was the most significantly associated with CR patients. PMID:26575327

  7. Quality of life in cancer patients: The role of optimism, hopelessness, and partner support.

    PubMed

    Gustavsson-Lilius, Mila; Julkunen, Juhani; Hietanen, Päivi

    2007-02-01

    The interaction of optimism, hopelessness and social support as predictors of Health-Related Quality of Life (HRQL) among seriously ill people is not well understood. Also, the impact of partner characteristics on patient quality of life has often been overlooked. In this study the relationships between optimism, hopelessness, partner support and HRQL were investigated in 155 cancer patients and their partners. Special attention was given to the effects of optimism and hopelessness as mediators and moderators in the partner support-HRQL relationship. The impact of partner optimism and hopelessness on perceived partner support and patient HRQL was also studied. The results indicated substantial gender differences in the relationships between the study variables. High levels of partner support were associated with female patients' optimistic appraisals, and together they predicted better HRQL at 8 months follow-up. Partial support was found for the effect of optimism as a mediator. For male patients, low hopelessness was the key variable predicting good HRQL. Clear evidence for the moderator effects of optimism/hopelessness was not found, and the expected impact of partner's characteristics on partner support or patient HRQL could not be confirmed. Although partner support, patient optimism and hopelessness all appeared to be important determinants of HRQL in cancer patients, the relationships between these variables differed by gender. The proposed mediation and moderation models needs to be confirmed in future studies.

  8. Optimal adjuvant treatment for patients with HER2-positive breast cancer in 2015.

    PubMed

    Zardavas, Dimitrios; Fouad, Tamer M; Piccart, Martine

    2015-11-01

    The introduction of trastuzumab as adjuvant treatment for patients with HER2-positive breast cancer changed the natural course of early-stage disease. Currently, one year of trastuzumab given concurrently with a taxane and following an anthracycline regimen is the preferred standard of care in Europe. The first attempt to escalate this approach, though the implementation of dual HER2 blockade with lapatinib added to trastuzumab, as assessed by the ALTTO trial, failed to improve further clinical outcomes; clinical assessment of the adjuvant trastuzumab/pertuzumab regimen is still ongoing in the APHINITY trial. Negative results were also reported for the addition of bevacizumab to adjuvant trastuzumab treatment within the context of the BETH study. Similarly, efforts to de-escalate through shortening the duration of adjuvant trastuzumab treatment failed (the PHARE trial), whereas others are still ongoing. Of note, evidence supports the use of lighter chemotherapy regimens with one year of adjuvant trastuzumab as backbone, for women with small HER2-positive breast tumors, where the omission of anthracyclines did not compromise the clinical outcome. Despite the successes achieved so far, a proportion of women with early-stage HER2-positive breast cancer, will still experience disease recurrence. The identification of these women is urgently needed, as well as the identification of predictive biomarkers to dictate the optimal treatment strategy. So far, HER2 expression status has been the only validated predictive biomarker for this patient population. Despite the clear association of pCR achieved through neoadjuvant trastuzumab-based chemotherapy with clinical outcome, results from neoadjuvant trials have not been always consistent with what was seen in the adjuvant setting. Similarly, inconsistent results have been reported for the predictive ability of alterations affecting the PI3K signaling pathway or the quantification of tumor infiltrating lymphocytes. In the era

  9. Achieving higher pathological complete response rates in HER-2-positive patients with induction chemotherapy without trastuzumab in operable breast cancer.

    PubMed

    Penault-Llorca, Frédérique; Abrial, Catherine; Mouret-Reynier, Marie-Ange; Raoelfils, Inès; Durando, Xavier; Leheurteur, Marianne; Gimbergues, Pierre; Tortochaux, Jacques; Curé, Hervé; Chollet, Philippe

    2007-04-01

    Recent trials of induction chemotherapy in bulky operable breast cancer have shown much higher pathological complete response (pCR) rates with trastuzumab-driven combinations. However, it is useful to take into account the specific chemosensitivity of HER-2-positive tumors. The aim of this study was to assess the pCR rate according to HER-2 status in response to chemotherapy, without an anti-HER-2 specific biological agent, in 710 operable breast cancer patients. Since 1982, these patients have been treated with several different neoadjuvant chemotherapy combinations. During this period, HER-2 overexpression was most often not assessed. Subsequently, we assessed HER-2 expression using archival paraffin-embedded tissue. A technically usable specimen was available for 413 of the 710 patients. Before treatment, 51 patients were HER-2 positive, 287 patients were HER-2 negative, and the results were inconclusive for 75 patients. Of these patients, a pCR in breast and nodes was obtained in 94 patients (14.3%), but this event was threefold more frequent for HER-2-positive patients (23.5%) than for HER-2-negative patients (7%). The overall survival (OS) and disease-free survival (DFS) rates at 10 years were 66.6% and 57.4%, respectively. The DFS rate was, as expected, better for HER-2-negative patients, with HER-2 status assessed before as well as after chemotherapy. A significant difference was found for OS in favor of HER-2-negative patients only with postchemotherapy assessment of HER-2, a fact similar to our previous findings. Finally, there was a tendency toward a higher DFS rate for HER-2-positive patients who achieved a pCR compared with HER-2-positive patients who did not.

  10. Academic Abilities in Children and Adolescents with a History of Autism Spectrum Disorders Who Have Achieved Optimal Outcomes

    ERIC Educational Resources Information Center

    Troyb, Eva; Orinstein, Alyssa; Tyson, Katherine; Helt, Molly; Eigsti, Inge-Marie; Stevens, Michael; Fein, Deborah

    2014-01-01

    This study examines the academic abilities of children and adolescents who were once diagnosed with an autism spectrum disorder, but who no longer meet diagnostic criteria for this disorder. These individuals have achieved social and language skills within the average range for their ages, receive little or no school support, and are referred to…

  11. 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

  12. A food recognition system for diabetic patients based on an optimized bag-of-features model.

    PubMed

    Anthimopoulos, Marios M; Gianola, Lauro; Scarnato, Luca; Diem, Peter; Mougiakakou, Stavroula G

    2014-07-01

    Computer vision-based food recognition could be used to estimate a meal's carbohydrate content for diabetic patients. This study proposes a methodology for automatic food recognition, based on the bag-of-features (BoF) model. An extensive technical investigation was conducted for the identification and optimization of the best performing components involved in the BoF architecture, as well as the estimation of the corresponding parameters. For the design and evaluation of the prototype system, a visual dataset with nearly 5000 food images was created and organized into 11 classes. The optimized system computes dense local features, using the scale-invariant feature transform on the HSV color space, builds a visual dictionary of 10000 visual words by using the hierarchical k-means clustering and finally classifies the food images with a linear support vector machine classifier. The system achieved classification accuracy of the order of 78%, thus proving the feasibility of the proposed approach in a very challenging image dataset.

  13. CAROTID - a web-based platform for optimal personalized management of atherosclerotic patients.

    PubMed

    Gastounioti, Aimilia; Kolias, Vasileios; Golemati, Spyretta; Tsiaparas, Nikolaos N; Matsakou, Aikaterini; Stoitsis, John S; Kadoglou, Nikolaos P E; Gkekas, Christos; Kakisis, John D; Liapis, Christos D; Karakitsos, Petros; Sarafis, Ioannis; Angelidis, Pantelis; Nikita, Konstantina S

    2014-04-01

    Carotid atherosclerosis is the main cause of fatal cerebral ischemic events, thereby posing a major burden for public health and state economies. We propose a web-based platform named CAROTID to address the need for optimal management of patients with carotid atherosclerosis in a twofold sense: (a) objective selection of patients who need carotid-revascularization (i.e., high-risk patients), using a multifaceted description of the disease consisting of ultrasound imaging, biochemical and clinical markers, and (b) effective storage and retrieval of patient data to facilitate frequent follow-ups and direct comparisons with related cases. These two services are achieved by two interconnected modules, namely the computer-aided diagnosis (CAD) tool and the intelligent archival system, in a unified, remotely accessible system. We present the design of the platform and we describe three main usage scenarios to demonstrate the CAROTID utilization in clinical practice. Additionally, the platform was evaluated in a real clinical environment in terms of CAD performance, end-user satisfaction and time spent on different functionalities. CAROTID classification of high- and low-risk cases was 87%; the corresponding stenosis-degree-based classification would have been 61%. Questionnaire-based user satisfaction showed encouraging results in terms of ease-of-use, clinical usefulness and patient data protection. Times for different CAROTID functionalities were generally short; as an example, the time spent for generating the diagnostic decision was 5min in case of 4-s ultrasound video. Large datasets and future evaluation sessions in multiple medical institutions are still necessary to reveal with confidence the full potential of the platform.

  14. Yearly reduction of glucocorticoid dose by 50% as tapering schedule achieves complete remission for 124 pemphigus vulgaris patients.

    PubMed

    Wang, Mingyue; Gao, Yu; Peng, Yang; Zhao, Junyu; Chen, Xixue; Zhu, Xuejun

    2016-03-01

    Glucocorticoids are the first-line treatment for pemphigus vulgaris. Among 140 patients receiving systemic glucocorticoids, 124 patients achieved complete remission off or on a prednisone dose of ≤10 mg/day or less for 6 months or more. The mean average steroid controlling doses were 0.65, 0.62, 0.80, 1.08 and 1.38 mg/kg per day for the mucosal-dominant patients and the mild, moderate, severe and extensive cutaneous-involved patients, respectively (P < 0.001). The mean durations of the initial tapering after controlling doses started were 77.98, 48.78, 31.74 and 28.83 days when the disease was controlled with doses of 40 mg/day or less, 45-60 mg/day, 65-80 mg/day and more than 80 mg/day for the cutaneous-involved types, respectively (P < 0.005). Of the patients, 79.51% achieved complete remission within 3 years, 98.36% within 5 years and all within 6 years, which corresponded to a 50% yearly reduction of glucocorticoid dose. These successfully treated patients indicate that a severity-tailored initial dose of glucocorticoids, an initial tapering duration based on the initial dose and a subsequent 50% yearly tapering regimen may cure pemphigus vulgaris within 3-6 years.

  15. Should patients with polycystic ovarian syndrome be treated with metformin? A note of cautious optimism.

    PubMed

    Homburg, Roy

    2002-04-01

    Hyperinsulinaemia has proved to be a key link in the enigmatic generation of the symptoms of polycystic ovarian syndrome (PCOS), i.e. anovulatory infertility and the skin stigmata induced by hyperandrogenism. Regression of these symptoms may be achieved by reducing the hyperinsulinaemia. As obesity exaggerates the expression of the symptoms induced by hyperinsulinaemia, a low calorie diet and lifestyle change resulting in loss of weight for obese women with PCOS is capable of reversing these symptoms. Insulin-sensitizing agents, predominantly metformin, have been examined for their ability, in all patients with PCOS, to achieve similar beneficial changes to those induced by loss of weight in the obese. While the scientific value of many of these studies is questionable and solid evidence of efficiency and safety is not complete, the honourable intent of lowering high insulin levels in this way prompts the bottom line of this debate to strike a note of cautious optimism that insulin-sensitizing agents will be of some clinical usefulness both in the short-term aiding of infertility treatment and, possibly, in the prevention of the long-term sequelae for this troublesome and very prevalent condition.

  16. 2011 John M. Eisenberg Patient Safety and Quality Awards. Individual Achievement. Interview by Eric J. Thomas.

    PubMed

    Shine, Kenneth

    2012-07-01

    Dr. Shine, who, as president, led the Institute of Medicine's focus on quality and patient safety, describes initiatives at the University of Texas System, including quality improvement training, systems engineering, assessment of projects' economic impact, and dissemination of good practices.

  17. 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

  18. Optimize patient health by treating literacy and language barriers.

    PubMed

    Dreger, Vicki; Tremback, Tom

    2002-02-01

    More than 90 million Americans have limited literacy skills. Almost two million US residents cannot speak English, and millions more speak it poorly. The stigma of illiteracy or the inability to speak a country's predominant language keep patients from disclosing their limitations. Recognizing these facts is an important first step in improving health education for this vulnerable population. By adapting teaching techniques to patients' special needs, nurses can ensure that patients understand their health problems and plan of care. Statistics dramatically demonstrate the high cost of neglecting these needs. Patients who do not understand their plan of care do not comply with instructions and, therefore, suffer unnecessary complications. Health care providers who can communicate with their patients through multilingual, low literacy patient education materials and with the use of qualified interpreters markedly improve the quality of care for their patients and the resulting outcomes.

  19. The Impact of a Standalone, Patient-centered Communication Course Series on Student Achievement, Preparedness, and Attitudes

    PubMed Central

    McNair, Chelsea D.; Linnebur, Sunny A.; Valdez, Connie; Trujillo, Toby C.

    2016-01-01

    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. PMID:28179723

  20. 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.

  1. Using ant colony optimization on the quadratic assignment problem to achieve low energy cost in geo-distributed data centers

    NASA Astrophysics Data System (ADS)

    Osei, Richard

    There are many problems associated with operating a data center. Some of these problems include data security, system performance, increasing infrastructure complexity, increasing storage utilization, keeping up with data growth, and increasing energy costs. Energy cost differs by location, and at most locations fluctuates over time. The rising cost of energy makes it harder for data centers to function properly and provide a good quality of service. With reduced energy cost, data centers will have longer lasting servers/equipment, higher availability of resources, better quality of service, a greener environment, and reduced service and software costs for consumers. Some of the ways that data centers have tried to using to reduce energy costs include dynamically switching on and off servers based on the number of users and some predefined conditions, the use of environmental monitoring sensors, and the use of dynamic voltage and frequency scaling (DVFS), which enables processors to run at different combinations of frequencies with voltages to reduce energy cost. This thesis presents another method by which energy cost at data centers could be reduced. This method involves the use of Ant Colony Optimization (ACO) on a Quadratic Assignment Problem (QAP) in assigning user request to servers in geo-distributed data centers. In this paper, an effort to reduce data center energy cost involves the use of front portals, which handle users' requests, were used as ants to find cost effective ways to assign users requests to a server in heterogeneous geo-distributed data centers. The simulation results indicate that the ACO for Optimal Server Activation and Task Placement algorithm reduces energy cost on a small and large number of users' requests in a geo-distributed data center and its performance increases as the input data grows. In a simulation with 3 geo-distributed data centers, and user's resource request ranging from 25,000 to 25,000,000, the ACO algorithm was able

  2. Follow-up of patients with celiac disease: achieving compliance with treatment.

    PubMed

    Pietzak, Michelle Maria

    2005-04-01

    Celiac disease is the only autoimmune condition for which we know the environmental trigger: gluten. Complete removal of gluten from the diet in a patient with celiac disease should result in symptomatic, serologic, and histologic remission. However, compliance with the gluten-free diet, especially in the United States, is extremely challenging. Compliance can be measured both noninvasively, by dietary history and measurement of serum antibodies, and invasively, by using endoscopic and histologic criteria. The advantages and disadvantages of these various modalities are discussed. The highest rates of compliance are reported in patients who are diagnosed as young children, whereas adolescents and those diagnosed via mass serologic screening have the most transgressions. Barriers to compliance include the poor palatability of gluten-free foods, confusing food-labeling practices, and common comorbid psychologic burdens such as anxiety and depression. Because celiac disease is a multisystemic disorder, physicians need to be aware of the potential autoimmune, nutritional, and malignant complications. An algorithm for the follow-up and management of the newly diagnosed celiac disease patient is presented, which includes regular follow-up; measurement of serum antibodies; eliciting a detailed dietary history; and examination for signs and symptoms of nutritional deficiencies, malignancy, and other autoimmune diseases. Ideally, a team approach to the follow-up of the newly diagnosed patient should include regular supervision by an interested physician, medical nutritional counseling by a registered dietician, and access to local and national support groups knowledgeable about this condition.

  3. Optimism, mental health, and quality of life: a study among breast cancer patients.

    PubMed

    Colby, Deborah A; Shifren, Kim

    2013-01-01

    Fifty one breast cancer patients participated in a cross-sectional study developed to assess the relation between their level of optimism, positive and negative mental health, and their quality of life. Patients were measured with the Life Orientation Test (LOT), the Center for Epidemiological Studies Depression Scale (CES-D), and the Functional Living Index-Cancer (FLIC). T-tests revealed that these breast cancer patients reported more optimism than pessimism, more positive than negative mental health, and the majority of the sample reported doing well on each qualify life domain of the FLIC. As expected, individuals who reported more depressive symptoms also reported less qualify of life. Breast cancer patients who scored lower on pessimism showed more positive mental health, but they showed no relation to negative mental health. Women who scored higher on optimism reported better social and mental functioning on the FLIC than women who scored low on optimism.

  4. 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.

  5. ACHIEVING NEW SOURCE PERFORMANCE STANDARDS (NSPS) EMISSION STANDARDS THROUGH INTEGRATION OF LOW-NOx BURNERS WITH AN OPTIMIZATION PLAN FOR BOILER COMBUSTION

    SciTech Connect

    Wayne Penrod; David Moyeda

    2003-07-01

    The objective of this project is to demonstrate the use of an Integrated Combustion Optimization System to achieve NO{sub x} emissions levels in the range of 0.15 to 0.22 lb/MMBtu while simultaneously enabling increased power output. The project consists of the integration of low-NO{sub x} burners and advanced overfire air technology with various process measurement and control devices on the Holcomb Station Unit 1 boiler. The project includes the use of sophisticated neural networks or other artificial intelligence technologies and complex software that can optimize several operating parameters, including NO{sub x} emissions, boiler efficiency, and CO emissions. The program is being performed in three phases. In Phase I, the boiler is being equipped with sensors that can be used to monitor furnace conditions and coal flow to permit improvements in boiler operation. In Phase II, the boiler will be equipped with burner modifications designed to reduce NO{sub x} emissions and automated coal flow dampers to permit on-line fuel balancing. In Phase III, the boiler will be equipped with an overfire air system to permit deep reductions in NO{sub x} emissions to be achieved. Integration of the overfire air system with the improvements made in Phases I and II will permit optimization of the boiler performance, output, and emissions. During this reporting period, efforts were focused on completion of Phase I and Phase II activities. The low-NO{sub x} burner modifications, the coal flow dampers, and the coal flow monitoring system were procured and installed during a boiler outage in March 2003. During this reporting period, optimization tests were performed to evaluate system performance and identify optimum operating conditions for the installed equipment. The overfire air system process design activities and preliminary engineering design were completed.

  6. 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

  7. Technology for monitoring shot-level light source performance data to achieve high-optimization of lithography processes

    NASA Astrophysics Data System (ADS)

    Moriya, Masato; Ochiai, Hideyuki; Watabe, Yoshinobu; Ishida, Keisuke; Masuda, Hiroyuki; Sasaki, Youichi; Kumazaki, Takahito; Kurosu, Akihiko; Ohta, Takeshi; Kakizaki, Kouji; Matsunaga, Takashi; Mizoguchi, Hakaru

    2014-03-01

    Gigaphoton has developed a new monitoring system that provides shot-level light source performance data to FDC systems during exposure time. The system provides basic monitoring data (e.g. Energy, Wavelength, Bandwidth, etc.) and beam performance data, such as Beam Profile, Pointing, Divergence, Polarization can also be monitored using a new metrology tool called the Beam Performance Monitor (BPM) module. During exposure time the system automatically identifies the start and end timing of the wafer and each shot based on the burst of firing signals from the scanner, and stores the measured data in sequence. The stored data is sorted by wafer or by shot, and sent to REDeeM Piece which in turn converts the data to the user's protocol and send it to the FDC system. The user also has the option to directly view or download the stored data using a GUI. Through this monitoring system, users can manage light sources data at the shot or reticle level to facilitate optimization of performance and running cost of the light source for each process. This monitoring system can be easily retrofitted to Gigaphoton's current ArF laser light sources. The beam splitter of the BPM was specially designed to bend only a small fraction of the source beam, so we are able to simply install the BPM without the need for special optical alignment.

  8. Imaging Live Cells at the Nanometer-Scale with Single-Molecule Microscopy: Obstacles and Achievements in Experiment Optimization for Microbiology

    PubMed Central

    Haas, Beth L.; Matson, Jyl S.; DiRita, Victor J.; Biteen, Julie S.

    2015-01-01

    Single-molecule fluorescence microscopy enables biological investigations inside living cells to achieve millisecond- and nanometer-scale resolution. Although single-molecule-based methods are becoming increasingly accessible to non-experts, optimizing new single-molecule experiments can be challenging, in particular when super-resolution imaging and tracking are applied to live cells. In this review, we summarize common obstacles to live-cell single-molecule microscopy and describe the methods we have developed and applied to overcome these challenges in live bacteria. We examine the choice of fluorophore and labeling scheme, approaches to achieving single-molecule levels of fluorescence, considerations for maintaining cell viability, and strategies for detecting single-molecule signals in the presence of noise and sample drift. We also discuss methods for analyzing single-molecule trajectories and the challenges presented by the finite size of a bacterial cell and the curvature of the bacterial membrane. PMID:25123183

  9. [Optimization of complex treatment of patients with severe oral leukoplakia].

    PubMed

    Rabinovich, O F; Rabinovich, I M; Abramova, E S

    2015-01-01

    The aim of the study was to prove the rationale for antiviral therapy combined with surgical procedures for treatment of severe oral leukoplakia. Complex clinical and laboratory evaluation and treatment was performed in 56 patients divided in 2 groups. Control group was presented by 13 patients receiving dental treatment, local and systemic keratoplastic formulations. Main group involved 43 patients in which conventional treatment protocol was completed by antiviral therapy and surgical procedures. Leukoplakia diagnosis was based on clinical findings, histological and immunohistochemical studies as well as optic coherent tomography data. The obtained results evidently prove the necessity for including antiviral therapy and surgical procedures in treatment scheme of severe oral leukoplakia.

  10. [Optimization of parodontitis treatment of patients with tuberculosis].

    PubMed

    Aleksandrova, E A; Lepilin, A V; Kazimirova, N E; Shul'diakov, A A

    2010-01-01

    For the purpose to determine the clinic-pathogenetic efficacy of Cycloferon liniment in the combined therapy of parodontitis of patients with focal tuberculosis medical examination and treatment of 40 patients is carried out. It is established, that use of liniment Cycloferon in the combined treatment of patients with focal tuberculosis allows to accelerate process of normalization of lipid peroxidation parameters and antioxidant potential of blood, to decrease infection load (Herpes symplex virus I, Candida albicans, Staphylococcus aureus) in parodontal recess and evidence of local inflammation with reduction of activity of the tumours necrosis factor and interleukin 1beta, that provides acceleration of recuperation processes, lowering the frequency of parodontitis relapses.

  11. Optimizing Survival Outcomes For Adult Patients With Nontraumatic Cardiac Arrest.

    PubMed

    Jung, Julianna

    2016-10-01

    Patient survival after cardiac arrest can be improved significantly with prompt and effective resuscitative care. This systematic review analyzes the basic life support factors that improve survival outcome, including chest compression technique and rapid defibrillation of shockable rhythms. For patients who are successfully resuscitated, comprehensive postresuscitation care is essential. Targeted temperature management is recommended for all patients who remain comatose, in addition to careful monitoring of oxygenation, hemodynamics, and cardiac rhythm. Management of cardiac arrest in circumstances such as pregnancy, pulmonary embolism, opioid overdose and other toxicologic causes, hypothermia, and coronary ischemia are also reviewed.

  12. Analysis of alternatives for insulinizing patients to achieve glycemic control and avoid accompanying risks of hypoglycemia.

    PubMed

    Gao, Jialin; Xiong, Qianyin; Miao, Jun; Zhang, Yao; Xia, Libing; Lu, Meiqin; Zhang, Binhua; Chen, Yueping; Zhang, Ansu; Yu, Cui; Wang, Li-Zhuo

    2015-05-01

    The aims of the present study were to explore the efficacy of glycemic control and the risks of hypoglycemia with different methods of insulin therapy, and to provide reference data for the clinical treatment of diabetes. In this retrospective study, hospitalized patients diagnosed with type 2 diabetes between March and December 2014, in the Department of Endocrinology in the First Affiliated Hospital of Wannan Medical College, were divided into three groups, including an intensive insulin analogue therapy group, a premixed insulin analogue treatment group and a premixed human insulin therapy group. The efficacy of glycemic control and the incidence of hypoglycemia were determined in each of the insulin treatment groups. Compared with the other treatment groups, the intensive insulin analogue therapy group was associated with superior blood glucose control, shorter time to reach standard insulin regimen, shorter hospitalization time, fewer fluctuations in blood glucose levels and lower insulin dosage on discharge from hospital. However, this treatment was also associated with a high risk of hypoglycemia. In conclusion, when combined with the effective prevention of hypoglycemia and appropriate nursing care (especially in hospital care), intensive insulin analogue therapy may provide the greatest benefit to patients.

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

    PubMed

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

    2007-10-07

    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.

  14. Achieving glycemic control in elderly patients with type 2 diabetes: a critical comparison of current options

    PubMed Central

    Du, Ye-Fong; Ou, Horng-Yih; Beverly, Elizabeth A; Chiu, Ching-Ju

    2014-01-01

    The prevalence of type 2 diabetes mellitus (T2DM) is increasing in the elderly. Because of the unique characteristics of elderly people with T2DM, therapeutic strategy and focus should be tailored to suit this population. This article reviews the guidelines and studies related to older people with T2DM worldwide. A few important themes are generalized: 1) the functional and cognitive status is critical for older people with T2DM considering their life expectancy compared to younger counterparts; 2) both severe hypoglycemia and persistent hyperglycemia are deleterious to older adults with T2DM, and both conditions should be avoided when determining therapeutic goals; 3) recently developed guidelines emphasize the avoidance of hypoglycemic episodes in older people, even in the absence of symptoms. In addition, we raise the concern of glycemic variability, and discuss the rationale for the selection of current options in managing this patient population. PMID:25429208

  15. How to optimally manage elderly bladder cancer patients?

    PubMed

    Soria, Francesco; Moschini, Marco; Korn, Stephan; Shariat, Shahrokh F

    2016-10-01

    Bladder cancer (BCa) is a disease of the elderly and as the population is aging, BCa will become an even bigger public health challenge in the future. Nowadays the correct management of BCa in the elderly remains controversial. The purpose of this article was to review the previous literature to summarize the current knowledge. Using Medline, a non-systematic review was performed including articles between January 2000 and February 2016 in order to describe the management of BCa in the elderly in all its aspects. English language original articles, reviews and editorials were selected based on their clinical relevance. In the literature, the definition of elderly is variable and based on chronological, not biological, age. BCa seems to be more aggressive in the elderly. The management of non-muscle invasive bladder cancer (NMIBC) does not strongly differ from younger patients, except for the role of adjuvant immunotherapy. In patients with muscle invasive bladder cancer (MIBC) the role of a multidisciplinary geriatric evaluation is potentially beneficial. The curative treatment in MIBC remains radical cystectomy (RC) and elderly patients should not be withheld a potentially life-saving intervention only based on chronological age. Patients unsuitable to a major surgical approach may be eligible for bladder-sparing techniques. Geriatric assessment could help identify the frail elderly and customize their perioperative care (i.e., pre and re habilitation). In conclusion the treatment of BCa in the elderly has to be patient-centered and focused on biological age and functional reserves.

  16. How to optimally manage elderly bladder cancer patients?

    PubMed Central

    Soria, Francesco; Moschini, Marco; Korn, Stephan

    2016-01-01

    Bladder cancer (BCa) is a disease of the elderly and as the population is aging, BCa will become an even bigger public health challenge in the future. Nowadays the correct management of BCa in the elderly remains controversial. The purpose of this article was to review the previous literature to summarize the current knowledge. Using Medline, a non-systematic review was performed including articles between January 2000 and February 2016 in order to describe the management of BCa in the elderly in all its aspects. English language original articles, reviews and editorials were selected based on their clinical relevance. In the literature, the definition of elderly is variable and based on chronological, not biological, age. BCa seems to be more aggressive in the elderly. The management of non-muscle invasive bladder cancer (NMIBC) does not strongly differ from younger patients, except for the role of adjuvant immunotherapy. In patients with muscle invasive bladder cancer (MIBC) the role of a multidisciplinary geriatric evaluation is potentially beneficial. The curative treatment in MIBC remains radical cystectomy (RC) and elderly patients should not be withheld a potentially life-saving intervention only based on chronological age. Patients unsuitable to a major surgical approach may be eligible for bladder-sparing techniques. Geriatric assessment could help identify the frail elderly and customize their perioperative care (i.e., pre and re habilitation). In conclusion the treatment of BCa in the elderly has to be patient-centered and focused on biological age and functional reserves. PMID:27785425

  17. Optimizing patient care with "natural" products: treatment of hyperpigmentation.

    PubMed

    Woolery-Lloyd, Heather; Friedman, Adam

    2009-06-01

    Patients with skin of color suffer from different cutaneous issues when compared with skin of light complexion, and therefore management of the former must be representative of these variations. The most common pigmentary complaints in patients with skin of color are post-inflammatory hyperpigmentation, melasma and sun-induced hyperpigmentation. Often, patients with darker skin will turn to naturally occurring ingredients over synthetic analogues both to satisfy cultural preferences and to limit potential adverse effects that have been tied to synthetics. Science-based natural products can offer an attractive adjunct to conventional therapies that treat melasma, post-inflammatory hyperpigmentaion, and other dyschromias. Increasing data on the biological effects and the efficacy of natural therapies support the use of these complementary therapies in treating hyperpigmentation.

  18. The roles of hope and optimism on posttraumatic growth in oral cavity cancer patients.

    PubMed

    Ho, Samuel; Rajandram, Rama Krsna; Chan, Natalie; Samman, Nabil; McGrath, Colman; Zwahlen, Roger Arthur

    2011-02-01

    To investigate the association of the positive coping strategies, hope and optimism, on posttraumatic growth (PTG) in oral cavity (OC) cancer patients. A retrospective cross-sectional study was conducted and performed in the outpatient station of the Oral and Maxillofacial Surgery at the University of Hong Kong, Hong Kong SAR, PR China. Fifty patients successfully treated for OC cancer were recruited after their informed consents had been obtained during the review clinic. During their regular follow-up controls in the outpatient clinic, the patients compiled the posttraumatic growth inventory (PTGI) questionnaire, hope scale (HS) and the life orientation scale-revised (LOT-R). Hope and optimism correlated significantly positive with PTG and accounting together for a 25% variance of posttraumatic growth. Hope positively correlated with posttraumatic growth (r=.49, p<.001) as well as optimism (r=.31, p<.05). When compared to unmarried patients, married patients showed high levels of PTG and hope (married participants: mean=53.15, SD=11.04; unmarried participants: mean=41.00, SD=6.36; t (48)=2.403, p<.05). Hope and optimism represent important indicators for PTG in OC cancer patients. An intact dyad relationship seems to be important for hope and consecutive higher levels of PTG when compared to unmarried patients. Supportive psychological treatment strategies related to these two coping factors might be beneficial for OC cancer patients.

  19. 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…

  20. Rapid Automated Treatment Planning Process to Select Breast Cancer Patients for Active Breathing Control to Achieve Cardiac Dose Reduction

    SciTech Connect

    Wang Wei; Purdie, Thomas G.; Rahman, Mohammad; Marshall, Andrea; Liu Feifei; Fyles, Anthony

    2012-01-01

    Purpose: To evaluate a rapid automated treatment planning process for the selection of patients with left-sided breast cancer for a moderate deep inspiration breath-hold (mDIBH) technique using active breathing control (ABC); and to determine the dose reduction to the left anterior descending coronary artery (LAD) and the heart using mDIBH. Method and Materials: Treatment plans were generated using an automated method for patients undergoing left-sided breast radiotherapy (n = 53) with two-field tangential intensity-modulated radiotherapy. All patients with unfavorable cardiac anatomy, defined as having >10 cm{sup 3} of the heart receiving 50% of the prescribed dose (V{sub 50}) on the free-breathing automated treatment plan, underwent repeat scanning on a protocol using a mDIBH technique and ABC. The doses to the LAD and heart were compared between the free-breathing and mDIBH plans. Results: The automated planning process required approximately 9 min to generate a breast intensity-modulated radiotherapy plan. Using the dose-volume criteria, 20 of the 53 patients were selected for ABC. Significant differences were found between the free-breathing and mDIBH plans for the heart V{sub 50} (29.9 vs. 3.7 cm{sup 3}), mean heart dose (317 vs. 132 cGy), mean LAD dose (2,047 vs. 594 cGy), and maximal dose to 0.2 cm{sup 3} of the LAD (4,155 vs. 1,507 cGy, all p <.001). Of the 17 patients who had a breath-hold threshold of {>=}0.8 L, 14 achieved a {>=}90% reduction in the heart V{sub 50} using the mDIBH technique. The 3 patients who had had a breath-hold threshold <0.8 L achieved a lower, but still significant, reduction in the heart V{sub 50}. Conclusions: A rapid automated treatment planning process can be used to select patients who will benefit most from mDIBH. For selected patients with unfavorable cardiac anatomy, the mDIBH technique using ABC can significantly reduce the dose to the LAD and heart, potentially reducing the cardiac risks.

  1. Ophthalmologists' practice patterns and challenges in achieving optimal management for glaucoma in Nigeria: results from a nationwide survey

    PubMed Central

    Kyari, Fatima; Nolan, Winifred; Gilbert, Clare

    2016-01-01

    Purpose of the study Glaucoma, a chronic non-communicable disease, and leading cause of irreversible blindness worldwide is a public health problem in Nigeria, with a prevalence of 5.02% in people aged ≥40 years. The purpose of this nationwide survey was to assess Nigerian ophthalmologists’ practice patterns and their constraints in managing glaucoma. Study design Ophthalmologists were sent a semistructured questionnaire on how they manage glaucoma, their training in glaucoma care, where they practice, their access to equipment for diagnosis and treatment, whether they use protocols and the challenges they face in managing patients with glaucoma. Results 153/250 ophthalmologists in 80 centres completed questionnaires. Although 79% felt their training was excellent or good, 46% needed more training in glaucoma diagnosis and surgery. All had ophthalmoscopes, 93% had access to applanation tonometers, 81% to visual field analysers and 29% to laser machines (in 19 centres). 3 ophthalmologists had only ophthalmoscopes and schiøtz tonometers. For 85%, a glaucomatous optic disc was the most important feature that would prompt glaucoma work-up. Only 56% routinely performed gonioscopy and 61% used slit-lamp stereoscopic biomicroscopy for disc assessment. Trabeculectomy (with/without antimetabolites) was the only glaucoma surgery performed with one mention of canaloplasty. Poor compliance with medical treatment (78%) and low acceptance of surgery (71%) were their greatest challenges. Conclusions This study indicates that a systems-oriented approach is required to enhance ophthalmologist's capability for glaucoma care. Strategies to improve glaucoma management include strengthening poorly equipped centres including provision of lasers and training, and improving patients’ awareness and education on glaucoma. PMID:27729348

  2. Optimizing patient care and research: the Amsterdam Dementia Cohort.

    PubMed

    van der Flier, Wiesje M; Pijnenburg, Yolande A L; Prins, Niels; Lemstra, Afina W; Bouwman, Femke H; Teunissen, Charlotte E; van Berckel, Bart N M; Stam, Cornelis J; Barkhof, Frederik; Visser, Pieter Jelle; van Egmond, Evan; Scheltens, Philip

    2014-01-01

    Since its opening in 2000, patient care and research go hand in hand at the Alzheimer center of the VU University Medical Center, both organized in such a way that they mutually strengthen each other. Our mission is to give patients a voice by lifting the stigma on dementia, to find new diagnostic and treatment strategies, and, ultimately, to cure diseases that cause dementia. Our healthcare pathway is uniquely designed to accommodate all necessary investigations for the diagnostic work-up of dementia in one day (one-stop shop). A second unique feature is that research has been fully integrated in the healthcare pathway. The resulting Amsterdam Dementia Cohort now includes over 4000 patients, and for the majority of these, we have MRI, EEG, blood (serum, plasma), DNA, and CSF available. The Amsterdam Dementia Cohort forms the basis of much of our research, which focuses on four major research lines: 1) variability in manifestation, 2) early diagnosis, 3) vascular factors, and 4) interventions. By answering research questions closely related to clinical practice, the results of our research can be looped back to improve clinical work-up for our patients.

  3. ACHIEVING NEW SOURCE PERFORMANCE STANDARDS (NSPS) EMISSION STANDARDS THROUGH INTEGRATION OF LOW-NOx BURNERS WITH AN OPTIMIZATION PLAN FOR BOILER COMBUSTION

    SciTech Connect

    Wayne Penrod; David Moyeda

    2003-04-01

    The objective of this project is to demonstrate the use of an Integrated Combustion Optimization System to achieve NO{sub x} emissions levels in the range of 0.15 to 0.22 lb/MMBtu while simultaneously enabling increased power output. The project consists of the integration of low-NO{sub x} burners and advanced overfire air technology with various process measurement and control devices on the Holcomb Station Unit 1 boiler. The project includes the use of sophisticated neural networks or other artificial intelligence technologies and complex software that can optimize several operating parameters, including NO{sub x} emissions, boiler efficiency, and CO emissions. The program is being performed in three phases. In Phase I, the boiler is being equipped with sensors that can be used to monitor furnace conditions and coal flow to permit improvements in boiler operation. In Phase II, the boiler will be equipped with burner modifications designed to reduce NO{sub x} emissions and automated coal flow dampers to permit on-line fuel balancing. In Phase III, the boiler will be equipped with an overfire air system to permit deep reductions in NO{sub x} emissions to be achieved. Integration of the overfire air system with the improvements made in Phases I and II will permit optimization of the boiler performance, output, and emissions. During this reporting period, efforts were focused on Phase I and Phase II activities. The furnace sensors were procured and installed in February 2003. Baseline testing was performed following the sensor installation. The low-NO{sub x} burner modifications, the coal flow dampers, and the coal flow monitoring system were procured and installed during a boiler outage in March 2003. Process design activities were performed to support design of the equipment installed and to develop specifications for the overfire air system. The overfire air system preliminary engineering design was initiated.

  4. Patients optimizing epilepsy management via an online community

    PubMed Central

    Barnes, Deborah; Parko, Karen; Durgin, Tracy; Van Bebber, Stephanie; Graham, Arianne; Wicks, Paul

    2015-01-01

    Objective: The study objective was to test whether engaging in an online patient community improves self-management and self-efficacy in veterans with epilepsy. Methods: The study primary outcomes were validated questionnaires for self-management (Epilepsy Self-Management Scale [ESMS]) and self-efficacy (Epilepsy Self-Efficacy Scale [ESES]). Results were based on within-subject comparisons of pre- and postintervention survey responses of veterans with epilepsy engaging with the PatientsLikeMe platform for a period of at least 6 weeks. Analyses were based on both completer and intention-to-treat scenarios. Results: Of 249 eligible participants enrolled, 92 individuals completed both surveys. Over 6 weeks, completers improved their epilepsy self-management (ESMS total score from 139.7 to 142.7, p = 0.02) and epilepsy self-efficacy (ESES total score from 244.2 to 254.4, p = 0.02) scores, with greatest impact on an information management subscale (ESMS–information management total score from 20.3 to 22.4, p < 0.001). Results were similar in intention-to-treat analyses. Median number of logins, postings to forums, leaving profile comments, and sending private messages were more common in completers than noncompleters. Conclusions: An internet-based psychosocial intervention was feasible to implement in the US veteran population and increased epilepsy self-management and self-efficacy scores. The greatest improvement was noted for information management behaviors. Patients with chronic conditions are increasingly encouraged to self-manage their condition, and digital communities have potential advantages, such as convenience, scalability to large populations, and building a community support network. Classification of evidence: This study provides Class IV evidence that for patients with epilepsy, engaging in an online patient community improves self-management and self-efficacy. PMID:26085605

  5. Optimize the Patient Appointment System: At Dewitt Army Community Hospital.

    DTIC Science & Technology

    1992-05-15

    endometriosus, ovarian cysts, uterine fibroids, pelvic relaxation, consultation for any gynecologic surgery (to include bilateral tubal ligation ) and infertility...education classes meet the 2nd Monday of each month (alternate Mondays will be posted in advance). This is on a consult basis and is scheduled by the...be accommodated. Patients may receive counseling on contraception,preconceptual counseling, health promotion, premenstrual syndrome , menopause, STD

  6. 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

  7. An alternative method to achieve one-lung ventilation by surgical pneumothorax in difficult lung isolation patient: a case report.

    PubMed

    Yeh, Pin-Hung; Hsu, Po-Kai

    2016-04-01

    It is challenging to establish one-lung ventilation in difficult airway patients. Surgical pneumothorax under spontaneous breathing to obtain well-collapsed lung is a feasible method for thoracic surgery. A 76-year-old man with right empyema was scheduled for decortication. The patient had limited mouth opening due to facial cellulitis extending from the left cheek to neck. Generally, lung isolation is achieved by double-lumen endotracheal tube or bronchial blocker. Double-lumen tube insertion is difficult for patients with limited mouth opening and right-side placement of bronchial blocker usually causes insufficient deflation. We introduce an alternative lung isolation technique by surgical pneumothorax under spontaneous breathing simply with an endotracheal tube placement. This technique has never been applied into the management of difficult one-lung ventilation. By this method, we provide an ideal surgical condition with safer, less time-consuming, and less skill-demanding anesthesia. It would be an alternative choice for management of one-lung ventilation in the difficult lung isolation patient.

  8. Augmented renal clearance in critically ill patients: etiology, definition and implications for beta-lactam dose optimization.

    PubMed

    Sime, Fekade Bruck; Udy, Andrew A; Roberts, Jason A

    2015-10-01

    The renal clearance of antibiotics may be elevated in some critically ill patients. This paper reviews this recently described phenomenon, referred to as augmented renal clearance (ARC). ARC is considered to be driven by pathophysiological elevation of glomerular filtration, and is defined as a creatinine clearance >130mL/min/173m(2). This in turn promotes very low antibiotic concentrations. This effect may lead to adverse clinical outcomes, particularly with beta-lactam antibiotics, as they require prolonged exposure for optimal antibacterial activity. The use of extended or continuous infusions is an effective strategy to improve exposure. However, because the effect of ARC is potentially quite variable, regular therapeutic drug monitoring (TDM) may be necessary to ensure all patients achieve effective concentrations.

  9. Optimism

    PubMed Central

    Carver, Charles S.; Scheier, Michael F.; Segerstrom, Suzanne C.

    2010-01-01

    Optimism is an individual difference variable that reflects the extent to which people hold generalized favorable expectancies for their future. Higher levels of optimism have been related prospectively to better subjective well-being in times of adversity or difficulty (i.e., controlling for previous well-being). Consistent with such findings, optimism has been linked to higher levels of engagement coping and lower levels of avoidance, or disengagement, coping. There is evidence that optimism is associated with taking proactive steps to protect one's health, whereas pessimism is associated with health-damaging behaviors. Consistent with such findings, optimism is also related to indicators of better physical health. The energetic, task-focused approach that optimists take to goals also relates to benefits in the socioeconomic world. Some evidence suggests that optimism relates to more persistence in educational efforts and to higher later income. Optimists also appear to fare better than pessimists in relationships. Although there are instances in which optimism fails to convey an advantage, and instances in which it may convey a disadvantage, those instances are relatively rare. In sum, the behavioral patterns of optimists appear to provide models of living for others to learn from. PMID:20170998

  10. Optimizing prophylactic treatment of migraine: Subtypes and patient matching

    PubMed Central

    Dib, Michel

    2008-01-01

    Advances in our understanding of the pathophysiology of migraine have resulted in important breakthroughs in treatment. For example, understanding of the role of serotonin in the cerebrovascular circulation has led to the development of triptans for the acute relief of migraine headaches, and the identification of cortical spreading depression as an early central event associated wih migraine has brought renewed interest in antiepileptic drugs for migraine prophylaxis. However, migraine still remains inadequately treated. Indeed, it is apparent that migraine is not a single disease but rather a syndrome that can manifest itself in a variety of pathological conditions. The consequences of this may be that treatment needs to be matched to particular patients. Clinical research needs to be devoted to identifying which sort of patients benefit best from which treatments, particularly in the field of prophylaxis. We propose four patterns of precipitating factors (adrenergic, serotoninergic, menstrual, and muscular) which may be used to structure migraine prophylaxis. Finally, little is known about long-term outcome in treated migraine. It is possible that appropriate early prophylaxis may modify the long-term course of the disease and avoid late complications. PMID:19209286

  11. Treatment optimization for HIV/HCV co-infected patients

    PubMed Central

    Scott, Jake A.; Chew, Kara W.

    2016-01-01

    Human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infections affect millions of persons around the globe and cause profound morbidity and mortality. A major intersection exists between these two epidemics, with HCV infection being more common in persons with HIV than in the general population, largely due to shared routes of transmission. HCV co-infection increases risk for liver- and non-liver-related morbidity and mortality, making HCV treatment a priority in HIV co-infected persons, but the treatment of HCV in co-infected patients has been daunting for multiple reasons. Until recently, HCV treatment has frequently been deferred due to the low rates of cure, significant adverse effects, burdensome duration of therapy and drug–drug interactions with HIV antiretroviral medications. Untreated HCV has resulted in significant health consequences for the millions of those infected and has led to multiple downstream impacts on our healthcare systems around the world. The development of a remarkable number of new HCV direct-acting agents (DAAs) that are significantly more efficacious and tolerable than the previous interferon-based regimens has transformed this important field of medicine, with the potential to dramatically reduce the burden of infection and improve health outcomes in this population. This review will summarize the epidemiology and clinical impact of HIV/HCV co-infection and current approaches to the treatment of HCV in HIV/HCV co-infected patients. PMID:28357062

  12. The impact of an educational program on HCV patient outcomes using boceprevir in community practices (OPTIMAL trial)

    PubMed Central

    Rustgi, Vinod; Brown, Robert S.; Patel, Vishal; Kugelmas, Marcelo; Regenstein, Fredric; Balart, Luis; LaBrecque, Douglas; Brown, Kimberly; Avila, Mark; Biederman, Michael; Freed, Glenn; Smith, Richard; Bernstein, Marc; Arnold, Hays; Cahan, Joel; Fink, Scott; Katkov, William; Massoumi, Hatef; Harrison, Stephen

    2015-01-01

    Objectives: Although effective, direct acting antiviral (DAA) therapies for genotype 1 (GT 1) hepatitis C virus (HCV) have been associated with compliance challenges. Additionally, treatment at predominantly community-based centers has been associated with low retention of patients on treatment and higher dropout rates. The OPTIMAL Phase IV interventional trial (ClinicalTrials.gov Identifier: NCT01405027) was designed to evaluate the impact of an education program for community investigator (CI) sites participating in a Chronic Liver Disease Foundation study treating chronic GT 1 HCV patients. Methods: This physician educational program was administered by 22 Hepatology Centers of Educational Expertise (HCEE) academic sites to 33 CI sites asked to participate from December 2011 to July 2012. The HCEE mentors from DAA-experienced academic sites educated those at CI sites on therapeutic management, practice, and patient outcomes through a series of four standardized educational sequence visits regarding the use of first generation HCV protease inhibitors and the overall treatment of HCV. Results: Treatment duration compliance rates for patients treated at CI sites versus those treated at HCEE academic sites were evaluable in 77 of 84 HCEE academic site patients, 102 of 113 patients treated at CI sites, and 179 of 197 overall patients. The treatment duration compliance rates for patients treated at HCEE academic sites, CI sites and overall were 85.4 ± 25.39%, 83.8 ± 27.37%, and 84.5 ± 26.48%, respectively, and did not differ statistically between the groups (p = 0.49). Almost half (47%) of the patients in the study achieved a sustained virological response for 24 weeks (SVR24) regardless of the type of site (p = 0.64). Safety profiles were similar at both HCEE and CI sites. Conclusions: These results demonstrated that education of CI sites unfamiliar with DAAs resulted in patient outcomes consistent with those observed at DAA-experienced academic sites. PMID

  13. Synthesize, optimize, analyze, repeat (SOAR): Application of neural network tools to ECG patient monitoring

    SciTech Connect

    Watrous, R.; Towell, G.; Glassman, M.S.

    1995-12-31

    Results are reported from the application of tools for synthesizing, optimizing and analyzing neural networks to an ECG Patient Monitoring task. A neural network was synthesized from a rule-based classifier and optimized over a set of normal and abnormal heartbeats. The classification error rate on a separate and larger test set was reduced by a factor of 2. When the network was analyzed and reduced in size by a factor of 40%, the same level of performance was maintained.

  14. Mediating role of coping in the dispositional optimism-posttraumatic growth relation in breast cancer patients.

    PubMed

    Büyükaşik-Colak, Canan; Gündoğdu-Aktürk, Elçin; Bozo, Ozlem

    2012-01-01

    The aim of the present study was to examine if coping strategies mediate dispositional optimism-posttraumatic growth relation in postoperative breast cancer patients. The data were collected from 90 patients in two hospitals. Regression analyses revealed that problem-focused coping fully mediated dispositional optimism-posttraumatic growth relation, but emotion-focused coping did not. That is, postoperative breast cancer patients who were optimistic were more likely to use problem-focused coping strategies that, in turn, led to the development of posttraumatic growth. The findings were congruent with the literature in which problem-focused coping was mostly highlighted as compared to emotion-focused coping, and in which optimism and problem-focused coping relationship was emphasized in the path of posttraumatic growth.

  15. A discussion of the optimal treatment of intracranial aneurysm rupture in elderly patients.

    PubMed

    Liu, C

    2014-08-25

    This study aimed to find an optimal treatment for intracranial aneurysm rupture in elderly patients. We adopted endovascular embolization and combined it with mini-invasive aspiration, vascular stenosis stenting, and rehabilitation training to treat 13 elderly patients with intracranial aneurysm rupture. When the 13 patients were discharged and evaluated by the Glasgow Outcome Score (GOS), 7 patients were grade 5, 4 patients were grade 4, and 2 patients were grade 2. We found that a combination of endovascular embolization with mini-invasive aspiration and vascular stenosis stenting allowed us to adapt this treatment to various types of aneurysms. Our approach is especially suitable for elderly patients, because it reduces the occurrence of complications, improves patient prognoses, shortens the duration of hospitalization, and improves the quality of life.

  16. 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.

  17. 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.

  18. Achieving New Source Performance Standards (NSPS) Emission Standards Through Integration of Low-NOx Burners with an Optimization Plan for Boiler Combustion

    SciTech Connect

    Wayne Penrod

    2006-12-31

    The objective of this project was to demonstrate the use of an Integrated Combustion Optimization System to achieve NO{sub X} emission levels in the range of 0.15 to 0.22 lb/MMBtu while simultaneously enabling increased power output. The project plan consisted of the integration of low-NO{sub X} burners and advanced overfire air technology with various process measurement and control devices on the Holcomb Station Unit 1 boiler. The plan included the use of sophisticated neural networks or other artificial intelligence technologies and complex software to optimize several operating parameters, including NO{sub X} emissions, boiler efficiency, and CO emissions. The program was set up in three phases. In Phase I, the boiler was equipped with sensors that can be used to monitor furnace conditions and coal flow to permit improvements in boiler operation. In Phase II, the boiler was equipped with burner modifications designed to reduce NO{sub X} emissions and automated coal flow dampers to permit on-line fuel balancing. In Phase III, the boiler was to be equipped with an overfire air system to permit deep reductions in NO{sub X} emissions. Integration of the overfire air system with the improvements made in Phases I and II would permit optimization of boiler performance, output, and emissions. This report summarizes the overall results from Phases I and II of the project. A significant amount of data was collected from the combustion sensors, coal flow monitoring equipment, and other existing boiler instrumentation to monitor performance of the burner modifications and the coal flow balancing equipment.

  19. [Optimization of preoperative hemoglobin levels in patients without anemia and/or patients who undergo surgery with high blood loss].

    PubMed

    Colomina, M J; Basora Macaya, M

    2015-06-01

    To minimize allogeneic blood transfusions (ABTs) during complex surgery and surgery with considerable blood loss risk, various blood-sparing techniques are needed (multimodal approach). All surgical patients should be assessed with sufficient time to optimize hemoglobin levels and iron reserves so that the established perioperative transfusion strategy is appropriate. Even if the patient does not have anemia, improving hemoglobin levels to reduce the risk of ABT is justified in some cases, especially those in which the patient refuses a transfusion. Treatment with iron and/or erythropoietic agents might also be justified for cases that need a significant autologous blood reserve to minimize ABT during surgery with considerable blood loss.

  20. The role of optimism and pessimism in chronic pain patients adjustment.

    PubMed

    Ramírez-Maestre, Carmen; Esteve, Rosa; López, Alicia E

    2012-03-01

    This study analyses the relationships between patients' dispositional optimism and pessimism and the coping strategies they use. In addition, the coping strategies repercussions on adjustment to chronic pain were studied. Ninety-eight patients with heterogeneous chronic pain participated. The assessment tools were as follows: Life Orientation Test (LOT), the Vanderbilt Pain Management Inventory (VPMI), the McGill Pain Questionnaire (MPQ), Hospital Anxiety and Depression Scale (HADS), and the Impairment and Functioning Inventory for Chronic Pain Patients (IFI). The hypothetical model establishes positive relationships between optimism and the use of active coping strategies, whereas pessimism is related to the use of passive coping. Active coping is associated with low levels of pain, anxiety, depression and impairment and high levels of functioning. However, passive coping is related to high levels of pain, anxiety, depression and impairment and low levels of functioning. The hypothetical model was empirically tested using the LISREL 8.20 software package and the unweighted least squares method. The results support the hypotheses formulated regarding the relations among optimism, pessimism, coping and adjust of chronic pain patients. By analysing optimism among chronic pain patients, clinicians could make better predictions regarding coping and adjustment.

  1. Young and elderly patients with type 2 diabetes have optimal B cell responses to the seasonal influenza vaccine

    PubMed Central

    Frasca, Daniela; Diaz, Alain; Romero, Maria; Mendez, Nicholas V.; Landin, Ana Marie; Ryan, John G.; Blomberg, Bonnie B.

    2013-01-01

    We evaluated immune response to the seasonal influenza vaccine in young and elderly patients with type 2 diabetes (T2D). Immune measures included the in vivo serum response to the vaccine by hemagglutination inhibition (HAI) and ELISA in 22 patients (14 young, 8 elderly) and 65 healthy age-matched controls (37 young, 28 elderly). B cell-specific biomarkers of optimal vaccine response were measured ex vivo by switched memory B cells and plasmablasts and in vitro by activation-induced cytidine deaminase (AID) in stimulated cells. Markers of systemic and B cell-intrinsic inflammation were also measured. Results show that in vivo responses, as well as B cell-specific markers identified above, decrease by age in healthy individuals but not in T2D patients. This occurred despite high levels of B cell-intrinsic inflammation (TNF-α) in T2D patients, which was surprising as we had previously demonstrated this negatively impacts B cell function. These results altogether suggest that valid protection against influenza can be achieved in T2D patients and proposed mechanisms are discussed. PMID:23711934

  2. Treating the whole patient for optimal management of type 2 diabetes: considerations for insulin therapy.

    PubMed

    Campos, Carlos

    2007-08-01

    Primary care physicians are responsible for providing healthcare to most patients with type 2 diabetes. In this role, it is critical that physicians utilize a whole-patient treatment approach that includes lifestyle modifications and pharmacotherapy aimed to achieve glycemic control, in addition to the management of any comorbid conditions or risk factors for cardiovascular complications of diabetes. Due to the progressive nature of the disease, most patients with type 2 diabetes will eventually require insulin to achieve and maintain glycemic control, because of both increased insulin resistance and diminished secretory capacity of the pancreatic beta cells. Thus, physicians need to be knowledgeable about and comfortable with the use of insulin, as well as with educating patients and discussing any potential barriers to insulin therapy. The use of a stepwise approach--beginning with basal insulin therapy and adding prandial insulin if necessary--is simple, effective, and appropriate for use in many patients.

  3. Effects of Workflow Optimization in Endovascularly Treated Stroke Patients – A Pre-Post Effectiveness Study

    PubMed Central

    Behme, Daniel; Tsogkas, Ioannis; Knauth, Michael; Maier, Ilko; Karch, André; Mikolajczyk, Rafael; Hinz, José; Liman, Jan; Psychogios, Marios-Nikos

    2016-01-01

    Endovascular treatment of acute ischemic stroke has become standard of care for patients with large artery occlusion. Early restoration of blood flow is crucial for a good clinical outcome. We introduced an interdisciplinary standard operating procedure (SOP) between neuroradiologists, neurologists and anesthesiologists in order to streamline patient management. This study analyzes the effect of optimized workflow on periprocedural timings and its potential influence on clinical outcome. Data were extracted from a prospectively maintained university hospital stroke database. The standard operating procedure was established in February 2014. Of the 368 acute stroke patients undergoing endovascular treatment between 2008 and 2015, 278 patients were treated prior to and 90 after process optimization. Outcome measures were periprocedural time intervals and residual functional impairment. After implementation of the SOP, time from symptom onset to reperfusion was significantly reduced (median 264 min prior and 211 min after SOP-introduction (IQR 228–32 min and 161–278 min, respectively); P<0.001). Especially faster supply of imaging and prompt transfer of patients to the angiography suite contributed to this effect. Time between hospital admission and groin puncture was reduced by half after process optimization (median 64 min after versus 121 min prior to SOP-introduction (IQR 54–77 min and 96–161 min, respectively); P<0.001). Clinical outcome was significantly better after workflow optimization as measured with the modified Rankin Scale (common odds ratio (OR) 0.56; 95% CI 0.32–0.98; P = 0.038). Optimization of workflow and interdisciplinary teamwork significantly improved the outcome of patients with acute ischemic stroke due to a significant reduction of in-hospital examination, transportation, imaging and treatment times. PMID:28036401

  4. Radiation therapy treatment plan optimization accounting for random and systematic patient setup uncertainties

    NASA Astrophysics Data System (ADS)

    Moore, Joseph Andrew

    2011-12-01

    External-beam radiotherapy is one of the primary methods for treating cancer. Typically a radiotherapy treatment course consists of radiation delivered to the patient in multiple daily treatment fractions over 6--8 weeks. Each fraction requires the patient to be aligned with the image acquired before the treatment course used in treatment planning. Unfortunately, patient alignment is not perfect and results in residual errors in patient setup. The standard technique for dealing with errors in patient setup is to expand the volume of the target by some margin to ensure the target receives the planned dose in the presence of setup errors. This work develops an alternative to margins for accommodating setup errors in the treatment planning process by directly including patient setup uncertainty in IMRT plan optimization. This probabilistic treatment planning (PTP) operates directly on the planning structure and develops a dose distribution robust to variations in the patient position. Two methods are presented. The first method includes only random setup uncertainty in the planning process by convolving the fluence of each beam with a Gaussian model of the distribution of random setup errors. The second method builds upon this by adding systematic uncertainty to optimization by way of a joint optimization over multiple probable patient positions. To assess the benefit of PTP methods, a PTP plan and a margin-based plan are developed for each of the 28 patients used in this study. Comparisons of plans show that PTP plans generally reduce the dose to normal tissues while maintaining a similar dose to the target structure when compared to margin-based plans. Physician assessment indicates that PTP plans are generally preferred over margin-based plans. PTP methods shows potential for improving patient outcome due to reduced complications associated with treatment.

  5. Analysis of the first therapeutic-target-achieving time of warfarin therapy and associated factors in patients with pulmonary embolism

    PubMed Central

    Gong, Xiaowei; Wang, Haiyan; Yuan, Yadong

    2016-01-01

    The present study aimed to investigate the factors affecting the first therapeutic-target-achieving (TTA) time of warfarin therapy in patients with acute pulmonary embolism (PTE). Between January 2008 and June 2013, patients with PTE confirmed by transpulmonary arterial enhanced computed tomographic pulmonary angiography or pulmonary ventilation perfusion scanning were included in the present study. Data collected included demographic information, history of tobacco and alcohol intake, basic diseases (stable and unstable hypertension, diabetes, heart failure, cancer/cerebral infarction, old myocardial infarction and atrial fibrillation), liver and kidney function, the haemoglobin and platelet count of the blood, international normalized ratio monitoring, warfarin dosage adjustment and medication combinations. Dynamic changes in international normalized ratio, anticoagulant efficacy, and adverse events within 90 days were monitored and analyzed. Univariate analysis demonstrated that the following factors affect the first TTA time: Initial dose, body mass index (BMI), liver function, heart failure, and the administration of levofloxacin, cephalosporins, and blood circulation-activating drugs. Logistic regression analysis revealed that the following were independent factors of the first TTA time: Initial dose, BMI, liver function, heart failure and levofloxacin. Therefore, the results of the present study demonstrated that various factors may affect the first TTA time of warfarin therapy, including the initial dose, BMI, liver function, heart function and concomitant medication. PMID:27698722

  6. Topological optimization for designing patient-specific large craniofacial segmental bone replacements

    PubMed Central

    Sutradhar, Alok; Paulino, Glaucio H.; Miller, Michael J.; Nguyen, Tam H.

    2010-01-01

    Restoring normal function and appearance after massive facial injuries with bone loss is an important unsolved problem in surgery. An important limitation of the current methods is heuristic ad hoc design of bone replacements by the operating surgeon at the time of surgery. This problem might be addressed by incorporating a computational method known as topological optimization into routine surgical planning. We tested the feasibility of using a multiresolution three-dimensional topological optimization to design replacements for massive midface injuries with bone loss. The final solution to meet functional requirements may be shaped differently than the natural human bone but be optimized for functional needs sufficient to support full restoration using a combination of soft tissue repair and synthetic prosthetics. Topological optimization for designing facial bone tissue replacements might improve current clinical methods and provide essential enabling technology to translate generic bone tissue engineering methods into specific solutions for individual patients. PMID:20628014

  7. 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

  8. Optimization of anti-TNF therapy in patients with Inflammatory Bowel Disease.

    PubMed

    Strik, A S; Bots, S J A; D'Haens, G; Löwenberg, M

    2016-01-01

    After the introduction of anti-tumor necrosis factor (anti-TNF) agents, the clinical outcome of patients with Inflammatory Bowel Disease (IBD) has improved significantly. However, use of anti-TNF therapy is complicated by loss of response. In order to maintain remission, adequate serum levels are required. Hence, therapeutic drug monitoring (TDM) is important in order to optimize serum drug levels, especially in patients with loss of response to these agents. Optimization of anti-TNF therapy by applying TDM enables clinicians to regain response to TNF blockers in a significant proportion of patients. It is important to use anti-TNF agents in their most optimal way, since these therapeutic agents are expensive and the medical options after failing anti-TNF therapy are limited. Here, we will discuss how to optimize treatment with anti-TNF agents in IBD patients in order to improve treatment efficacy, prevent anti-drug antibody formation, reduce side effects, discontinue unnecessary treatment and manage costs.

  9. 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…

  10. 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.

  11. Design of Optimal Treatments for Neuromusculoskeletal Disorders using Patient-Specific Multibody Dynamic Models

    PubMed Central

    Fregly, Benjamin J.

    2011-01-01

    Disorders of the human neuromusculoskeletal system such as osteoarthritis, stroke, cerebral palsy, and paraplegia significantly affect mobility and result in a decreased quality of life. Surgical and rehabilitation treatment planning for these disorders is based primarily on static anatomic measurements and dynamic functional measurements filtered through clinical experience. While this subjective treatment planning approach works well in many cases, it does not predict accurate functional outcome in many others. This paper presents a vision for how patient-specific multibody dynamic models can serve as the foundation for an objective treatment planning approach that identifies optimal treatments and treatment parameters on an individual patient basis. First, a computational paradigm is presented for constructing patient-specific multibody dynamic models. This paradigm involves a combination of patient-specific skeletal models, muscle-tendon models, neural control models, and articular contact models, with the complexity of the complete model being dictated by the requirements of the clinical problem being addressed. Next, three clinical applications are presented to illustrate how such models could be used in the treatment design process. One application involves the design of patient-specific gait modification strategies for knee osteoarthritis rehabilitation, a second involves the selection of optimal patient-specific surgical parameters for a particular knee osteoarthritis surgery, and the third involves the design of patient-specific muscle stimulation patterns for stroke rehabilitation. The paper concludes by discussing important challenges that need to be overcome to turn this vision into reality. PMID:21785529

  12. Evaluation of plan quality assurance models for prostate cancer patients based on fully automatically generated Pareto-optimal treatment plans

    NASA Astrophysics Data System (ADS)

    Wang, Yibing; Breedveld, Sebastiaan; Heijmen, Ben; Petit, Steven F.

    2016-06-01

    IMRT planning with commercial Treatment Planning Systems (TPSs) is a trial-and-error process. Consequently, the quality of treatment plans may not be consistent among patients, planners and institutions. Recently, different plan quality assurance (QA) models have been proposed, that could flag and guide improvement of suboptimal treatment plans. However, the performance of these models was validated using plans that were created using the conventional trail-and-error treatment planning process. Consequently, it is challenging to assess and compare quantitatively the accuracy of different treatment planning QA models. Therefore, we created a golden standard dataset of consistently planned Pareto-optimal IMRT plans for 115 prostate patients. Next, the dataset was used to assess the performance of a treatment planning QA model that uses the overlap volume histogram (OVH). 115 prostate IMRT plans were fully automatically planned using our in-house developed TPS Erasmus-iCycle. An existing OVH model was trained on the plans of 58 of the patients. Next it was applied to predict DVHs of the rectum, bladder and anus of the remaining 57 patients. The predictions were compared with the achieved values of the golden standard plans for the rectum D mean, V 65, and V 75, and D mean of the anus and the bladder. For the rectum, the prediction errors (predicted-achieved) were only  -0.2  ±  0.9 Gy (mean  ±  1 SD) for D mean,-1.0  ±  1.6% for V 65, and  -0.4  ±  1.1% for V 75. For D mean of the anus and the bladder, the prediction error was 0.1  ±  1.6 Gy and 4.8  ±  4.1 Gy, respectively. Increasing the training cohort to 114 patients only led to minor improvements. A dataset of consistently planned Pareto-optimal prostate IMRT plans was generated. This dataset can be used to train new, and validate and compare existing treatment planning QA models, and has been made publicly available. The OVH model was highly accurate

  13. Evaluation of plan quality assurance models for prostate cancer patients based on fully automatically generated Pareto-optimal treatment plans.

    PubMed

    Wang, Yibing; Breedveld, Sebastiaan; Heijmen, Ben; Petit, Steven F

    2016-06-07

    IMRT planning with commercial Treatment Planning Systems (TPSs) is a trial-and-error process. Consequently, the quality of treatment plans may not be consistent among patients, planners and institutions. Recently, different plan quality assurance (QA) models have been proposed, that could flag and guide improvement of suboptimal treatment plans. However, the performance of these models was validated using plans that were created using the conventional trail-and-error treatment planning process. Consequently, it is challenging to assess and compare quantitatively the accuracy of different treatment planning QA models. Therefore, we created a golden standard dataset of consistently planned Pareto-optimal IMRT plans for 115 prostate patients. Next, the dataset was used to assess the performance of a treatment planning QA model that uses the overlap volume histogram (OVH). 115 prostate IMRT plans were fully automatically planned using our in-house developed TPS Erasmus-iCycle. An existing OVH model was trained on the plans of 58 of the patients. Next it was applied to predict DVHs of the rectum, bladder and anus of the remaining 57 patients. The predictions were compared with the achieved values of the golden standard plans for the rectum D mean, V 65, and V 75, and D mean of the anus and the bladder. For the rectum, the prediction errors (predicted-achieved) were only  -0.2  ±  0.9 Gy (mean  ±  1 SD) for D mean,-1.0  ±  1.6% for V 65, and  -0.4  ±  1.1% for V 75. For D mean of the anus and the bladder, the prediction error was 0.1  ±  1.6 Gy and 4.8  ±  4.1 Gy, respectively. Increasing the training cohort to 114 patients only led to minor improvements. A dataset of consistently planned Pareto-optimal prostate IMRT plans was generated. This dataset can be used to train new, and validate and compare existing treatment planning QA models, and has been made publicly available. The OVH model was highly accurate

  14. Brentuximab vedotin administered to platinum-refractory, transplant-naïve Hodgkin lymphoma patients can increase the proportion achieving FDG PET negative status.

    PubMed

    Onishi, Maika; Graf, Solomon A; Holmberg, Leona; Behnia, Sanaz; Shustov, Andrei R; Schiavo, Karen; Philip, Mary; Libby, Edward N; Cassaday, Ryan D; Pagel, John M; Roden, Jennifer E; Maloney, David G; Green, Damian J; Till, Brian G; Press, Oliver W; Smith, Stephen D; Gopal, Ajay K

    2015-12-01

    Normalization of fluorodeoxyglucose positron emission tomography (FDG PET) imaging prior to high-dose therapy and autologous stem cell transplantation (ASCT) improves outcomes in relapsed and refractory (RR) Hodgkin lymphoma (HL), but many patients refractory to platinum-based salvage regimens are unable to achieve this goal. We therefore investigated whether brentuximab vedotin (BV) could normalize FDG PET in platinum-refractory HL prior to ASCT. Fifteen consecutive patients with RR HL and FDG PET positive disease after platinum-based salvage therapy were treated with a median of 4 cycles of BV. Normalization of FDG PET (Deauville ≤2) occurred in 8/15 (53%) patients but was only observed in patients that had achieved partial remission or stable disease after platinum-based salvage therapy. All patients eventually proceeded to ASCT, regardless of FDG PET status. Our data suggest that BV can normalize FDG PET in a subset of patients with platinum-refractory HL prior to ASCT.

  15. Neoadjuvant Gemcitabine Chemotherapy followed by Concurrent IMRT Simultaneous Boost Achieves High R0 Resection in Borderline Resectable Pancreatic Cancer Patients

    PubMed Central

    Huang, Xiaolun; Knoble, Jeanna L.; Aguila, Fernando N.; Patel, Tara; Chambers, Lowell W.; Hu, Honglin; Liu, Hao

    2016-01-01

    Background To study the feasibility of down stage the borderline resectable pancreatic cancer (BRPC) to resectable disease, we reported our institutional results using an intensity-modulated radiation therapy (IMRT) simultaneous integrated boost (SIB) dose escalation approach to improve R0 resectability. Methods We reviewed our past 7 years of experience of using neoadjuvant induction chemotherapy with Gemcitabine followed by concurrent chemoradiaiton for BRPC. During the concurrent, chemo was 5-FU and radiation were IMRT with SIB technique to target the key areas with dose escalation to 5600 in 28 fractions. The key areas were defined by PET positive area. This was followed by restaging imaging to rule out distant metastases before resection. Results 25 finished dose escalation protocol. 2 of the 25 cases developed distant metastases, 23 (92%) patients without distant metastases underwent pancreatectomy. Among the those received pancreatectomy, 22 (95%) achieved negative margin (R0). The gastrointestinal toxicity > grade 2 was 8% and there was no grade 4 toxicity. Conclusion Neoadjuvant Gemcitabine-based induction chemotherapy followed by 5-FU-based IMRT-SIB is a feasible option in improving the likelihood of R0 resection rate in BRPC without compromising the organs at risk for toxicity. PMID:27935952

  16. Optimal Combination Treatment and Vascular Outcomes in Recent Ischemic Stroke Patients by Premorbid Risk Level

    PubMed Central

    Park, Jong-Ho; Ovbiagele, Bruce

    2015-01-01

    Background 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. Methods 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 level 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. Results 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. Conclusion 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. PMID:26044963

  17. Comparisons of treatment optimization directly incorporating random patient setup uncertainty with a margin-based approach.

    PubMed

    Moore, Joseph A; Gordon, John J; Anscher, Mitchell S; Siebers, Jeffrey V

    2009-09-01

    The purpose of this study is to incorporate the dosimetric effect of random patient positioning uncertainties directly into a commercial treatment planning system's IMRT plan optimization algorithm through probabilistic treatment planning (PTP) and compare coverage of this method with margin-based planning. In this work, PTP eliminates explicit margins and optimizes directly on the estimated integral treatment dose to determine optimal patient dose in the presence of setup uncertainties. Twenty-eight prostate patient plans adhering to the RTOG-0126 criteria are optimized using both margin-based and PTP methods. Only random errors are considered. For margin-based plans, the planning target volume is created by expanding the clinical target volume (CTV) by 2.1 mm to accommodate the simulated 3 mm random setup uncertainty. Random setup uncertainties are incorporated into IMRT dose evaluation by convolving each beam's incident fluence with a sigma = 3 mm Gaussian prior to dose calculation. PTP optimization uses the convolved fluence to estimate dose to ensure CTV coverage during plan optimization. PTP-based plans are compared to margin-based plans with equal CTV coverage in the presence of setup errors based on dose-volume metrics. The sensitivity of the optimized plans to patient-specific setup uncertainty variations is assessed by evaluating dose metrics for dose distributions corresponding to halving and doubling of the random setup uncertainty used in the optimization. Margin-based and PTP-based plans show similar target coverage. A physician review shows that PTP is preferred for 21 patients, margin-based plans are preferred in 2 patients, no preference is expressed for 1 patient, and both autogenerated plans are rejected for 4 patients. For the PTP-based plans, the average CTV receiving the prescription dose decreases by 0.5%, while the mean dose to the CTV increases by 0.7%. The CTV tumor control probability (TCP) is the same for both methods with the exception

  18. 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.

  19. Initial experience in primal-dual optimization reconstruction from sparse-PET patient data

    NASA Astrophysics Data System (ADS)

    Zhang, Zheng; Ye, Jinghan; Chen, Buxin; Perkins, Amy E.; Rose, Sean; Sidky, Emil Y.; Kao, Chien-Min; Xia, Dan; Tung, Chi-Hua; Pan, Xiaochuan

    2016-03-01

    There exists interest in designing a PET system with reduced detectors due to cost concerns, while not significantly compromising the PET utility. Recently developed optimization-based algorithms, which have demonstrated the potential clinical utility in image reconstruction from sparse CT data, may be used for enabling such design of innovative PET systems. In this work, we investigate a PET configuration with reduced number of detectors, and carry out preliminary studies from patient data collected by use of such sparse-PET configuration. We consider an optimization problem combining Kullback-Leibler (KL) data fidelity with an image TV constraint, and solve it by using a primal-dual optimization algorithm developed by Chambolle and Pock. Results show that advanced algorithms may enable the design of innovative PET configurations with reduced number of detectors, while yielding potential practical PET utilities.

  20. Patients, doctors, and videotape: a prescription for creating optimal healing environments?

    PubMed

    Frankel, Richard M; Sung, Sue Hee; Hsu, John T

    2005-01-01

    Despite repeated calls for greater patient autonomy, shared decision making, and exploration of patient preferences, relatively little is known about how patients actually experience care as a face-to-face interactional process. A selected review of the literature in this area suggests that important asymmetries exist. Key among them is the tendency to report experiences from the point of view of only one member of the doctor-patient dyad. Thus, patients might report on their experiences of the system gone awry or professionals might attempt to understand the root cause(s) of an error by describing the conditions under which it occurred. Either way, information about the experience of care tends to be reported as a "my side" telling. Optimal healing environments are defined as health care contexts that are based upon mutual respect and build positive, resilient relationships among participants, using the qualities and resources of those relationships to enhance health. Understanding optimal healing environments also requires a knowledge of how doctors and patients share time and space together in the consultation (an etic or outsider perspective) and also a knowledge of the participants' experience of their time together (an emic or insider perspective). After reviewing its methodological roots, the IMPACT approach (Interactive Methodology for Preserving and Analyzing Clinical Transactions) using videotaped encounters along with independent commentaries by participants is described and applied in two different types of analyses: one in which the doctor-patient dyad is the unit of measure; the second in which physicians are stratified by having historically high or low satisfaction scores. In the latter approach, doctors' and patients' comments are compared across strata. At the dyadic level, and despite large gaps in income and social status, doctors and patients exhibit a strong tendency to cluster in terms of where they comment, so much so that in a pilot study

  1. Update on the optimal management of patients with colorectal liver metastases.

    PubMed

    Alberts, Steven R

    2012-10-01

    Patients with colorectal liver metastases represent a distinct subset of metastatic colorectal cancer. Optimal management requires a multidisciplinary approach, local and systemic. Curative hepatic surgery is standard for resectable cases, but unfortunately, the majority of patients are not initially resectable due to the size, location, and/or extent of disease, inadequate remnant liver volume, or comorbidities. Other local approaches may be complementary (such as portal vein embolization) or alternative (such as ablation, hepatic arterial infusion, selective internal radiation therapy, and stereotactic body radiotherapy) to surgery. Systemic therapy can downsize disease, allowing surgical resection and, potentially, long-term survival, but it must be balanced against the potential for hepatotoxicity. Current standard approaches including cytotoxics and biologics, such as bevacizumab and particularly anti-epidermal growth factor receptor therapy, improve response rates and may enhance downsizing and resection rates. Optimization of local therapies and systemic conversion strategies via controlled, randomized trials is still a pending question.

  2. Association of Optimism with Emotional and Cardiovascular Reactivity in Coronary Patients, and Healthy Controls

    DTIC Science & Technology

    2007-04-12

    Aging Study, and found a protective dose-response relationship between higher levels of optimism and reduced occurrence of nonfatal MI, angina pectoris ...post surgical sternal wound infection, angina , MI, need for angioplasty, and need for another bypass surgery (N=247, b=-.09 +.04, p<.05; odds ratio...unstable angina , (6) critical valvular pathology, and (7) refusal of informed consent. CAD patients (N = 31) Inclusion criteria: (1

  3. Optimal patterns of care in patients with chronic obstructive pulmonary disease.

    PubMed

    Martin-Harris, B

    2000-01-01

    An intimate relationship exists between the physiological processes of respiration and swallowing at all levels of neuromotor control and peripheral function in healthy adults. Little is known regarding the potential alterations in these patterns in patients with chronic obstructive pulmonary disease (COPD), yet the impact of swallowing impairment and aspiration on the health outcomes of patients with COPD may be significant. COPD is a common comorbidity in patients with head and neck cancer and neurological disorders seen by swallowing clinicians, and warrants consideration during swallowing treatment. This article summarizes reports of alterations in the nutritional status, airway protective mechanisms, and swallowing efficiency that potentially contribute to or exacerbate the chronic and debilitating pulmonary condition. Care guidelines are given for modification of eating and swallowing behavior to optimize the health status of the patient with COPD. The need for controlled clinical trials for validation of the impact of these care guidelines on clinical outcomes is explained.

  4. [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.

  5. A data-integrated simulation-based optimization for assigning nurses to patient admissions.

    PubMed

    Sundaramoorthi, Duraikannan; Chen, Victoria C P; Rosenberger, Jay M; Kim, Seoung Bum; Buckley-Behan, Deborah F

    2010-09-01

    The health care system in the United States has a shortage of nurses. A careful planning of nurse resources is needed to ease the health care system from the burden of the nurse shortage and standardize nurse workload. An earlier research study developed a data-integrated simulation to evaluate nurse-patient assignments (SIMNA) at the beginning of a shift based on a real data set provided by a northeast Texas hospital. In this research, with the aid of the same SIMNA model, two policies are developed to make nurse-to-patient assignments when new patients are admitted during a shift. A heuristic (HEU) policy assigns a newly-admitted patient to the nurse who has performed the least assigned direct care among all the nurses. A partially-optimized (OPT) policy seeks to minimize the difference in workload among nurses for the entire shift by estimating the assigned direct care from SIMNA. Results comparing HEU and OPT policies are presented.

  6. Regional gray matter abnormalities in patients with schizophrenia determined with optimized voxel-based morphometry

    NASA Astrophysics Data System (ADS)

    Guo, XiaoJuan; Yao, Li; Jin, Zhen; Chen, Kewei

    2006-03-01

    This study examined regional gray matter abnormalities across the whole brain in 19 patients with schizophrenia (12 males and 7 females), comparing with 11 normal volunteers (7 males and 4 females). The customized brain templates were created in order to improve spatial normalization and segmentation. Then automated preprocessing of magnetic resonance imaging (MRI) data was conducted using optimized voxel-based morphometry (VBM). The statistical voxel based analysis was implemented in terms of two-sample t-test model. Compared with normal controls, regional gray matter concentration in patients with schizophrenia was significantly reduced in the bilateral superior temporal gyrus, bilateral middle frontal and inferior frontal gyrus, right insula, precentral and parahippocampal areas, left thalamus and hypothalamus as well as, however, significant increases in gray matter concentration were not observed across the whole brain in the patients. This study confirms and extends some earlier findings on gray matter abnormalities in schizophrenic patients. Previous behavior and fMRI researches on schizophrenia have suggested that cognitive capacity decreased and self-conscious weakened in schizophrenic patients. These regional gray matter abnormalities determined through structural MRI with optimized VBM may be potential anatomic underpinnings of schizophrenia.

  7. Achievement of recommended lipid and lipoprotein levels with combined ezetimibe/statin therapy versus statin alone in patients with and without diabetes.

    PubMed

    Guyton, John R; Betteridge, D John; Farnier, Michel; Leiter, Lawrence A; Lin, Jianxin; Shah, Arvind; Johnson-Levonas, Amy O; Brudi, Philippe

    2011-04-01

    Treatment guidelines identify low-density lipoprotein cholesterol (LDL-C) as the primary target of therapy with secondary targets of non-high-density lipoprotein cholesterol (non-HDL-C) and apolipoprotein B (apoB). Data were pooled from 27 randomised, double-blind, active or placebo-controlled trials in 21,794 adult hypercholesterolaemic patients (LDL-C 1.81-6.48 mmol/L) receiving ezetimibe/statin or statin for 4-24 weeks. Percentages of patients achieving various targets were calculated among diabetes (n = 6541) and non-diabetes (n = 15,253) subgroups. Significantly more patients with and without diabetes achieved specified levels of LDL-C (< 2.59, < 1.99, < 1.81 mmol/L), non-HDL-C (< 3.37, < 2.59 mmol/L) and apoB (< 0.9, < 0.8 g/L) with ezetimibe/statin versus statin. Patients with diabetes had larger mean per cent reductions in LDL-C and non-HDL-C than non-diabetes patients. A greater percentage of patients achieved both the LDL-C and apoB targets and all three LDL-C, apoB, and non-HDL-C targets with ezetimibe/statin versus statin in both subgroups. Patients with diabetes benefitted at least as much as, and sometimes more than, non-diabetes patients following treatment with ezetimibe/statin.

  8. Pups of dams fed low-fat diet during pregnancy and lactation showed strong preference for high-fat diet to achieve optimal growth.

    PubMed

    Nakashima, Yoko; Sato, Akie

    2011-01-01

    To investigate the causes why pups of dams fed a low-fat high-carbohydrate diet (LFD) showed a strong preference for fat, three groups of dams were fed one of three diets during pregnancy and lactation: the LFD, a control diet (CTD) or a high-fat low-carbohydrate diet (HFD). After weaning, pups of each of the three groups were divided into two equal subgroups (Pair 1 and Pair 2), for a total of six pup subgroups. Each subgroup was placed on a two-choice diet program of the LFD and the HFD (Pair 1), or the LFD and a HFDLE (with cellulose added to maintain the same energy concentration as the LFD) (Pair 2), for 3 wk. Although the energy intake of dams fed the LFD during the nursing period was lower than that of the HFD group, no significant difference in body weight was observed among the three groups. At weaning, the body weight of pups nursed by dams fed the LFD was lower than that of the other groups. In Pair 1, the HFD intake ratio of the LFD and the HFD groups during the self-selection period was higher than that of the CTD group. In Pair 2, the HFDLE intake ratio of the LFD and the CTD groups was lower than that of the HFD group. At the end of the self-selection period, no significant difference in body weight was observed among the three groups of Pair 1. However, in Pair 2, the body weight of the LFD group was lower than that of the other groups. Therefore, it was supposed that pups of dams fed the LFD showed strong preference for the HFD containing high energy in order to achieve optimal growth.

  9. Extended duration of thromboprophylaxis in acutely ill medical patients: optimizing therapy?

    PubMed

    Turpie, A G G

    2007-01-01

    Summary. Patients who are hospitalized for an acute medical illness are at risk of venous thromboembolism (VTE). Current evidence-based guidelines recommend prophylaxis with unfractionated heparin or low-molecular-weight heparin in acutely ill medical patients who are admitted to hospital with congestive heart failure, severe respiratory disease, or who are bedridden with an additional VTE risk factor. The need for thromboprophylaxis is therefore clear in this patient population; however, the optimal duration of prophylaxis in these patients is less clear. In patients undergoing orthopedic or cancer surgery, extended-duration prophylaxis has been shown to be superior to placebo. To date, however, no large-scale clinical trials have assessed the benefits of extended-duration prophylaxis in acutely ill medical patients. This review therefore focuses on the VTE risk profile of acutely ill medical patients, examines the currently available literature for evidence of a potential benefit of extended-duration prophylaxis in these patients, and provides a rationale for the testing of such a hypothesis in a randomized clinical trial.

  10. Do patients on oral chemotherapy have sufficient knowledge for optimal adherence? A mixed methods study.

    PubMed

    Arber, A; Odelius, A; Williams, P; Lemanska, A; Faithfull, S

    2017-03-01

    A new treatment paradigm has emerged with many patients now receiving oral chemotherapy (OC) as first-line treatment for cancer. Treatment with OC has resulted in reduced hospital costs, more autonomy for patients but with added responsibilities for patient self-management. Little is known about patient's knowledge following patient education to enable optimal adherence with OC. A mixed methods study was carried out using a self-report questionnaire to patients on OC for multiple myeloma (MM) followed by semi-structured interviews with patients at home. Analysis identifies high rates of adherence (92.2%) with OC for MM. However, statistically significant knowledge deficits were identified, which were related to patient ethnicity and to gender. There is the potential for non-intentional non-adherence with OC due to deficits in knowledge of OC. Support at home needs to include primary care practitioners such as GPs, practice nurses and pharmacists so that timely support is easily accessible especially in the early phase of treatment.

  11. Strategies for Achieving Whole-Practice Engagement and Buy-in to the Patient-Centered Medical Home

    PubMed Central

    Bleser, William K.; Miller-Day, Michelle; Naughton, Dana; Bricker, Patricia L.; Cronholm, Peter F.; Gabbay, Robert A.

    2014-01-01

    PURPOSE The current model of primary care in the United States limits physicians’ ability to offer high-quality care. The patient-centered medical home (PCMH) shows promise in addressing provision of high-quality care, but achieving a PCMH practice model often requires comprehensive organizational change. Guided by Solberg’s conceptual framework for practice improvement, which argues for shared prioritization of improvement and change, we describe strategies for obtaining organizational buy-in to and whole-staff engagement of PCMH transformation and practice improvement. METHODS Semistructured interviews with 136 individuals and 7 focus groups involving 48 individuals were conducted in 20 small- to mid-sized medical practices in Pennsylvania during the first regional rollout of a statewide PCMH initiative. For this study, we analyzed interview transcripts, monthly narrative reports, and observer notes from site visits to identify discourse pertaining to organizational buy-in and strategies for securing buy-in from personnel. Using a consensual qualitative research approach, data were reduced, synthesized, and managed using qualitative data management and analysis software. RESULTS We identified 13 distinct strategies used to obtain practice buy-in, reflecting 3 overarching lessons that facilitate practice buy-in: (1) effective communication and internal PCMH campaigns, (2) effective resource utilization, and (3) creation of a team environment. CONCLUSION Our study provides a list of strategies useful for facilitating PCMH transformation in primary care. These strategies can be investigated empirically in future research, used to guide medical practices undergoing or considering PCMH transformation, and used to inform health care policy makers. Our study findings also extend Solberg’s conceptual framework for practice improvement to include buy-in as a necessary condition across all elements of the change process. PMID:24445102

  12. Optimal pathological response indicated better long-term outcome among patients with stage IB2 to IIB cervical cancer submitted to neoadjuvant chemotherapy

    PubMed Central

    Huang, Kecheng; Sun, Haiying; Chen, Zhilan; Li, Xiong; Wang, ShaoShuai; Zhao, Xiaolin; Tang, Fangxu; Jia, Yao; Hu, Ting; Du, Xiaofang; Wang, Haoran; Lu, Zhiyong; Huang, Jia; Gui, Juan; Wang, Xiaoli; Zhou, Shasha; Wang, Lin; Zhang, Jincheng; Guo, Lili; Yang, Ru; Shen, Jian; Zhang, Qinghua; Li, Shuang; Wang, Shixuan

    2016-01-01

    The role of pathological response in long-term outcome is still unclear in cervical cancer patients treated with neoadjuvant chemotherapy (NACT) in China. This study aimed to investigate the effect of optimal pathologic response (OPR) on survival in the patients treated with NACT and radical hysterectomy. First, 853 patients with stage IB2-IIB cervical cancer were included in a retrospective analysis; a Cox proportional hazards model was used to investigate the relationship between pathological response and disease-free survival (DFS). In the retrospective database, 64 (7.5%) patients were found to have achieved an OPR (residual disease <3 mm stromal invasion); in the multivariate Cox model, the risk of death was much greater in the non-OPR group than in the OPR group (HR, 2.61; 95%CI, 1.06 to 6.45; P = 0.037). Next, the role of OPR was also evaluated in a prospective cohort of 603 patients with cervical cancer. In the prospective cohort, 56 (9.3%) patients were found to have achieved an OPR; the log-rank tests showed that the risk of recurrence was higher in the non-OPR patients than in the OPR group (P = 0.05). After combined analysis, OPR in cervical cancer was found to be an independent prognostic factor for DFS. PMID:27325186

  13. Weight loss and achievement of minimal disease activity in patients with psoriatic arthritis starting treatment with tumour necrosis factor α blockers

    PubMed Central

    Di Minno, Matteo Nicola Dario; Peluso, Rosario; Iervolino, Salvatore; Russolillo, Anna; Lupoli, Roberta; Scarpa, Raffaele

    2014-01-01

    Objectives To evaluate prospectively the effect of weight loss on the achievement of minimal disease activity (MDA) in overweight/obese patients with psoriatic arthritis (PsA) starting treatment with tumour necrosis factor α (TNFα) blockers. Methods Among subjects with PsA starting treatment with TNFα blockers, 138 overweight/obese patients received a concomitant dietary intervention (69 a hypocaloric diet (HD) and 69 a free-managed diet (FD)). Changes in metabolic variables were measured and a complete clinical rheumatological evaluation was made in all patients at baseline and after a 6-month follow-up to define the achievement of MDA. Results 126 subjects completed the study. MDA was more often achieved by HD than by FD subjects (HR=1.85, 95% CI 1.019 to 3.345, p=0.043). A diet was successful (≥5% weight loss) in 74 (58.7%) patients. Regardless of the type of diet, after 6 months of treatment with TNFα blockers, ≥5% of weight loss was a predictor of the achievement of MDA (OR=4.20, 95% CI 1.82 to 9.66, p<0.001). For increasing weight-loss categories (<5%, 5–10%, >10%), MDA was achieved by 23.1%, 44.8% and 59.5%, respectively. A higher rate of MDA achievement was found in subjects with 5–10% (OR=3.75, 95% CI 1.36 to 10.36, p=0.011) and in those with >10% (OR=6.67, 95% CI 2.41 to 18.41, p<0.001) weight loss in comparison with those with <5% weight loss. Conclusions Regardless of the type of diet, a successful weight loss (≥5% from baseline values) is associated with a higher rate of achievement of MDA in overweight/obese patients with PsA who start treatment with TNFα blockers. PMID:23771989

  14. Initial Stage Affects Survival Even After Complete Pathologic Remission is Achieved in Locally Advanced Esophageal Cancer: Analysis of 70 Patients With Pathologic Major Response After Preoperative Chemoradiotherapy

    SciTech Connect

    Kim, Min Kyoung; Cho, Kyung-Ja; Park, Seung-Il; Kim, Yong Hee; Kim, Jong Hoon; Song, Ho-Young; Shin, Ji Hoon; Jung, Hwoon Yong; Lee, Gin Hyug; Choi, Kee Don; Song, Ho June; Ryu, Jin-Sook; Kim, Sung-Bae

    2009-09-01

    Purpose: To analyze outcomes and factors predictive for recurrence and survival in patients with operable esophageal carcinoma who achieved pathologic complete response (PCR) or microscopic residual disease (MRD) after preoperative chemoradiotherapy (CRT). Materials and Methods: Outcomes were assessed in 70 patients with locally advanced esophageal cancer who achieved pathologic major response (53 with PCR and 17 with MRD) after preoperative CRT. Results: At a median follow-up of 38.6 months for surviving patients, 17 of 70 patients (24.3%) experienced disease recurrence and 31 (44.3%) died. Clinical stage (II vs III; p = 0.013) and pathologic response (PCR vs. MRD; p = 0.014) were independent predictors of disease recurrence. Median overall survival (OS) was 99.6 months (95% CI, 44.1-155.1 months) and the 5-year OS rate was 57%. Median recurrence-free survival (RFS) was 71.5 months (95% CI, 39.5-103.6 months) and the 5-year RFS rate was 51.3%. Median OS of patients with Stage II and Stage III disease was 108.8 months and 39.9 months, respectively, and the 5-year OS rates were 68.2% and 27.0%, respectively (p = 0.0003). In a subgroup of patients with PCR, median OS and RFS were also significantly different according to clinical stage. Multivariate analysis showed that clinical stage was an independent predictor of RFS (p = 0.01) and OS (p = 0.008). Conclusions: Even though patients achieved major response after preoperative CRT, pretreatment clinical stage is an important prognostic marker for recurrence and survival. Patients with MRD have an increased recurrence risk but similar survival compared with patients achieved PCR.

  15. Image quality and dose optimization using novel x-ray source filters tailored to patient size

    NASA Astrophysics Data System (ADS)

    Toth, Thomas L.; Cesmeli, Erdogan; Ikhlef, Aziz; Horiuchi, Tetsuya

    2005-04-01

    The expanding set of CT clinical applications demands increased attention to obtaining the maximum image quality at the lowest possible dose. Pre-patient beam shaping filters provide an effective means to improve dose utilization. In this paper we develop and apply characterization methods that lead to a set of filters appropriately matched to the patient. We developed computer models to estimate image noise and a patient size adjusted CTDI dose. The noise model is based on polychromatic X-ray calculations. The dose model is empirically derived by fitting CTDI style dose measurements for a demographically representative set of phantom sizes and shapes with various beam shaping filters. The models were validated and used to determine the optimum IQ vs dose for a range of patient sizes. The models clearly show that an optimum beam shaping filter exists as a function of object diameter. Based on noise and dose alone, overall dose efficiency advantages of 50% were obtained by matching the filter shape to the size of the object. A set of patient matching filters are used in the GE LightSpeed VCT and Pro32 to provide a practical solution for optimum image quality at the lowest possible dose over the range of patient sizes and clinical applications. Moreover, these filters mark the beginning of personalized medicine where CT scanner image quality and radiation dose utilization is truly individualized and optimized to the patient being scanned.

  16. Optimizing Physical Activity Among Older Adults Post Trauma: Overcoming System and Patient Challenges

    PubMed Central

    Resnick, Barbara; Galik, Elizabeth; Wells PT, Chris L.; Boltz, Marie; Holtzman, Lauren

    2015-01-01

    By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery post trauma for these individuals is more complicated than among younger individuals. Specifically there is an increased risk for: (1) functional decline; (2) higher mortality rates; (3) longer length of stay; (4) greater resource consumption; (5) nursing home placement; (6) adverse events such as infections, pressure ulcers and falls; and (7) rehospitalization post discharge. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges. The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention. Overall the intervention was implemented as intended and recruitment rates were consistent with other studies. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients. Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period. PMID:26547682

  17. Achieving Bidirectional Long Delays In Pulmonary Vein Antral Lines Prior To Bidirectional Block In Patients With Paroxysmal Atrial Fibrillation (The Bi-Bi Technique For Atrial Fibrillation Ablation).

    PubMed

    Mina Md Facc Fhrs, Adel F; L Warnecke Pa-C, Nicholas

    2016-01-01

    Background: Pulmonary Vein Antral isolation (PVAI) is currently the standard of care for both paroxysmal and persistent atrial fibrillation ablation. Reconnection to the pulmonary vein is the most common cause of recurrence of atrial fibrillation. Achieving the endpoint of bidirectional block (BDB) for cavotricuspid isthmus dependant flutter has improved our outcomes for atrial flutter ablation. With this we tried to achieve long delays in the pulmonary veins antral lines prior to complete isolation comparable to those delays found in patient with bidirectional block of atrial flutter lines. Study Objective:The objective of this paper was to evaluate feasibility and efficacy of achieving Bidirectional long delays in pulmonary vein antral lines prior to Bidirectional Block in patient with paroxysmal atrial fibrillation. Method: A retrospective analysis was performed on patients who had paroxysmal atrial fibrillation procedures at Unity Point Methodist from January 2015 to January 2016. 20 consecutive patients with paroxysmal atrial fibrillation who had AF ablation using the Bi-Bi technique were evaluated. Result: Mean age was 63, number of antiarrhythmic used prior to ablation was 1.4, mean left atrial size was 38 mm. Mean chads score was 1.3. Mean EF was 53%. Long delays in the left antral circumferential lines were achieved with mean delay of 142 milliseconds +/-100. Also long delays in the right antral circumferential lines were achieved with mean delay of 150 milliseconds +/-80. 95 % (19/20) of patients were free of any atrial arrhythmias and were off antiarrhythmic medications for AF post procedure. There was only one transient complication in one patient who developed a moderate pericardial effusion that was successfully drained with no hemodynamic changes. The only patient who had recurrence was found to have asymptomatic AF with burden on his device <1%, this patient was also found to have non PV triggers for his AF. In patients with only PV triggered AF

  18. Pharmacokinetic Modeling and Optimal Sampling Strategies for Therapeutic Drug Monitoring of Rifampin in Patients with Tuberculosis

    PubMed Central

    Sturkenboom, Marieke G. G.; Mulder, Leonie W.; de Jager, Arthur; van Altena, Richard; Aarnoutse, Rob E.; de Lange, Wiel C. M.; Proost, Johannes H.; Kosterink, Jos G. W.; van der Werf, Tjip S.

    2015-01-01

    Rifampin, together with isoniazid, has been the backbone of the current first-line treatment of tuberculosis (TB). The ratio of the area under the concentration-time curve from 0 to 24 h (AUC0–24) to the MIC is the best predictive pharmacokinetic-pharmacodynamic parameter for determinations of efficacy. The objective of this study was to develop an optimal sampling procedure based on population pharmacokinetics to predict AUC0–24 values. Patients received rifampin orally once daily as part of their anti-TB treatment. A one-compartmental pharmacokinetic population model with first-order absorption and lag time was developed using observed rifampin plasma concentrations from 55 patients. The population pharmacokinetic model was developed using an iterative two-stage Bayesian procedure and was cross-validated. Optimal sampling strategies were calculated using Monte Carlo simulation (n = 1,000). The geometric mean AUC0–24 value was 41.5 (range, 13.5 to 117) mg · h/liter. The median time to maximum concentration of drug in serum (Tmax) was 2.2 h, ranging from 0.4 to 5.7 h. This wide range indicates that obtaining a concentration level at 2 h (C2) would not capture the peak concentration in a large proportion of the population. Optimal sampling using concentrations at 1, 3, and 8 h postdosing was considered clinically suitable with an r2 value of 0.96, a root mean squared error value of 13.2%, and a prediction bias value of −0.4%. This study showed that the rifampin AUC0–24 in TB patients can be predicted with acceptable accuracy and precision using the developed population pharmacokinetic model with optimal sampling at time points 1, 3, and 8 h. PMID:26055359

  19. The optimal number of lymph nodes removed in maximizing the survival of breast cancer patients

    NASA Astrophysics Data System (ADS)

    Peng, Lim Fong; Taib, Nur Aishah; Mohamed, Ibrahim; Daud, Noorizam

    2014-07-01

    The number of lymph nodes removed is one of the important predictors for survival in breast cancer study. Our aim is to determine the optimal number of lymph nodes to be removed for maximizing the survival of breast cancer patients. The study population consists of 873 patients with at least one of axillary nodes involved among 1890 patients from the University of Malaya Medical Center (UMMC) breast cancer registry. For this study, the Chi-square test of independence is performed to determine the significant association between prognostic factors and survival status, while Wilcoxon test is used to compare the estimates of the hazard functions of the two or more groups at each observed event time. Logistic regression analysis is then conducted to identify important predictors of survival. In particular, Akaike's Information Criterion (AIC) are calculated from the logistic regression model for all thresholds of node involved, as an alternative measure for the Wald statistic (χ2), in order to determine the optimal number of nodes that need to be removed to obtain the maximum differential in survival. The results from both measurements are compared. It is recommended that, for this particular group, the minimum of 10 nodes should be removed to maximize survival of breast cancer patients.

  20. Optimizing the use of patient data to improve outcomes for patients: narcotics for chronic noncancer pain.

    PubMed

    Busse, Jason W; Guyatt, Gordon H

    2009-04-01

    Randomized trials can provide important direction to clinical decision-making; however, their strength of inferences may be weakened by methodological limitations, the extent that their reported outcomes fail to address patient-important end points and by failing to report results that provide interpretable estimates of magnitude of effect. Strategies that investigators can use to address interpretability include reporting mean differences between groups in relation to the minimal important difference and reporting the proportion of patients who benefit from treatment and the associated number needed to treat. These strategies also apply to reporting pooled estimates from meta-analyses, even when studies use different instruments to measure the same construct. We illustrate these techniques using, as an example, current evidence for the use of opioids in chronic noncancer pain.

  1. Optimizing resource allocation and patient flow: process analysis and reorganization in three chemotherapy outpatient clinics.

    PubMed

    Holmes, Morgan; Bodie, Kelly; Porter, Geoffrey; Sullivan, Victoria; Tarasuk, Joy; Trembley, Jodie; Trudeau, Maureen

    2010-01-01

    Optimizing human and physical resources is a major concern for cancer care decision-makers and practitioners. This issue is particularly acute in the context of ambulatory out patient chemotherapy clinics, especially when - as is the case almost everywhere in the industrialized world - the number of people requiring systemic therapy is increasing while budgets, staffing and physical space remain static. Recent initiatives at three hospital-based chemotherapy units - in Halifax, Toronto and Kingston - shed light on the value of process analysis and reorganization for using existing human and physical resources to their full potential, improving patient flow and enhancing patient satisfaction. The steps taken in these settings are broadly applicable to other healthcare settings and would likely result in similar benefits in those environments.

  2. Kinetics of Hepatitis B Surface Antigen Level in Chronic Hepatitis B Patients who Achieved Hepatitis B Surface Antigen Loss during Pegylated Interferon Alpha-2a Treatment

    PubMed Central

    Li, Ming-Hui; Zhang, Lu; Qu, Xiao-Jing; Lu, Yao; Shen, Ge; Wu, Shu-Ling; Chang, Min; Liu, Ru-Yu; Hu, Lei-Ping; Li, Zhen-Zhen; Hua, Wen-Hao; Song, Shu-Jing; Xie, Yao

    2017-01-01

    Background: Hepatitis B surface antigen (HBsAg) loss/seroconversion is considered to be the ideal endpoint of antiviral therapy and the ultimate treatment goal in chronic hepatitis B (CHB). This study aimed to assess the patterns of HBsAg kinetics in CHB patients who achieved HBsAg loss during the treatment of pegylated interferon (PEG-IFN) α-2a. Methods: A total of 150 patients were enrolled, composing of 83 hepatitis B envelope antigen (HBeAg)-positive and 67 HBeAg-negative patients. Patients were treated with PEG-IFN α-2a180 μg/week until HBsAg loss/seroconversion was achieved, which occurred within 96 weeks. Serum hepatitis B virus deoxyribonucleic acid and serological indicators (HBsAg, anti-HBs, HBeAg, and anti-HBe) were determined before and every 3 months during PEG-IFN α-2a treatment. Biochemical markers and peripheral blood neutrophil and platelet counts were tested every 1–3 months. Results: Baseline HBsAg levels were 2.5 ± 1.3 log IU/ml, and decreased rapidly at 12 and 24 weeks by 48.3% and 88.3%, respectively. The mean time to HBsAg loss was 54.2 ± 30.4 weeks, though most patients needed extended treatment and 30.0% of HBsAg loss occurred during 72–96 weeks. Baseline HBsAg levels were significantly higher in HBeAg-positive patients (2.9 ± 1.1 log IU/ml) compared with HBeAg-negative patients (2.0 ± 1.3 log IU/ml; t = 4.733, P < 0.001), but the HBsAg kinetics were similar. Patients who achieved HBsAg loss within 48 weeks had significantly lower baseline HBsAg levels and had more rapid decline of HBsAg at 12 weeks compared to patients who needed extended treatment to achieve HBsAg loss. Conclusions: Patients with lower baseline HBsAg levels and more rapid decline during early treatment with PEG-IFN are more likely to achieve HBsAg loss during 96 weeks of treatment, and extended therapy longer than 48 weeks may be required to achieve HBsAg loss. PMID:28229987

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

    PubMed

    Tsapaki, V

    2016-06-01

    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. 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.

  4. Further Optimization of the Reliability of the 28-Joint Disease Activity Score in Patients with Early Rheumatoid Arthritis

    PubMed Central

    Siemons, Liseth; ten Klooster, Peter M.; Vonkeman, Harald E.; van de Laar, Mart A. F. J.; Glas, Cees A. W.

    2014-01-01

    Background The 28-joint Disease Activity Score (DAS28) combines scores on a 28-tender and swollen joint count (TJC28 and SJC28), a patient-reported measure for general health (GH), and an inflammatory marker (either the erythrocyte sedimentation rate [ESR] or the C-reactive protein [CRP]) into a composite measure of disease activity in rheumatoid arthritis (RA). This study examined the reliability of the DAS28 in patients with early RA using principles from generalizability theory and evaluated whether it could be increased by adjusting individual DAS28 component weights. Methods Patients were drawn from the DREAM registry and classified into a “fast response” group (N = 466) and “slow response” group (N = 80), depending on their pace of reaching remission. Composite reliabilities of the DAS28-ESR and DAS28-CRP were determined with the individual components' reliability, weights, variances, error variances, correlations and covariances. Weight optimization was performed by minimizing the error variance of the index. Results Composite reliabilities of 0.85 and 0.86 were found for the DAS28-ESR and DAS28-CRP, respectively, and were approximately equal across patients groups. Component reliabilities, however, varied widely both within and between sub-groups, ranging from 0.614 for GH (“slow response” group) to 0.912 for ESR (“fast response” group). Weight optimization increased composite reliability even further. In the total and “fast response” groups, this was achieved mostly by decreasing the weight of the TJC28 and GH. In the “slow response” group, though, the weights of the TJC28 and SJC28 were increased, while those of the inflammatory markers and GH were substantially decreased. Conclusions The DAS28-ESR and the DAS28-CRP are reliable instruments for assessing disease activity in early RA and reliability can be increased even further by adjusting component weights. Given the low reliability and weightings of the general health

  5. 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

  6. 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

    2016-10-21

    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.

  7. Optimal feature selection for automated classification of FDG-PET in patients with suspected dementia

    NASA Astrophysics Data System (ADS)

    Serag, Ahmed; Wenzel, Fabian; Thiele, Frank; Buchert, Ralph; Young, Stewart

    2009-02-01

    FDG-PET is increasingly used for the evaluation of dementia patients, as major neurodegenerative disorders, such as Alzheimer's disease (AD), Lewy body dementia (LBD), and Frontotemporal dementia (FTD), have been shown to induce specific patterns of regional hypo-metabolism. However, the interpretation of FDG-PET images of patients with suspected dementia is not straightforward, since patients are imaged at different stages of progression of neurodegenerative disease, and the indications of reduced metabolism due to neurodegenerative disease appear slowly over time. Furthermore, different diseases can cause rather similar patterns of hypo-metabolism. Therefore, classification of FDG-PET images of patients with suspected dementia may lead to misdiagnosis. This work aims to find an optimal subset of features for automated classification, in order to improve classification accuracy of FDG-PET images in patients with suspected dementia. A novel feature selection method is proposed, and performance is compared to existing methods. The proposed approach adopts a combination of balanced class distributions and feature selection methods. This is demonstrated to provide high classification accuracy for classification of FDG-PET brain images of normal controls and dementia patients, comparable with alternative approaches, and provides a compact set of features selected.

  8. Optimizing treatment of the partially platinum-sensitive ovarian cancer patient.

    PubMed

    Colombo, Nicoletta

    2013-12-01

    Ovarian cancer is the leading cause of gynecological cancer deaths worldwide. Despite primary treatment with platinum-containing regimens, the majority of women will experience recurrent disease and subsequent death. Recurrent ovarian cancer remains a challenge for successful management, and the choice of second-line chemotherapy is complex due to the range of different factors that need to be considered. One of the main considerations is the platinum-free interval and, specifically, the optimal treatment for patients who are partially platinum-sensitive (platinum-free interval: 6-12 months). Data from the large, multicenter, randomized OVA-301 study have shown that combined trabectedin-pegylated liposomal doxorubicin (PLD) significantly prolonged median overall survival compared with PLD alone (p = 0.0027) in 214 patients with partially platinum-sensitive advanced relapsed ovarian cancer. Furthermore, in OVA-301 patients with partially platinum-sensitive disease who received platinum therapy immediately after disease progression (n = 94), final median overall survival was improved by 9 months (p = 0.0153) in trabectedin-PLD patients compared with PLD alone. In addition to demonstrating a survival advantage, trabectedin-PLD may also allow the treatment of patients having not yet recovered from previous platinum toxicity. In summary, the data suggest the use of combined trabectedin-PLD as a second-line treatment option in patients with partially platinum-sensitive recurrent ovarian cancer, followed by a third-line platinum-containing regimen.

  9. Analysis of the immune system of multiple myeloma patients achieving long-term disease control by multidimensional flow cytometry.

    PubMed

    Pessoa de Magalhães, Roberto J; Vidriales, María-Belén; Paiva, Bruno; Fernandez-Gimenez, Carlos; García-Sanz, Ramón; Mateos, Maria-Victoria; Gutierrez, Norma C; Lecrevisse, Quentin; Blanco, Juan F; Hernández, Jose; de las Heras, Natalia; Martinez-Lopez, Joaquin; Roig, Monica; Costa, Elaine Sobral; Ocio, Enrique M; Perez-Andres, Martin; Maiolino, Angelo; Nucci, Marcio; De La Rubia, Javier; Lahuerta, Juan-Jose; San-Miguel, Jesús F; Orfao, Alberto

    2013-01-01

    Multiple myeloma remains largely incurable. However, a few patients experience more than 10 years of relapse-free survival and can be considered as operationally cured. Interestingly, long-term disease control in multiple myeloma is not restricted to patients with a complete response, since some patients revert to having a profile of monoclonal gammopathy of undetermined significance. We compared the distribution of multiple compartments of lymphocytes and dendritic cells in the bone marrow and peripheral blood of multiple myeloma patients with long-term disease control (n=28), patients with newly diagnosed monoclonal gammopathy of undetermined significance (n=23), patients with symptomatic multiple myeloma (n=23), and age-matched healthy adults (n=10). Similarly to the patients with monoclonal gammopathy of undetermined significance and symptomatic multiple myeloma, patients with long-term disease control showed an expansion of cytotoxic CD8(+) T cells and natural killer cells. However, the numbers of bone marrow T-regulatory cells were lower in patients with long-term disease control than in those with symptomatic multiple myeloma. It is noteworthy that B cells were depleted in patients with monoclonal gammopathy of undetermined significance and in those with symptomatic multiple myeloma, but recovered in both the bone marrow and peripheral blood of patients with long-term disease control, due to an increase in normal bone marrow B-cell precursors and plasma cells, as well as pre-germinal center peripheral blood B cells. The number of bone marrow dendritic cells and tissue macrophages differed significantly between patients with long-term disease control and those with symptomatic multiple myeloma, with a trend to cell count recovering in the former group of patients towards levels similar to those found in healthy adults. In summary, our results indicate that multiple myeloma patients with long-term disease control have a constellation of unique immune changes

  10. To Evaluate the Effectiveness of Achievement Motivation Training for Mental Patients Being Rehabilitated to the Community: Goal Planning in Mental Health Rehabilitation.

    ERIC Educational Resources Information Center

    Houts, Peter S.; Scott, Robert A.

    A project sought to identify how the strategies used in training programs for the development of achievement motivation could be applied to the field of mental health. In addition to using goal planning in all its aspects, if focused on the patients' strengths rather than their problems. It also trained the staff who worked with the patients…

  11. AV delay optimization and management of DDD paced patients with dilated cardiomyopathy.

    PubMed

    Guardigli, G; Ansani, L; Percoco, G F; Toselli, T; Spisani, P; Braggion, G; Antonioli, G E

    1994-11-01

    Ten DDD paced patients, suffering from dilated cardiomyopathy in the NYHA functional classes III or IV were studied by means of Doppler echocardiography at different programmed values of atrioventricular (AV) delay (200, 150, 120, 100, and 80 msec). The following variables were evaluated: LV diameter, ejection fraction, mitral and aortic flow velocity integrals, and stroke volume. During VDD pacing, a resting AV delay associated with the best diastolic filling and systolic function was identified and programmed individually. Shortening of the AV delay to about 100 msec was associated with a gradual and progressive improvement. Further decrease caused an impairment of systolic function. The patients were clinically and hemodynamically reevaluated after 2 months of follow-up. A reduction of NYHA class and an improvement of LV function were consistently found. The reported data suggest that programming of an optimal AV delay may improve myocardial function in DDD paced patients with congestive heart failure. This result may be the consequence of an optimization of left ventricular filling and a better use of the Frank-Starling law.

  12. Currently used dosage regimens of vancomycin fail to achieve therapeutic levels in approximately 40% of intensive care unit patients

    PubMed Central

    Obara, Vitor Yuzo; Zacas, Carolina Petrus; Carrilho, Claudia Maria Dantas de Maio; Delfino, Vinicius Daher Alvares

    2016-01-01

    Objective This study aimed to assess whether currently used dosages of vancomycin for treatment of serious gram-positive bacterial infections in intensive care unit patients provided initial therapeutic vancomycin trough levels and to examine possible factors associated with the presence of adequate initial vancomycin trough levels in these patients. Methods A prospective descriptive study with convenience sampling was performed. Nursing note and medical record data were collected from September 2013 to July 2014 for patients who met inclusion criteria. Eighty-three patients were included. Initial vancomycin trough levels were obtained immediately before vancomycin fourth dose. Acute kidney injury was defined as an increase of at least 0.3mg/dL in serum creatinine within 48 hours. Results Considering vancomycin trough levels recommended for serious gram-positive infection treatment (15 - 20µg/mL), patients were categorized as presenting with low, adequate, and high vancomycin trough levels (35 [42.2%], 18 [21.7%], and 30 [36.1%] patients, respectively). Acute kidney injury patients had significantly greater vancomycin trough levels (p = 0.0055, with significance for a trend, p = 0.0023). Conclusion Surprisingly, more than 40% of the patients did not reach an effective initial vancomycin trough level. Studies on pharmacokinetic and dosage regimens of vancomycin in intensive care unit patients are necessary to circumvent this high proportion of failures to obtain adequate initial vancomycin trough levels. Vancomycin use without trough serum level monitoring in critically ill patients should be discouraged. PMID:28099635

  13. How to optimize HCV therapy in genotype 1 patients: predictors of response.

    PubMed

    Petta, Salvatore; Craxì, Antonio

    2013-02-01

    The advent of triple therapy (TT) with first-generation protease inhibitors boceprevir (BOC) and telaprevir (TVR) in addition to pegylated interferon and ribavirin (PEG-IFN/RBV) has resulted in a significant improvement in the sustained virological response (SVR) rate and potentially in life years gained compared to dual therapy (DT), when treating naïve or treatment-experienced patients with genotype 1 (G1) chronic hepatitis C (CHC). This benefit is partly offset by the increased complexity of treatment, and the increased costs and risks of therapy, making it necessary to optimize the indications for TT. Naïve patients with mild fibrosis and the IL28B CC polymorphism and/or with a rapid virological response (RVR) to DT can still benefit from DT, while TT is preferable in all others. Phase 3 trials have clearly shown that a 1 log(10) decrease in HCVRNA after 4 weeks of DT associated with a favourable IL28B genotype and a low stage of fibrosis, and a pattern of previous response to DT in treatment-experienced patients are the strongest predictors of an SVR to TT. Moreover, an extended rapid virological response (eRVR) is associated with an SVR rate >90%, so that the overall duration of treatment can be shortened in a high proportion of patients. Further efforts to optimize the current TT regimens both by increasing efficacy and improving tolerance are still needed. Most important, in the future, treatment can probably be personalized based on data from post-marketing surveillance of TT providing information about patient groups that were underrepresented in phase 3 studies such as those with cirrhosis.

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

    SciTech Connect

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

    2014-12-15

    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

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

    SciTech Connect

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

    2014-08-15

    Purpose: 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. Methods: 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. Results: 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

  16. CT Radiation Dose Management: A Comprehensive Optimization Process for Improving Patient Safety.

    PubMed

    Parakh, Anushri; Kortesniemi, Mika; Schindera, Sebastian T

    2016-09-01

    Rising concerns of radiation exposure from computed tomography have caused various advances in dose reduction technologies. While proper justification and optimization of scans has been the main focus to address increasing doses, the value of dose management has been largely overlooked. The purpose of this article is to explain the importance of dose management, provide an overview of the available options for dose tracking, and discuss the importance of a dedicated dose team. The authors also describe how a digital radiation tracking software can be used for analyzing the big data on doses for auditing patient safety, scanner utilization, and productivity, all of which have enormous personal and institutional implications. (©) RSNA, 2016.

  17. Proactive strategies for regorafenib in metastatic colorectal cancer: implications for optimal patient management

    PubMed Central

    Khan, Gazala; Moss, Rebecca A; Braiteh, Fadi; Saltzman, Marc

    2014-01-01

    Regorafenib is a broad-spectrum oral multikinase inhibitor that targets several angiogenic, oncogenic, and stromal receptor tyrosine kinases that support the tumor microenvironment. Results from the pivotal Phase III Patients with Metastatic Colorectal Cancer Treated with Regorafenib or Placebo After Failure of Standard Therapy (CORRECT) trial showed that the addition of regorafenib to best supportive care resulted in a significant improvement in median overall survival and progression-free survival compared with placebo plus best supportive care in patients with metastatic colorectal cancer (mCRC) following all available approved therapies. Thus, regorafenib is the first oral multikinase inhibitor indicated for mCRC; it currently has approval in the USA, EU, Japan, Canada, and Singapore for the treatment of mCRC patients who have been previously treated with fluoropyrimidine-, oxaliplatin-, and irinotecan-based chemotherapy, an anti-vascular endothelial growth factor therapy, and, if the tumor is KRAS wild-type, an anti-epidermal growth factor receptor therapy. In this review, we highlight regorafenib’s mechanism of action, present key efficacy data from the CORRECT trial, and discuss how to proactively manage common adverse events (eg, hand-foot skin reaction, hypertension, oral mucositis, diarrhea, and fatigue) experienced by patients receiving regorafenib. Increased awareness of potential adverse events associated with regorafenib and the implementation of proactive strategies to prevent, monitor, and manage these events early in the course of treatment will be instrumental in ensuring optimal patient management and continuation of regorafenib therapy. PMID:24623990

  18. Comparison of patient evaluations of health care quality in relation to WHO measures of achievement in 12 European countries.

    PubMed Central

    Kerssens, Jan J.; Groenewegen, Peter P.; Sixma, Herman J.; Boerma, Wienke G. W.; van der Eijk, Ingrid

    2004-01-01

    OBJECTIVES: To gain insight into similarities and differences in patient evaluations of quality of primary care across 12 European countries and to correlate patient evaluations with WHO health system performance measures (for example, responsiveness) of these countries. METHODS: Patient evaluations were derived from a series of Quote (QUality of care Through patients' Eyes) instruments designed to measure the quality of primary care. Various research groups provided a total sample of 5133 patients from 12 countries: Belarus, Denmark, Finland, Greece, Ireland, Israel, Italy, the Netherlands, Norway, Portugal, United Kingdom, and Ukraine. Intraclass correlations of 10 Quote items were calculated to measure differences between countries. The world health report 2000 - Health systems: improving performance performance measures in the same countries were correlated with mean Quote scores. FINDINGS: Intra-class correlation coefficients ranged from low to very high, which indicated little variation between countries in some respects (for example, primary care providers have a good understanding of patients' problems in all countries) and large variation in other respects (for example, with respect to prescription of medication and communication between primary care providers). Most correlations between mean Quote scores per country and WHO performance measures were positive. The highest correlation (0.86) was between the primary care provider's understanding of patients' problems and responsiveness according to WHO. CONCLUSIONS: Patient evaluations of the quality of primary care showed large differences across countries and related positively to WHO's performance measures of health care systems. PMID:15042232

  19. Strategizing EHR use to achieve patient-centered care in exam rooms: a qualitative study on primary care providers

    PubMed Central

    Zhang, Jing; Ashfaq, Shazia; Bell, Kristin; Calvitti, Alan; Farber, Neil J; Gabuzda, Mark T; Gray, Barbara; Liu, Lin; Rick, Steven; Street, Richard L; Zheng, Kai; Zuest, Danielle; Agha, Zia

    2016-01-01

    Objective Electronic health records (EHRs) have great potential to improve quality of care. However, their use may diminish “patient-centeredness” in exam rooms by distracting the healthcare provider from focusing on direct patient interaction. The authors conducted a qualitative interview study to understand the magnitude of this issue, and the strategies that primary care providers devised to mitigate the unintended adverse effect associated with EHR use. Methods and Materials Semi-structured interviews were conducted with 21 healthcare providers at 4 Veterans Affairs (VAs) outpatient primary care clinics in San Diego County. Data analysis was performed using the grounded theory approach. Results The results show that providers face demands from both patients and the EHR system. To cope with these demands, and to provide patient-centered care, providers attempt to perform EHR work outside of patient encounters and create templates to streamline documentation work. Providers also attempt to use the EHR to engage patients, establish patient buy-in for EHR use, and multitask between communicating with patients and using the EHR. Discussion and Conclusion This study has uncovered the challenges that primary care providers face in integrating the EHR into their work practice, and the strategies they use to overcome these challenges in order to maintain patient-centered care. These findings illuminate the importance of developing “best” practices to improve patient-centered care in today’s highly “wired” health environment. These findings also show that more user-centered EHR design is needed to improve system usability. PMID:26568605

  20. The Importance of Supportive Care in Optimizing Treatment Outcomes of Patients with Advanced Prostate Cancer

    PubMed Central

    2012-01-01

    Optimal oncologic care of older men with prostate cancer, including effective prevention and management of the disease and treatment side effects (so-called best supportive care measures) can prolong survival, improve quality of life, and reduce depressive symptoms. In addition, the proportion of treatment discontinuations can be reduced through early reporting and management of side effects. Pharmacologic care may be offered to manage the side effects of androgen-deprivation therapy and chemotherapy, which may include hot flashes, febrile neutropenia, fatigue, and diarrhea. Nonpharmacologic care (e.g., physical exercise, acupuncture, relaxation) has also been shown to benefit patients. At the Georges Pompidou European Hospital, the Program of Optimization of Chemotherapy Administration has demonstrated that improved outpatient follow-up by supportive care measures can reduce the occurrence of chemotherapy-related side effects, reduce cancellations and modifications of treatment, reduce chemotherapy wastage, and reduce the length of stay in the outpatient unit. The importance of supportive care measures to optimize management and outcomes of older men with advanced prostate cancer should not be overlooked. PMID:23015682

  1. The rationale for patient-reported outcomes surveillance in cancer and a reproducible method for achieving it.

    PubMed

    Smith, Tenbroeck G; Castro, Kathleen M; Troeschel, Alyssa N; Arora, Neeraj K; Lipscomb, Joseph; Jones, Shelton M; Treiman, Katherine A; Hobbs, Connie; McCabe, Ryan M; Clauser, Steven B

    2016-02-01

    Patient-reported outcomes (PROs) measure quality of life, symptoms, patient functioning, and patient perceptions of care; they are essential for gaining a full understanding of cancer care and the impact of cancer on people's lives. Repeatedly captured facility-level and/or population-level PROs (PRO surveillance) could play an important role in quality monitoring and improvement, benchmarking, advocacy, policy making, and research. This article describes the rationale for PRO surveillance and the methods of the Patient Reported Outcomes Symptoms and Side Effects Study (PROSSES), which is the first PRO study to use the American College of Surgeons Commission on Cancer's Rapid Quality Reporting System to identify patients and manage study data flow. The American Cancer Society, the National Cancer Institute, the Commission on Cancer, and RTI International collaborated on PROSSES. PROSSES was conducted at 17 cancer programs that participated in the National Cancer Institute Community Cancer Centers Program among patients diagnosed with locoregional breast or colon cancer. The methods piloted in PROSSES were successful as demonstrated by high eligibility (93%) and response (61%) rates. Differences in clinical and demographic characteristics between respondents and nonrespondents were mostly negligible, with the exception that non-white individuals were somewhat less likely to respond. These methods were consistent across cancer centers and reproducible over time. If repeated and expanded, they could provide PRO surveillance data from patients with cancer on a national scale.

  2. Is administrating branched-chain amino acid-enriched nutrition achieved symptom-free in malnourished cirrhotic patients?

    PubMed

    Tsuda, Yasuhiro; Fukui, Hideo; Sujishi, Tetsuya; Ohama, Hideko; Tsuchimoto, Yusuke; Asai, Akira; Fukunisi, Shinya; Higuchi, Kazuhide

    2014-01-01

    Administration of branched-chain amino acids (BCAA) has been reported to improve liver function, quality of life (QOL). However, in some malnourished patients, serum albumin levels do not improve in response to BCAA granules. In this study, we examined the effects of BCAA-enriched enteral nutrition in patients unresponsive to BCAA granules. Thirty-two decompensated cirrhotic patients at Osaka Medical College were enrolled in this study. Since all patients showed no improvement in serum albumin levels despite 3 months of BCAA granule administration, they were administered 50 g of a flavored BCAA-enriched enteral nutrient twice daily, i.e., during the daytime and late evening. Serum albumin levels and major cirrhotic symptoms were examined 1, 3, and 5 months after treatment initiation. Serum albumin levels improved significantly 3 months after treatment initiation (3.14 ± 0.32 g/dl vs 3.5 ± 0.31 g/dl, p<0.01), and Child-Pugh scores decreased significantly (p<0.01). In the majority (53-80%) of patients, muscles cramps, fatigue, fatigability, edema, and sleep disturbance improved within 3 months after therapy initiation. Moreover, approximately 90% of the patients became symptom-free 5 months after treatment initiation. These results indicate that switching to BCAA-enriched nutrients improves QOL of cirrhotic patients unresponsive to BCAA granules.

  3. Optimization of Carbon Ion Treatment Plans by Integrating Tissue Specific α/β-Values for Patients with Non-Resectable Pancreatic Cancer

    PubMed Central

    Scholz, Christian; Pommer, Mira; Brons, Stephan; Prokesch, Hannah; Ecker, Swantje; Debus, Jürgen; Jäkel, Oliver; Combs, Stephanie E.; Habermehl, Daniel

    2016-01-01

    Background The aim of the thesis is to improve treatment plans of carbon ion irradiation by integrating the tissues’ specific αβ-values for patients with locally advanced pancreatic cancer (LAPC). Material and Methods Five patients with LAPC were included in this study. By the use of the treatment planning system Syngo RT Planning (Siemens, Erlangen, Germany) treatment plans with carbon ion beams have been created. Dose calculation was based on αβ-values for both organs at risk (OAR) and the tumor. Twenty-five treatment plans and thirty-five forward calculations were created. With reference to the anatomy five field configurations were included. Single Beam Optimization (SBO) and Intensity Modulated Particle Therapy (IMPT) were used for optimization. The plans were analyzed with respect to both dose distributions and individual anatomy. The plans were evaluated using a customized index. Results With regard to the target, a field setup with one single posterior field achieves the highest score in our index. Field setups made up of three fields achieve good results in OAR sparing. Nevertheless, the field setup with one field is superior in complex topographic conditions. But, allocating an αβ-value of 2 Gy to the spinal cord leads to critical high maximum doses in the spinal cord. The evaluation of dose profiles showed significant dose peaks at borders of the αβ-gradient, especially in case of a single posterior field. Conclusion Optimization with specific αβ-values allows a more accurate view on dose distribution than previously. A field setup with one single posterior field achieves good results in case of difficult topographic conditions, but leads to high maximum doses to the spinal cord. So, field setups with multiple fields seem to be more adequate in case of LAPC, being surrounded by highly radiosensitive normal tissues. PMID:27736917

  4. Virtual couch shift (VCS): accounting for patient translation and rotation by online IMRT re-optimization.

    PubMed

    Bol, G H; Lagendijk, J J W; Raaymakers, B W

    2013-05-07

    When delivering conventional intensity modulated radiotherapy (IMRT), discrepancies between the pre-treatment CT/MRI/PET based patient geometry and the daily patient geometry are minimized by performing couch translations and/or small rotations. However, full compensation of, in particular, rotations is usually not possible. In this paper, we introduce an online 'virtual couch shift (VCS)': we translate and/or rotate the pre-treatment dose distribution to compensate for the changes in patient anatomy and generate a new plan which delivers the transformed dose distribution automatically. We show for a phantom and a cervical cancer patient case that VCS accounts for both translations and large rotations equally well in terms of DVH results and 2%/2 mm γ analyses and when the various aspects of the clinical workflow can be implemented successfully, VCS can potentially outperform physical couch translations and/or rotations. This work is performed in the context of our hybrid 1.5 T MRI linear accelerator, which can provide translations and rotations but also deformations of the anatomy. The VCS is the first step toward compensating all of these anatomical changes by online re-optimization of the IMRT dose distribution.

  5. Personalizing colon cancer adjuvant therapy: selecting optimal treatments for individual patients.

    PubMed

    Dienstmann, Rodrigo; Salazar, Ramon; Tabernero, Josep

    2015-06-01

    For more than three decades, postoperative chemotherapy-initially fluoropyrimidines and more recently combinations with oxaliplatin-has reduced the risk of tumor recurrence and improved survival for patients with resected colon cancer. Although universally recommended for patients with stage III disease, there is no consensus about the survival benefit of postoperative chemotherapy in stage II colon cancer. The most recent adjuvant clinical trials have not shown any value for adding targeted agents, namely bevacizumab and cetuximab, to standard chemotherapies in stage III disease, despite improved outcomes in the metastatic setting. However, biomarker analyses of multiple studies strongly support the feasibility of refining risk stratification in colon cancer by factoring in molecular characteristics with pathologic tumor staging. In stage II disease, for example, microsatellite instability supports observation after surgery. Furthermore, the value of BRAF or KRAS mutations as additional risk factors in stage III disease is greater when microsatellite status and tumor location are taken into account. Validated predictive markers of adjuvant chemotherapy benefit for stage II or III colon cancer are lacking, but intensive research is ongoing. Recent advances in understanding the biologic hallmarks and drivers of early-stage disease as well as the micrometastatic environment are expected to translate into therapeutic strategies tailored to select patients. This review focuses on the pathologic, molecular, and gene expression characterizations of early-stage colon cancer; new insights into prognostication; and emerging predictive biomarkers that could ultimately help define the optimal adjuvant treatments for patients in routine clinical practice.

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

    PubMed Central

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

    2016-01-01

    Backgrounds 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. Methods 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. Results 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. Conclusions Guideline-compliant FMC2D ≤ 90 min is achievable for rural STEMI patients within a 50 mile radius of a PCI-capable hospital by use

  7. Pediatric Oncology Clinic Care Model: Achieving Better Continuity of Care for Patients in a Medium-sized Program.

    PubMed

    Johnston, Donna L; Halton, Jacqueline; Bassal, Mylène; Klaassen, Robert J; Mandel, Karen; Ramphal, Raveena; Simpson, Ewurabena; Peckan, Li

    2016-10-25

    Providing the best care in both the inpatient and outpatient settings to pediatric oncology patients is all programs goal. Using continuous improvement methodologies, we changed from a solely team-based physician care model to a hybrid model. All patients were assigned a dedicated oncologist. There would then be 2 types of weeks of outpatient clinical service. A "Doc of the Day" week where each oncologist would have a specific day in clinic when their assigned patients would be scheduled, and then a "Doc of the Week" week where one physician would cover clinic for the week. Patient satisfaction surveys done before and 14 months after changing the model of care showed that patients were very satisfied with the care they received in both models. A questionnaire to staff 14 months after changing showed that the biggest effect was increased continuity of care, followed by more efficient clinic workflow and increased consistency of care. Staff felt it provided better planning and delivery of care. A hybrid model of care with a primary physician for each patient and assigned clinic days, alternating with weeks of single physician coverage is a feasible model of care for a medium-sized pediatric oncology program.

  8. Daclatasvir plus sofosbuvir, with or without ribavirin, achieved high sustained virological response rates in patients with HCV infection and advanced liver disease in a real-world cohort

    PubMed Central

    Welzel, Tania M; Petersen, Jörg; Herzer, Kerstin; Ferenci, Peter; Gschwantler, Michael; Wedemeyer, Heiner; Berg, Thomas; Spengler, Ulrich; Weiland, Ola; van der Valk, Marc; Rockstroh, Jürgen; Peck-Radosavljevic, Markus; Zhao, Yue; Jimenez-Exposito, Maria Jesus; Zeuzem, Stefan

    2016-01-01

    Objective We assessed the effectiveness and safety of daclatasvir (DCV) plus sofosbuvir (SOF), with or without ribavirin (RBV), in a large real-world cohort, including patients with advanced liver disease. Design Adults with chronic HCV infection at high risk of decompensation or death within 12 months and with no available treatment options were treated in a European compassionate use programme. The recommended regimen was DCV 60 mg plus SOF 400 mg for 24 weeks; RBV addition or shorter duration was allowed at physicians' discretion. The primary endpoint was sustained virological response at post-treatment week 12 (SVR12). Results Of the 485 evaluable patients, 359 received DCV+SOF and 126 DCV+SOF+RBV. Most patients were men (66%), white (93%) and treatment-experienced (70%). The most frequent HCV genotypes were 1b (36%), 1a (33%) and 3 (21%), and 80% of patients had cirrhosis (42% Child–Pugh B/C; 46% Model for End-Stage Liver Disease score >10). SVR12 (modified intention-to-treat) was achieved by 91% of patients (419/460); 1 patient had virological breakthrough and 13 patients relapsed. Virological failure was not associated with treatment group (adjusted risk difference DCV+SOF minus DCV+SOF+RBV: 1.06%; 95% CI −2.22% to 4.35%). High SVR12 was observed regardless of HCV genotype or cirrhosis, liver transplant or HIV/HCV coinfection status. Twenty eight patients discontinued treatment due to adverse events (n=18) or death (n=10) and 18 died during follow-up. Deaths and most safety events were associated with advanced liver disease and not considered treatment related. Conclusions DCV+SOF with or without RBV achieved high SVR12 and was well tolerated in a diverse cohort of patients with severe liver disease. Trial registration number NCT0209966. PMID:27605539

  9. Optimizing Patient Preparation and Surgical Experience Using eHealth Technology

    PubMed Central

    Forshaw, Kristy; Carey, Mariko; Robinson, Sancha; Kerridge, Ross; Proietto, Anthony; Sanson-Fisher, Rob

    2015-01-01

    With population growth and aging, it is expected that the demand for surgical services will increase. However, increased complexity of procedures, time pressures on staff, and the demand for a patient-centered approach continue to challenge a system characterized by finite health care resources. Suboptimal care is reported in each phase of surgical care, from the time of consent to discharge and long-term follow-up. Novel strategies are thus needed to address these challenges to produce effective and sustainable improvements in surgical care across the care pathway. The eHealth programs represent a potential strategy for improving the quality of care delivered across various phases of care, thereby improving patient outcomes. This discussion paper describes (1) the key functions of eHealth programs including information gathering, transfer, and exchange; (2) examples of eHealth programs in overcoming challenges to optimal surgical care across the care pathway; and (3) the potential challenges and future directions for implementing eHealth programs in this setting. The eHealth programs are a promising alternative for collecting patient-reported outcome data, providing access to credible health information and strategies to enable patients to take an active role in their own health care, and promote efficient communication between patients and health care providers. However, additional rigorous intervention studies examining the needs of potential role of eHealth programs in augmenting patients’ preparation and recovery from surgery, and subsequent impact on patient outcomes and processes of care are needed to advance the field. Furthermore, evidence for the benefits of eHealth programs in supporting carers and strategies to maximize engagement from end users are needed. PMID:26330206

  10. 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

  11. Optimization of epoetin therapy with intravenous iron therapy in hemodialysis patients.

    PubMed

    Besarab, A; Amin, N; Ahsan, M; Vogel, S E; Zazuwa, G; Frinak, S; Zazra, J J; Anandan, J V; Gupta, A

    2000-03-01

    Iron deficiency limits the efficacy of recombinant human erythropoietin (rhEPO) therapy in end-stage renal disease (ESRD) patients. Functional iron deficiency occurs with serum ferritin >500 ng/ml and/or transferrin saturation (TSAT) of 20 to 30%. This study examines the effects of a maintenance intravenous iron dextran (ivID) protocol that increased TSAT in ESRD hemodialysis patients from conventional levels of 20 to 30% (control group) to those of 30 to 50% (study group) for a period of 6 mo. Forty-two patients receiving chronic hemodialysis completed a 16- to 20-wk run-in period, during which maintenance ivID and rhEPO were administered in amounts to achieve average TSAT of 20 to 30% and baseline levels of hemoglobin of 9.5 to 12.0 g/dl. After the run-in period, 19 patients randomized to the control group received ivID doses of 25 to 150 mg/wk for 6 mo. Twenty-three patients randomized to the study group received four to six loading doses of ivID, 100 mg each, over a 2-wk period to achieve a TSAT >30% followed by 25 to 150 mg weekly to maintain TSAT between 30 and 50% for 6 mo. Both regimens were effective in maintaining targeted hemoglobin levels. Fifteen patients in the control group and 17 patients in the study group finished the study in which the primary outcome parameter by intention to treat analysis was the rhEPO dose needed to maintain prestudy hemoglobin levels. Maintenance ivID requirements in the study group increased from 176 to 501 mg/mo and were associated with a progressive increase in serum ferritin to 658 ng/ml. Epoetin dose requirements for the study group decreased by the third month and remained 40% lower than for the control group, resulting in an overall cost savings in managing the anemia. Secondary indicators of iron-deficient erythropoiesis were also assessed. Zinc protoporphyrin did not change in either group. Reticulocyte hemoglobin content increased only in the study group from 28.5 to 30.1 pg. It is concluded that maintenance of

  12. Mediating the Cognitive Walkthrough with Patient Groups to achieve Personalized Health in Chronic Disease Self-Management System Evaluation.

    PubMed

    Georgsson, Mattias; Kushniruk, Andre

    2016-01-01

    The cognitive walkthrough (CW) is a task-based, expert inspection usability evaluation method involving benefits such as cost effectiveness and efficiency. A drawback of the method is that it doesn't involve the user perspective from real users but instead is based on experts' predictions about the usability of the system and how users interact. In this paper, we propose a way of involving the user in an expert evaluation method by modifying the CW with patient groups as mediators. This along with other modifications include a dual domain session facilitator, specific patient groups and three different phases: 1) a preparation phase where suitable tasks are developed by a panel of experts and patients, validated through the content validity index 2) a patient user evaluation phase including an individual and collaborative process part 3) an analysis and coding phase where all data is digitalized and synthesized making use of Qualitative Data Analysis Software (QDAS) to determine usability deficiencies. We predict that this way of evaluating will utilize the benefits of the expert methods, also providing a way of including the patient user of these self-management systems. Results from this prospective study should provide evidence of the usefulness of this method modification.

  13. Barriers to the optimal rehabilitation of surgical cancer patients in the managed care environment: an administrator's perspective.

    PubMed

    Germain, Pamela

    2007-04-01

    Ensuring that surgical cancer patients obtain optimal rehabilitation care (defined here as all care provided post-operatively following cancer surgery) can be challenging because of the fragmented nature of the U.S. healthcare delivery and payment systems. In the managed care environment, surgical cancer patients' access to rehabilitation care is likely to vary by type of health insurance plan, by setting, by type of provider, and by whether care is provided in-network or out-of-network. The author of this article, who negotiates managed care contracts for the Roswell Park Cancer Institute (RPCI), gives examples of strategies used with some success by RPCI to collaborate with local payers to ensure that surgical cancer patients get optimal rehabilitation care, especially as they make the transition from hospital to outpatient care. She suggests that further collaborations of healthcare providers, payers, consumers, and policymakers are needed to help ensure optimal rehabilitation care for surgical cancer patients.

  14. Lamivudine switch therapy in chronic hepatitis B patients achieving undetectable hepatitis B virus DNA after 3 years of entecavir therapy: A prospective, open-label, multicenter study.

    PubMed

    Yeh, Ming-Lun; Huang, Ching-I; Hsieh, Ming-Yen; Huang, Chung-Feng; Hsieh, Meng-Hsuan; Huang, Jee-Fu; Dai, Chia-Yen; Lin, Zu-Yau; Chen, Shinn-Chern; Yu, Ming-Lung; Chuang, Wan-Long

    2016-11-01

    The subsequent maintenance therapy in chronic hepatitis B (CHB) patients after long-term viral replication suppression is still uncertain. We aim to evaluate the efficacy of lamivudine (LAM) maintenance therapy in CHB patients achieving undetectable hepatitis B virus (HBV) DNA after 3 years of entecavir (ETV) therapy. Consecutive CHB patients who received at least 3 years of ETV and achieved HBV DNA negativity were allocated either LAM switch therapy or stopped ETV therapy in a prospective, open-label study. Another group of sex- and age-matched patients with continuous ETV therapy for at least 4 years served as historical control group. The primary outcome measurement of the study was relapse of HBV DNA (defined as serum HBV DNA level ≥ 2000 IU/mL). A total of 74 patients, including 42 of LAM switch and 32 of the nonswitch group, were enrolled. There were no significant differences in demographics, except a higher proportion of patients with positive hepatitis B envelope antigen in the nonswitch group at the initiation of ETV therapy. The LAM switch group had significantly lower 1-year relapse rate of HBV within 1 year compared to the nonswitch group (14.3% vs. 75%, p<0.001). However, none of the 48 historical control patients developed relapse of HBV, which was significantly lower than the rate in LAM switch group (p < 0.001). LAM switch was the only factor associated with HBV DNA relapse. In conclusion, continuous long-term potent nucleot(s)ide analogue therapy is mandatory for prevention of viral relapse in CHB patients.

  15. [Optimization of postoperative medical therapy of infective endocarditis in patients with congenital valvular heart disease].

    PubMed

    Chistyakov, I S; Medvedev, A P; Pichugin, V V

    2016-01-01

    The purpose of this study was to evaluate the effectiveness of combined surgical and medical treatment of infective endocarditis in patients with congenital valvular heart disease when included in a regimen of the drug Reamberin. In this regard, the analysis of the effectiveness of a combination regimen of 74 patients with valvular congenital heart diseases complicated with infective endocarditis. Given the indications for surgical correction operative technique features and possible technical difficulties in carrying out such operations, due to the inflammatory changes and tissue destruction, and ways to overcome them. For the correction of metabolic disorders in the postoperative period, 47 patients (main group) was appointed Reamberin: once, intravenous drip 400 ml/day during the first 5 days after surgery. 27 patients (control group) was conducted infusion therapy depending on the severity of the condition according to the classical scheme. In addition to standard clinical and laboratory examination, to assess the effectiveness of Reamberin was investigated catalase activity of CPK in blood serum in the dynamics of observation (1, 3 and 5 days after surgery). It is revealed that surgical approach, used in complex treatment of patients with valvular congenital heart diseases, including reorganization of the cavities of the heart, increasing the frequency of joints and the use of reinforcing strips of synthetic material that prevents the cutting of sutures through the inflamed tissue has achieved good short-and long-term results. Infective endocarditis and destruction of the valvular annulus fibrosus the use of a frame of strips of polytetrafluoroethylene allows you to restore its integrity and to implant a mechanical prosthesis. The inclusion in the regimen of patients with infective endocarditis complicated by cardiac insufficiency in the early postoperative period the drug Reamberin improves the efficiency of treatment by a more rapid restoration of the normal

  16. Controversial issues of optimal surgical timing and patient selection in the treatment planning of otosclerosis.

    PubMed

    Shiao, An-Suey; Kuo, Chin-Lung; Cheng, Hsiu-Lien; Wang, Mao-Che; Chu, Chia-Huei

    2014-05-01

    The aim of this study was to analyze the impact of clinical factors on the outcomes of otosclerosis surgery and support patients' access to evidence-based information in pre-operative counseling to optimize their choices. A total of 109 ears in 93 patients undergoing stapes surgery in a tertiary referral center were included. Variables with a potential impact on hearing outcomes were recorded, with an emphasis on factors that were readily available pre-operatively. Hearing success was defined as a post-operative air-bone gap ≤10 dB. Logistic regression analysis was used to determine the factors independently contributing to the prediction of hearing success. The mean follow-up period was 18.0 months. Univariate and multivariate analyses indicated that none of the pre-operative factors (piston type, age, sex, affected side, tinnitus, vertigo, and pre-operative hearing thresholds) affected hearing success significantly (all p > 0.05). In conclusion, self-crimping Nitinol piston provides comparable hearing outcomes with conventional manual-crimping prostheses. However, Nitinol piston offers a technical simplification of a surgical procedure and an easier surgical choice for patients. In addition, age is not a detriment to hearing gain and instead might result in better use of hearing aids in older adults, thus facilitating social hearing recovery. Finally, hearing success does not depend on the extent of pre-operative hearing loss. Hence, patients with poor cochlear function should not be considered poor candidates for surgery. The predictive model has established recommendations for otologists for better case selection, and factors that are readily available pre-operatively may inform patients more explicitly about expected post-operative audiometric results.

  17. The First Global Patient Safety Challenge "Clean Care is Safer Care": from launch to current progress and achievements.

    PubMed

    Allegranzi, Benedetta; Storr, Julie; Dziekan, Gerald; Leotsakos, Agnès; Donaldson, Liam; Pittet, Didier

    2007-06-01

    Healthcare-associated infection is a major safety issue affecting the quality of care of hundreds of millions of patients every year in both developed and developing countries. To meet the goal of ensuring patient safety across healthcare settings around the globe, the World Health Organization launched the World Alliance for Patient Safety in October 2004. Healthcare-associated infections were identified as a fundamental work priority and selected as the topic of the First Global Patient Safety Challenge launched by the Alliance. Under the banner "Clean Care is Safer Care", the Challenge aims at implementing several actions to reduce healthcare-associated infections worldwide, regardless of the level of development of healthcare systems and the availability of resources. Implementation strategies include the integration of multiple interventions in the areas of blood safety, injection safety, clinical procedure safety, and water, sanitation and waste management, with the promotion of hand hygiene in healthcare as the cornerstone. Several initiatives have been undertaken to raise global awareness and to obtain country commitment to support action on this issue. The new Guidelines on Hand Hygiene in Health Care, including the most consistent scientific evidence available, have been issued in an advanced draft form. An implementation strategy is proposed therein to provide solutions to overcome obstacles to improvement in compliance with hand hygiene practices, together with a range of practical tools for use in healthcare settings. The latter are currently undergoing testing in several pilot sites to evaluate feasibility, acceptability and sustainability.

  18. Adequacy of patient pools to support predoctoral students' achievement of competence in pediatric dentistry in U.S. dental schools.

    PubMed

    Casamassimo, Paul S; Seale, N Sue

    2015-06-01

    The aim of this study was to characterize the current status of predoctoral pediatric dentistry patient pools in U.S. dental schools and compare their status to that in 2001. A 2014 survey of school clinic-based and community-based dental patient pools was developed, piloted, and sent to pediatric predoctoral program directors in 57 U.S. dental schools via SurveyMonkey. Two follow-up contacts were made to increase the response rate. A total of 49 surveys were returned for a response rate of 86%. The responding program directors reported that their programs' patient pools had declined in number and had changed in character with more diversity and fewer procedures. They attributed the changes to competition, cost, and location of the dental school. The respondents reported that community-based dental education clinical sites continued to provide additional service experiences for dental students, with contributions varying by the nature of the site. A large number of the respondents felt that their graduates lacked some basic pediatric dentistry clinical skills and were not ready for independent practice with children. The results of this study suggest that the predoctoral pediatric dentistry patient pool has changed and general dentists may be graduating with inadequate experiences to practice dentistry for children.

  19. Monte Carlo optimization of total body irradiation in a phantom and patient geometry

    NASA Astrophysics Data System (ADS)

    Chakarova, R.; Müntzing, K.; Krantz, M.; Hedin, E.; Hertzman, S.

    2013-04-01

    The objective of this work is to apply a Monte Carlo (MC) accelerator model, validated by experimental data at isocentre distances, to a large-field total body irradiation (TBI) technique and to develop a strategy for individual patient treatment on the basis of MC dose distributions. Calculations are carried out using BEAMnrc/DOSXYZnrc code packages for a 15 MV Varian accelerator. Acceptable agreement is obtained between MC data and measurements in a large water phantom behind a spoiler at source-skin distances (SSD) = 460 cm as well as in a CIRS® thorax phantom. Dose distributions in patients are studied when simulating bilateral beam delivery at a distance of 480 cm to the patient central sagittal plane. A procedure for individual improvement of the dose uniformity is suggested including the design of compensators in a conventional treatment planning system (TPS) and a subsequent update of the dose distribution. It is demonstrated that the dose uniformity for the simple TBI technique can be considerably improved. The optimization strategy developed is straightforward and suitable for clinics where the TPS available is deficient to calculate 3D dose distributions at extended SSD.

  20. 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…

  1. Achievement of recommended glucose and blood pressure targets in patients with type 2 diabetes and hypertension in clinical practice – study rationale and protocol of DIALOGUE

    PubMed Central

    2012-01-01

    Background Patients with type 2 diabetes have 2–4 times greater risk for cardiovascular morbidity and mortality than those without, and this is even further aggravated if they also suffer from hypertension. Unfortunately, less than one third of hypertensive diabetic patients meet blood pressure targets, and more than half fail to achieve target HbA1c values. Thus, appropriate blood pressure and glucose control are of utmost importance. Since treatment sometimes fails in clinical practice while clinical trials generally suggest good efficacy, data from daily clinical practice, especially with regard to the use of newly developed anti-diabetic and anti-hypertensive compounds in unselected patient populations, are essential. The DIALOGUE registry aims to close this important gap by evaluating different treatment approaches in hypertensive type 2 diabetic patients with respect to their effectiveness and tolerability and their impact on outcomes. In addition, DIALOGUE is the first registry to determine treatment success based on the new individualized treatment targets recommended by the ADA and the EASD. Methods DIALOGUE is a prospective observational German multicentre registry and will enrol 10,000 patients with both diabetes and hypertension in up to 700 sites. After a baseline visit, further documentations are scheduled at 6, 12 and 24 months. There are two co-primary objectives referring to the most recent guidelines for the treatment of diabetes and hypertension: 1) individual HbA1c goal achievement with respect to anti-diabetic pharmacotherapy and 2) individual blood pressure goal achievement with different antihypertensive treatments. Among the secondary objectives the rate of major cardio-vascular and cerebro-vascular events (MACCE) and the rate of hospitalizations are the most important. Conclusion The registry will be able to gain insights into the reasons for the obvious gap between the demonstrated efficacy and safety of anti-diabetic and anti

  2. HBcrAg Identifies Patients Failing to Achieve HBeAg Seroconversion Treated with Pegylated Interferon Alfa-2b

    PubMed Central

    Ma, Hui; Yang, Rui-Feng; Li, Xiao-He; Jin, Qian; Wei, Lai

    2016-01-01

    Background: We aimed to evaluate the usefulness of serum hepatitis B virus core-related antigens (HBcrAg) for predicting hepatitis B e antigen (HBeAg) seroconversion in HBeAg-positive chronic hepatitis B patients treated with conventional interferon (IFN) alfa-2b or pegylated IFN. Methods: Fifty-eight patients were enrolled: 29 for the training group and 29 for the validating group. HBcrAg was measured at baseline, week 12, end of the treatment, and 12- and 24-week follow-ups. Sixteen patients in the training group were enrolled in the long-term follow-up (LTFU), during which time the dynamics of the HBcrAg was monitored. Results: The serum HBcrAg level gradually declined during treatment among the HBeAg seroconversion patients of the training group (from baseline, week 12, end of the treatment, 12-week follow-up to 24-week follow-up were 110,245 kU/ml, 3760 kU/ml, 7410 kU/ml, 715 kU/ml, 200 kU/ml, respectively). HBcrAg <19,565 kU/ml at week 24, HBcrAg <34,225 kU/ml at 12-week follow-up, and HBcrAg decrease ≥0.565 log10 kU/ml from the baseline to the end of treatment (EOT) had negative predictive values (NPVs) of 100% for HBeAg seroconversion at the end of follow-up, whereas the positive predictive values (PPVs) were 30.77%, 26.67%, and 25.00%, respectively. The patients with HBeAg seroconversion at the end of 24-week follow-up remained in seroconversion during the LTFU, during which time their serum HBcrAg levels steadily declined or even became undetectable, ranging from 0 to 2.1 kU/ml. Conclusions: Effective antiviral treatment can decrease HBcrAg levels in the serum. The NPVs of HBcrAg for predicting HBeAg seroconversion at 24-week follow-up was 100%, but the PPVs were not satisfactory (all <31%). The serum HBcrAg levels of the patients with HBeAg seroconversion at the end of the 24-week follow-up steadily declined or even became undetectable during the LTFU. PMID:27625094

  3. High-performance n-type organic semiconductors: incorporating specific electron-withdrawing motifs to achieve tight molecular stacking and optimized energy levels.

    PubMed

    Yun, Sun Woo; Kim, Jong H; Shin, Seunghoon; Yang, Hoichang; An, Byeong-Kwan; Yang, Lin; Park, Soo Young

    2012-02-14

    Novel π–conjugated cyanostilbene-based semiconductors (Hex-3,5-TFPTA and Hex-4-TFPTA) with tight molecular stacking and optimized energy levels are synthesized. Hex-4-TFPTA exhibits high-performance n-type organic field-effect transistor (OFET) properties with electron mobilities as high as 2.14 cm2 V−1s−1 and on-off current ratios

  4. An achievement of professional, public, and patient education: the design and evaluation of a comprehensive cancer control plan for Alabama.

    PubMed

    Litton, Allison; Waterbor, John W; Chapman, Kathryn; Abdullah, Farhan; Thomas, Scott; Desmond, Renee A

    2012-06-01

    This Alabama statewide cancer control plan for 2011-2015 seeks to build on the successes of two previous 5-year plans while developing new objectives that address cancer disparities and cancer prevention over the entire lifespan. The approach to defining objectives for this Plan was systematic and sought input from all members of the Alabama Comprehensive Cancer Control Coalition (ACCCC). The Plan that was fashioned is based on input from academic medical centers, private physicians, government agencies, regulatory agencies, health societies, private citizens, and cancer survivors, all of whom are active Coalition members who exchange information, opinions, and knowledge from their respective points of view. The Plan could not have taken shape without the full input of health professionals, statisticians, graduate students, former patients, and concerned citizens; it is truly an example of the synergy of professional, public, and patient education.

  5. What is the optimal bone-preserving strategy for patients with Addison's disease?

    PubMed

    Lee, Paul; Greenfield, Jerry R

    2015-08-01

    Addison's disease is associated with low bone mineral density and increased risk of hip fractures. Causes are multifactorial, contributed by underlying adrenocortical hormonal deficiency, associated autoimmune endocrinopathies, electrolyte disturbances and, in some patients, supraphysiologic glucocorticoid replacement. Recent realization of physiologic cortisol production rate has revised downwards glucocorticoid replacement dosages. Meanwhile, new research has emerged suggesting complex interplay between sodium and calcium homoeostasis under the influence of mineralocorticoid and parathyroid hormone that may impact bone health. As the prevalence of Addison's disease is rising, and osteoporosis and fractures are associated with significant morbidity and increased mortality, attention to bone preservation in Addison's disease is of clinical relevance and importance. We suggest an approach to bone health in Addison's disease integrating physiologic adrenocortical hormonal replacement with electrolyte and mineral homoeostasis optimization.

  6. Getting it Right: Optimizing the Patient and Technique for the Procedure

    PubMed Central

    Stammers, Alfred H.

    2009-01-01

    Abstract: The methodological approach to decision making in optimizing medical care has focused on using the best available evidence with the primary endpoint being patient outcome. Through this emphasis, quality becomes relegated as the quintessential factor in determining application of medical intervention and in directing resource allocation. When evidence is inconclusive or absent, then clinical judgment becomes elevated in the decision analysis schema. The paucity of well designed controlled trials in perfusion technology has resulted in a greater reliance on clinical judgment than published information. This has created an environment where significant variability exists throughout the perfusion community. The following report will discuss several reasons for this variability, and describe techniques where the preponderance of evidence is available supporting inclusion in perfusion practice. PMID:20092089

  7. Optimizing the use of biological therapy in patients with inflammatory bowel disease.

    PubMed

    Moss, Alan C

    2015-02-01

    Biological therapy revolutionized the treatment of inflammatory bowel disease (IBD) during the last decade. These monoclonal antibodies, which target tumor necrosis factor (TNF), integrins or IL12/23, have been approved-or are in development for-both Crohn's disease (CD) and ulcerative colitis (UC). Early use of these agents taught clinicians that induction and maintenance therapy, coupled with immunomodulator agents, reduced the immunogenicity of these agents, and led to sustained remission in many patients. More recent data has demonstrated that, through dose adjustments, optimizing serum drug levels may also provide more durable maintenance of remission, and improved mucosal healing. This review examines clinical practices that may enhance clinical outcomes from biological therapy in IBD.

  8. The Optimal Management of Acute Febrile Encephalopathy in the Aged Patient: A Systematic Review

    PubMed Central

    Sheybani, Fereshte; Naderi, HamidReza; Sajjadi, Sareh

    2016-01-01

    The elderly comprise less than 13 percent of world population. Nonetheless, they represent nearly half of all hospitalized adults. Acute change in mental status from baseline is commonly seen among the elderly even when the main process does not involve the central nervous system. The term “geriatric syndrome” is used to capture those clinical conditions in older people that do not fit into discrete disease categories, including delirium, falls, frailty, dizziness, syncope, and urinary incontinence. Despite the growing number of elderly population, especially those who require hospitalization and the high burden of common infections accompanied by encephalopathy among them, there are several unresolved questions regarding the optimal management they deserve. The questions posed in this systematic review concern the need to rule out CNS infection in all elderly patients presented with fever and altered mental status in the routine management of febrile encephalopathy. In doing so, we sought to identify all potentially relevant articles using searches of web-based databases with no language restriction. Finally, we reviewed 93 research articles that were relevant to each part of our study. No prospective study was found to address how should AFE in the aged be optimally managed. PMID:26989409

  9. Adherence to All Steps of a Pain Management Protocol in Intensive Care Patients after Cardiac Surgery Is Hard to Achieve

    PubMed Central

    Ahlers, S. J. G. M.; Bruins, P.; Tibboel, D.; Knibbe, C. A. J.; van Dijk, M.

    2017-01-01

    Purpose. To investigate adherence to our pain protocol considering analgesics administration, number and timing of pain assessments, and adjustment of analgesics upon unacceptably high (NRS ≥ 4) and low (NRS ≤ 1) pain scores. Material and Methods. The pain protocol for patients in the intensive care unit (ICU) after cardiac surgery consisted of automated prescriptions for paracetamol and morphine, automated reminders for pain assessments, a flowchart to guide interventions upon high and low pain scores, and reassessments after unacceptable pain. Results. Paracetamol and morphine were prescribed in all 124 patients. Morphine infusion was stopped earlier than protocolized in 40 patients (32%). During the median stay of 47 hours [IQR 26 to 74 hours], 702/706 (99%) scheduled pain assessments and 218 extra pain scores were recorded. Unacceptably high pain scores accounted for 96/920 (10%) and low pain scores for 546/920 (59%) of all assessments. Upon unacceptable pain additional morphine was administered in 65% (62/96) and reassessment took place in 15% (14/96). Morphine was not tapered in 273 of 303 (90%) eligible cases of low pain scores. Conclusions. Adherence to automated prescribed analgesics and pain assessments was good. Adherence to nonscheduled, flowchart-guided interventions was poor. Improving adherence may refine pain management and reduce side effects. PMID:28298879

  10. Patient satisfaction questionnaire and quality achievement in hospital care: the case of a Greek public university hospital.

    PubMed

    Matis, Georgios K; Birbilis, Theodossios A; Chrysou, Olga I

    2009-11-01

    The scope of this research has been to investigate the satisfaction of Greek patients hospitalized in a tertiary care university public hospital in Alexandroupolis, Greece, in order to improve medical, nursing and organizational/administrative services. It is a cross-sectional study involving 200 patients hospitalized for at least 24 h. We administered a satisfaction questionnaire previously approved by the Greek Health Ministry. Four aspects of satisfaction were employed (medical, hotel facilities/organizational, nursing, global). Using principal component analysis, summated scales were formed and tested for internal consistency with the aid of Cronbach's alpha coefficient. The non-parametric Spearman rank correlation coefficient was also used. The results reveal a relatively high degree of global satisfaction (75.125%), yet satisfaction is higher for the medical (89.721%) and nursing (86.432%) services. Moreover, satisfaction derived from the hotel facilities and the general organization was found to be more limited (76.536%). Statistically significant differences in participant satisfaction were observed (depending on age, gender, citizenship, education, number of previous admissions and self-assessment of health status at the first and last day of patients' stay) for the medical, nursing and hotel facilities/organizational dimension, but not for global satisfaction. The present study confirms the results of previously published Greek surveys.

  11. Airway Microbiota and Bronchial Hyperresponsiveness in Patients with Sub-optimally Controlled Asthma

    PubMed Central

    Huang, Yvonne J.; Nelson, Craig E.; Brodie, Eoin L.; DeSantis, Todd Z.; Baek, Marshall S.; Liu, Jane; Woyke, Tanja; Allgaier, Martin; Bristow, Jim; Wiener-Kronish, Jeanine P.; Sutherland, E. Rand; King, Tonya S.; Icitovic, Nikolina; Martin, Richard J.; Calhoun, William J.; Castro, Mario; Denlinger, Loren C.; DiMango, Emily; Kraft, Monica; Peters, Stephen P.; Wasserman, Stephen I.; Wechsler, Michael E.; Boushey, Homer A.; Lynch, Susan V.

    2010-01-01

    Background Improvement in lung function following macrolide antibiotic therapy has been attributed to reduction in bronchial infection due to specific bacteria. However, the airway may be populated by a more diverse microbiota, and clinical features of asthma may be associated with characteristics of the airway microbiota present. Objective To determine if relationships exist between the composition of the airway bacterial microbiota and clinical features of asthma, using culture-independent tools capable of detecting the presence and relative abundance of most known bacteria. Methods In this pilot study, bronchial epithelial brushings were collected from sixty-five adults with sub-optimally controlled asthma participating in a multicenter study of the effects of clarithromycin on asthma control, and ten healthy subjects. A combination of high-density 16S rRNA microarray and parallel clone library-sequencing analysis was used to profile the microbiota and examine relationships with clinical measurements. Results Compared to controls, 16S rRNA amplicon concentrations (a proxy for bacterial burden) and bacterial diversity were significantly higher among asthmatic patients. In multivariate analyses, airway microbiota composition and diversity were significantly correlated with bronchial hyperresponsiveness. Specifically, the relative abundance of particular phylotypes, including members of the Comamonadaceae, Sphingomonadaceae, Oxalobacteraceae and other bacterial families, were highly correlated with the degree of bronchial hyperresponsiveness. Conclusion The composition of bronchial airway microbiota is associated with the degree of bronchial hyperresponsiveness among patients with sub-optimally controlled asthma. These findings support the need for further functional studies to examine the potential contribution of members of the airway microbiota in asthma pathogenesis. PMID:21194740

  12. [A patient with invasive carcinoma derived from IPMN who achieved long-term survival despite lymph node metastasis].

    PubMed

    Ueda, Nobuhiko; Kaida, Daisuke; Tomita, Yasuto; Ohnishi, Toshio; Funaki, Hiroshi; Fujita, Hideto; Kinami, Shinichi; Nakano, Yasuharu; Kosaka, Takeo

    2014-11-01

    A woman in her 70s was referred for examination of liver dysfunction. A cystic lesion with irregular contrast was observed at the pancreas head. The bile and pancreatic ducts were obstructed by the lesion. Part of the branch of the pancreatic duct at the pancreas head, continuous with the main pancreatic duct, was observed to be extended by using pancreatography. Pancreaticoduodenectomy was performed, and a diagnosis of invasive carcinoma from an intraductal papillary-mucinous neoplasm (IPMN) was made. Postoperative pathological diagnosis showed 16b1 inter-node metastasis. Liver and lung metastases were also detected after surgery; nevertheless, long-term survival was achieved for 5 years and 2 months by using various treatment modalities.

  13. [Low calorie diet influence optimization on body composition at obese patients with secondary diastolic heart failure].

    PubMed

    Bogdanov, A R; Derbeneva, S A; Bogdanova, A A; Feofanova, T B; Panfilova, N V; Nesierova, V E

    2015-01-01

    In open prospective monocentric study in 3 parallel groups we studied the effectiveness of correction of body composition using low calorie diet therapy with inclusion of specialized food products (SFP)--sources of polyphenols and iridoids made on the basis of the juice of Morinda citrifolia L. fruits. We studied 90 patients aged from 30 to 50 years old with grade III obesity and clinically expressed secondary diastolic heart failure. The duration of diet therapy was 42 days. It was shown that low-calorie diet has non-optimal effect on the body composition in morbidly obese patients with secondary diastolic heart failure, namely leading to the expressed loss of body fatless (7.2%, p=0.00008) and muscle mass (by 16.6%, p=0.00004); at the same time the reduction of total body weight is noted only by 2.3% (p=0.053), reduction of waist measurement by 1.3% (p=0.028) and reduction of hips measurement by 1.3% (p=0.09), accompanied by the reduction of body fat by 8.5% (p=0.000017) and of liquid by 7.3% (p=0.0018). The introduction of the SFP into the diet optimizes the effect of low calorie diet therapy on the anthropometric parameters and body composition. The most important effect of the SFP is the ability to prevent the excess loss of muscle mass in patients, and this effect is being dose-dependent. The loss of muscle mass in two groups of patients was 3.1-4.1% after 6 weeks of diet therapy, while in the control group it was 8.5% (p=0.0051). We have concluded that the inclusion of the SFP, manufactured on the basis Morinda citrifolia L. (noni) juice to the low calorie diet allows to initiate mainly the loss of the body fat with the simultaneous protection of active cellular mass, which is without doubt can be considered as the advantage compared to the standard low calorie diet.

  14. Percutaneous Coronary Intervention Is More Beneficial Than Optimal Medical Therapy in Elderly Patients with Angina Pectoris

    PubMed Central

    Won, Hoyoun; Her, Ae-Young; Kim, Byeong-Keuk; Kim, Yong Hoon; Shin, Dong-Ho; Kim, Jung-Sun; Ko, Young-Guk; Choi, Donghoon; Kwon, Hyuck Moon; Jang, Yangsoo

    2016-01-01

    Purpose Data comparing the clinical benefits of medical treatment with those of percutaneous coronary intervention (PCI) in an elderly population with angina pectoris are limited. Therefore, we evaluated the efficacy of elective PCI versus optimal medical treatment (OMT) in elderly patients (between 75 and 84 years old) with angina pectoris. Materials and Methods One hundred seventy-seven patients with significant coronary artery stenosis were randomly assigned to either the PCI group (n=90) or the OMT group (n=87). The primary outcome was a composite of major adverse events in the 1-year follow-up period that included cardiovascular death, non-fatal myocardial infarction, coronary revascularization, and stroke. Results Major adverse events occurred in 5 patients (5.6%) of the PCI group and in 17 patents (19.5%) of the OMT group (p=0.015). There were no significant differences between the PCI group and the OMT group in cardiac death [hazard ratio (HR) for the PCI group 0.454; 95% confidence interval (CI) 0.041–5.019, p=0.520], myocardial infarction (HR 0.399; 95% CI 0.039–4.050, p=0.437), or stroke (HR 0.919; 95% CI 0.057–14.709, p=0.952). However, the PCI group showed a significant preventive effect of the composite of major adverse events (HR 0.288; 95% CI 0.106–0.785, p=0.015) and against the need for coronary revascularization (HR 0.157; 95% CI 0.035–0.703, p=0.016). Conclusion Elective PCI reduced major adverse events and was found to be an effective treatment modality in elderly patients with angina pectoris and significant coronary artery stenosis, compared to OMT. PMID:26847290

  15. Optimizing iron delivery in the management of anemia: patient considerations and the role of ferric carboxymaltose

    PubMed Central

    Toblli, Jorge Eduardo; Angerosa, Margarita

    2014-01-01

    With the challenge of optimizing iron delivery, new intravenous (iv) iron–carbohydrate complexes have been developed in the last few years. A good example of these new compounds is ferric carboxymaltose (FCM), which has recently been approved by the US Food and Drug Administration for the treatment of iron deficiency anemia in adult patients who are intolerant to oral iron or present an unsatisfactory response to oral iron, and in adult patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). FCM is a robust and stable complex similar to ferritin, which minimizes the release of labile iron during administration, allowing higher doses to be administered in a single application and with a favorable cost-effective rate. Cumulative information from randomized, controlled, multicenter trials on a diverse range of indications, including patients with chronic heart failure, postpartum anemia/abnormal uterine bleeding, inflammatory bowel disease, NDD-CKD, and those undergoing hemodialysis, supports the efficacy of FCM for iron replacement in patients with iron deficiency and iron-deficiency anemia. Furthermore, as FCM is a dextran-free iron–carbohydrate complex (which has a very low risk for hypersensitivity reactions) with a small proportion of the reported adverse effects in a large number of subjects who received FCM, it may be considered a safe drug. Therefore, FCM appears as an interesting option to apply high doses of iron as a single infusion in a few minutes in order to obtain the quick replacement of iron stores. The present review on FCM summarizes diverse aspects such as pharmacology characteristics and analyzes trials on the efficacy/safety of FCM versus oral iron and different iv iron compounds in multiple clinical scenarios. Additionally, the information on cost effectiveness and data on change in quality of life are also discussed. PMID:25525337

  16. Optimizing iron delivery in the management of anemia: patient considerations and the role of ferric carboxymaltose.

    PubMed

    Toblli, Jorge Eduardo; Angerosa, Margarita

    2014-01-01

    With the challenge of optimizing iron delivery, new intravenous (iv) iron-carbohydrate complexes have been developed in the last few years. A good example of these new compounds is ferric carboxymaltose (FCM), which has recently been approved by the US Food and Drug Administration for the treatment of iron deficiency anemia in adult patients who are intolerant to oral iron or present an unsatisfactory response to oral iron, and in adult patients with non-dialysis-dependent chronic kidney disease (NDD-CKD). FCM is a robust and stable complex similar to ferritin, which minimizes the release of labile iron during administration, allowing higher doses to be administered in a single application and with a favorable cost-effective rate. Cumulative information from randomized, controlled, multicenter trials on a diverse range of indications, including patients with chronic heart failure, postpartum anemia/abnormal uterine bleeding, inflammatory bowel disease, NDD-CKD, and those undergoing hemodialysis, supports the efficacy of FCM for iron replacement in patients with iron deficiency and iron-deficiency anemia. Furthermore, as FCM is a dextran-free iron-carbohydrate complex (which has a very low risk for hypersensitivity reactions) with a small proportion of the reported adverse effects in a large number of subjects who received FCM, it may be considered a safe drug. Therefore, FCM appears as an interesting option to apply high doses of iron as a single infusion in a few minutes in order to obtain the quick replacement of iron stores. The present review on FCM summarizes diverse aspects such as pharmacology characteristics and analyzes trials on the efficacy/safety of FCM versus oral iron and different iv iron compounds in multiple clinical scenarios. Additionally, the information on cost effectiveness and data on change in quality of life are also discussed.

  17. The optimal succinylcholine dose for intubating emergency patients: retrospective comparative study

    PubMed Central

    Ezzat, Alaa; Fathi, Essam; Zarour, Ahmad; Singh, Rajvir; Abusaeda, M. Osama; Hussien, M. Magdy

    2011-01-01

    Background Succinylcholine remains the drug of choice for satisfactory rapid-sequence tracheal intubation. It is not clear from the literature why the 1 mg/kg dose of succinylcholine has been traditionally used. The effective dose (ED95) of succinylcholine is less than 0.3 mg/kg. The dose of 1 mg/kg represents 3.5 to 4 times the ED95. Objectives To compare the effect of the traditionally used 1 mg/kg of succinylcholine with lower doses of 0.6 mg/kg and 0.45 mg/kg on intubation condition regarding the onset time, duration of action, duration of abdominal fasciculation, and the intubation grading. Methods This retrospective comparative study was carried into three groups of ASA III & IV (American Society of Anesthesiologist's Physical Status III and IV) non-prepared emergency patients who were intubated at emergency department of Hamad General Hospital, Doha, Qatar during January 1st 2007 to August 31, 2010. The Institutional Research Board (IRB) approval was obtained. This study was limited to 88 patients who received fentanyl 1µg/kg followed by etomidate 0.3 mg/kg intravenously as induction agents and succinylcholine as a muscle relaxant agent in doses of 0.45 mg/kg, 0.6 mg/kg, or 1 mg/kg. Results Increasing the succinylcholine dosage shortened the onset time, prolonged the duration of action, and prolonged the duration of abdominal fasciculation significantly (P<.001). Tracheal intubation was 100% successful in the three groups of patients. Conclusion Succinylcholine dose of 0.45 mg/kg provides an optimal intubation condition in ASA III & IV emergency non-prepared patients. Duration of action of succinylcholine is dose dependent; reducing the dose allows a more rapid return of spontaneous respiration and airway reflexes. PMID:21772925

  18. Implications for determining the optimal treatment for locally advanced rectal cancer in elderly patients aged 75 years and older.

    PubMed

    Wan, Jue-feng; Zhu, Ji; Li, Gui-chao; Sun, Wen-jie; Zhang, Zhen

    2015-10-06

    Patients were excluded if they were older than 75 years of age in most clinical trials. Thus, the optimal treatment strategies in elderly patients with locally advanced rectal cancer (LARC) are still controversial. We designed our study to specifically evaluate the cancer specific survival of four subgroups of patients according to four different treatment modalities: surgery only, radiation (RT) only, neoadjuvant RT and adjuvant RT by analyzing the Surveillance, Epidemiology, and End Results (SEER)-registered database. The results showed that the 5-year cancer specific survival (CSS) was 52.1% in surgery only, 27.7% in RT only, 70.4% in neoadjuvant RT and 60.4% in adjuvant RT, which had significant difference in univariate log-rank test (P < 0.001) and multivariate Cox regression (P < 0.001). Thus, the neoadjuvant RT and surgery may be the optimal treatment pattern in elderly patients, especially for patients who are medically fit for the operation.

  19. Aliskiren in Patients Failing to Achieve Blood Pressure Targets With Angiotensin Converting Enzyme Inhibitors or Angiotensin Receptor Blockers

    PubMed Central

    Hawkins, Elizabeth B.; Ling, Hua; Burns, Tammy L.; Mooss, Aryan N.; Hilleman, Daniel E.

    2012-01-01

    Background To assess the efficacy of aliskiren in patients failing to reach blood pressure (BP) goals with angiotensin converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). Methods A total of 107 patients who failed to reach BP goals on ACEI or ARB were switched to aliskiren. Changes in BP were determined during maximal ACEI, ARB, or aliskiren therapy. Results Mean reduction in sBP and dBP with ACEI was 8.5 ± 6.3 mmHg and 6.0 ± 4.7 mmHg, respectively. Mean reduction in sBP and dBP with ARB was 8.3 ± 6.7 mmHg and 5.0 ± 5.2 mmHg, respectively. Mean reduction in sBP and dBP with aliskiren 150 mg/d was 6.7 ± 5.4 mmHg and 5.4 ± 4.8 mmHg, respectively. Mean reduction in sBP and dBP with aliskiren 300 mg/d was 8.6 ± 6.3 mmHg and 6.0 ± 4.9 mmHg, respectively. BP reductions between ACEI, ARB, and aliskiren were not significantly different. Conclusions Aliskiren is ineffective in patients failing ACEI or ARB therapy. Given the label changes restricting the use of aliskiren in combination with ACEI and ARB, excess cost compared to ACEI and ARB, and a paucity of outcome data, there is a limited role for aliskiren in practice.

  20. Ultralong, small-diameter TiOTiO₂ nanotubes achieved by an optimized two-step anodization for efficient dye-sensitized solar cells.

    PubMed

    Wang, Xiaoyan; Sun, Lidong; Zhang, Sam; Wang, Xiu

    2014-02-12

    An optimized two-step anodization is developed to fabricate ultralong, small-diameter TiO2 nanotubes, that is, with tube length of up to 31 μm and pore diameter of about 35 nm in this work. This overcomes the length limitation of small diameter tubes that usually presents in conventional one-step anodization. The small tubes with lengths of 23 μm yield a conversion efficiency of 5.02% in dye-sensitized solar cells under nonoptimized conditions.

  1. Patient specific optimization of the relation between CT-Hounsfield units and proton stopping power with proton radiography

    SciTech Connect

    Schneider, Uwe; Pemler, Peter; Besserer, Juergen; Pedroni, Eros; Lomax, Antony; Kaser-Hotz, Barbara

    2005-01-01

    The purpose of this work is to show the feasibility of using in vivo proton radiography of a radiotherapy patient for the patient individual optimization of the calibration from CT-Hounsfield units to relative proton stopping power. Water equivalent tissue (WET) calibrated proton radiographs of a dog patient treated for a nasal tumor were used as baseline in comparison with integrated proton stopping power through the calibrated CT of the dog. In an optimization procedure starting with a stoichiometric calibration curve, the calibration was modified randomly. The result of this iteration is an optimized calibration curve which was used to recalculate the dose distribution of the patient. One result of this experiment was that the mean value of the deviations between WET calculations based on the stoichiometric calibration curve and the measurements was shifted systematically away from zero. The calibration produced by the optimization procedure reduced this shift to around 0.4 mm. Another result was that the precision of the calibration, reflected as the standard deviation of the normally distributed deviations between WET calculation and measurement, could be reduced from 7.9 to 6.7 mm with the optimized calibration. The dose distributions based on the two calibration curves showed major deviations at the distal end of the target volume.

  2. Patient specific optimization of the relation between CT-hounsfield units and proton stopping power with proton radiography.

    PubMed

    Schneider, Uwe; Pemler, Peter; Besserer, Jürgen; Pedroni, Eros; Lomax, Antony; Kaser-Hotz, Barbara

    2005-01-01

    The purpose of this work is to show the feasibility of using in vivo proton radiography of a radiotherapy patient for the patient individual optimization of the calibration from CT-Hounsfield units to relative proton stopping power. Water equivalent tissue (WET) calibrated proton radiographs of a dog patient treated for a nasal tumor were used as baseline in comparison with integrated proton stopping power through the calibrated CT of the dog. In an optimization procedure starting with a stoichiometric calibration curve, the calibration was modified randomly. The result of this iteration is an optimized calibration curve which was used to recalculate the dose distribution of the patient. One result of this experiment was that the mean value of the deviations between WET calculations based on the stoichiometric calibration curve and the measurements was shifted systematically away from zero. The calibration produced by the optimization procedure reduced this shift to around 0.4 mm. Another result was that the precision of the calibration, reflected as the standard deviation of the normally distributed deviations between WET calculation and measurement, could be reduced from 7.9 to 6.7 mm with the optimized calibration. The dose distributions based on the two calibration curves showed major deviations at the distal end of the target volume.

  3. Cinacalcet HCl and Concurrent Low-dose Vitamin D Improves Treatment of Secondary Hyperparathyroidism in Dialysis Patients Compared with Vitamin D Alone: The ACHIEVE Study Results

    PubMed Central

    Fishbane, Steven; Shapiro, Warren B.; Corry, Dalila B.; Vicks, Steven L.; Roppolo, Michael; Rappaport, Kenneth; Ling, Xiang; Goodman, William G.; Turner, Stewart; Charytan, Chaim

    2008-01-01

    Background and objectives: Patients with chronic kidney disease (CKD) receiving dialysis often develop secondary hyperparathyroidism with disturbed calcium and phosphorus metabolism. The National Kidney Foundation-Kidney Disease Outcomes Quality Initiative (KDOQI) was established to guide treatment practices for these disorders. The ACHIEVE study was designed to test two treatment strategies for achieving KDOQI goals. Design, setting, participants, measurements: Individuals on hemodialysis treated with vitamin D sterols were enrolled in this 33-week study. Subjects were randomly assigned to treatment with either cinacalcet and low-dose vitamin D (Cinacalcet-D) or flexible vitamin D alone (Flex-D) to achieve KDOQI-recommended bone mineral targets. ACHIEVE included a 6-week screening phase, including vitamin D washout, a 16-week dose-titration phase, and an 11-week assessment phase. Results: Of 173 subjects enrolled, 83% of Cinacalcet-D and 67% of Flex-D subjects completed the study. A greater proportion of Cinacalcet-D versus Flex-D subjects had a ≥30% reduction in parathyroid hormone (PTH) (68% versus 36%, P < 0.001) as well as PTH ≤300 pg/ml (44% versus 23%, P = 0.006). The proportion of subjects simultaneously achieving targets for intact PTH (150–300 pg/ml) and calcium-phosphorus product (Ca×P) (<55 mg2/dl2) was also greater (21% versus 14%), but this was not statistically significant. This was attributable to 19% of Cinacalcet-D subjects with a PTH value below the KDOQI target range. Conclusions: Achievement of KDOQI targets was difficult, especially with Flex-D. Maintaining calcium and phosphorus target values precluded the use of vitamin D doses necessary to lower PTH to within the narrow target range and highlighted limitations inherent to the KDOQI treatment algorithm. PMID:18945995

  4. Optimal medication dosing in patients with diabetes mellitus and chronic kidney disease.

    PubMed

    MacCallum, Lori

    2014-10-01

    Diabetes mellitus is the leading cause of chronic kidney disease (CKD) in Canada. As rates of diabetes rise, so does the prevalence of CKD. Diabetes and CKD are chronic diseases that require multiple medications for their management. Many of the anticipated effects of these medications are altered by the physiologic changes that occur in CKD. Failure to individualize drug dosing in this population may lead to toxicity or decreased therapeutic response, leading to treatment failure. At times this can be challenging for a multitude of reasons, including the limitations of available calculations for estimating renal function, inconsistent dosing recommendations and the lack of dosing recommendations for some medications. Clinicians caring for these patients need to consider an approach of individualized drug therapy that will ensure optimal outcomes. The better understanding that clinicians have of these challenges, the more effective they will be at using the available information as a guide together with their own professional judgement to make appropriate dosing changes. This article discusses the following: 1) physiologic changes that occur in CKD and its impact on drug dosing; 2) advantages and disadvantages of various calculations used for estimating renal function; 3) pharmacokinetic and pharmacodynamic changes of some commonly used medications in diabetes, and finally, 4) an approach to individualized drug dosing for this patient population.

  5. Application- and patient size-dependent optimization of x-ray spectra for CT

    SciTech Connect

    Kalender, Willi A.; Deak, Paul; Kellermeier, Markus; Straten, Marcel van; Vollmar, Sabrina V.

    2009-03-15

    Although x-ray computed tomography (CT) has been in clinical use for over 3 decades, spectral optimization has not been a topic of great concern; high voltages around 120 kV have been in use since the beginning of CT. It is the purpose of this study to analyze, in a rigorous manner, the energies at which the patient dose necessary to provide a given contrast-to-noise ratio (CNR) for various diagnostic tasks can be minimized. The authors used cylindrical water phantoms and quasianthropomorphic phantoms of the thorax and the abdomen with inserts of 13 mm diameter mimicking soft tissue, bone, and iodine for simulations and measurements. To provide clearly defined contrasts, these inserts were made of solid water with a 1% difference in density (DD) to represent an energy-independent soft-tissue contrast of 10 Hounsfield units (HU), calcium hydroxyapatite (Ca) representing bone, and iodine (I) representing the typical contrast medium. To evaluate CT of the thorax, an adult thorax phantom (300x200 mm{sup 2}) plus extension rings up to a size of 460x300 mm{sup 2} to mimic different patient cross sections were used. For CT of the abdomen, we used a phantom of 360x200 mm{sup 2} and an extension ring of 460x300 mm{sup 2}. The CT scanner that the authors used was a SOMATOM Definition (Siemens Healthcare, Forchheim, Germany) at 80, 100, 120, and 140 kV. Further voltage settings of 60, 75, 90, and 105 kV were available in an experimental mode. The authors determined contrast for the density difference, calcium, and iodine, and noise and 3D dose distributions for the available voltages by measurements. Additional voltage values and monoenergetic sources were evaluated by simulations. The dose-weighted contrast-to-noise ratio (CNRD) was used as the parameter for optimization. Simulations and measurements were in good agreement with respect to absolute values and trends regarding the dependence on energy for the parameters investigated. For soft-tissue imaging, the standard

  6. Excellent therapeutic results achieved in chronic myeloid leukemia patients with front-line imatinib and early treatment modifications in suboptimal responders: a retrospective study on 91 unselected patients.

    PubMed

    Cerrano, Marco; Crisà, Elena; Pregno, Patrizia; Aguzzi, Chiara; Riccomagno, Paola; Boccadoro, Mario; Ferrero, Dario

    2013-10-01

    Second generation tyrosine kinase-inhibitors (TKI) have been claimed to represent now the first-choice therapy for chronic myeloid leukemia (CML). Indeed, they generally induce faster and deeper molecular responses compared to imatinib that, however, is equally effective in at least 50% of patients. Moreover, some recent reports have questioned the long term safety of dasatinib and nilotinib. Therefore, upfront imatinib with early shift to second generation TKI for patients with slow/incomplete response might be as effective as front-line second generation TKI, with a possibly better safety profile. We retrospectively evaluated 91 chronic phase CML patients (median follow-up 57 months, median age 61 years), treated front-line with standard-dose imatinib and early therapy modifications (at 3-12 months) in case of unsatisfactory response or intolerance. Thirty-three patients (24 with unsatisfactory response, 9 intolerant) changed therapy, either by increasing imatinib dose (11/91) or by switching to second generation TKI (22 directly, 4 after high-dose imatinib). Globally, our strategy led to complete cytogenetic response (CCyR) in 98% of the patients, major molecular response (MMR) in 88% and molecular response 4 logs (MR(4.0) ) in 62%. Three patients in CCyR (3%), 2 of them in MMR too, suddenly progressed to blastic phase. At the last follow-up nine patients had died, seven of CML-unrelated causes and two only of CML progression. These results suggest that our strategy could be as effective as front line second generation TKI, with most of patients still receiving imatinib, a drug of better known long-term side effects and lower cost.

  7. 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.

  8. Low educational level but not low income impairs the achievement of cytogenetic remission in chronic myeloid leukemia patients treated with imatinib in Brazil

    PubMed Central

    Rego, Monica Napoleão Fortes; Metze, Konradin; Lorand-Metze, Irene

    2015-01-01

    OBJECTIVES: In Brazil, imatinib mesylate is supplied as the first-line therapy for chronic myeloid leukemia in the chronic phase through the public universal healthcare program, Sistema Único de Saúde (SUS). We studied the socio-demographic factors that influenced therapy success in a population in the northeast region of Brazil. METHODS: Patients with chronic myeloid leukemia from the state of Piauí were treated in only one reference center. Diagnosis was based on WHO 2008 criteria. Risk was assessed by Sokal, Hasford and EUTOS scores. Patients received 400 mg imatinib daily. We studied the influence of the following factors on the achievement of complete cytogenetic response within one year of treatment: age, clinical risk category, time interval between diagnosis and the start of imatinib treatment, geographic distance from the patient's home to the hospital, years of formal education and monthly income. RESULTS: Among 103 patients studied, the median age was 42 years; 65% of the patients had 2-9 years of formal education, and the median monthly income was approximately 100 US$. Imatinib was started in the first year after diagnosis (early chronic phase) in 69 patients. After 12 months of treatment, 68 patients had a complete cytogenetic response. The Hasford score, delay to start imatinib and years of formal education influenced the attainment of a complete cytogenetic response, whereas income and the distance from the home to the healthcare facility did not. CONCLUSION: Patients require additional healthcare information to better understand the importance of long-term oral anticancer treatment and to improve their compliance with the treatment. PMID:26039947

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

    SciTech Connect

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

    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 both 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.

  10. Stroke Event Rates and the Optimal Antithrombotic Choice of Patients With Paroxysmal Atrial Fibrillation

    PubMed Central

    Chen, Yicong; Zhao, Yuhui; Dang, Ge; Ouyang, Fubing; Chen, Xinran; Zeng, Jinsheng

    2015-01-01

    Abstract The risks of stroke or systemic embolism and major bleeding are considered similar between paroxysmal and sustained atrial fibrillation (AF), and warfarin has demonstrated superior efficacy to aspirin, irrespective of the AF type. However, with the advent of novel oral anticoagulants (NOACs) and antiplatelet agents, the optimal antithrombotic prophylaxis for paroxysmal AF remains unclear. We searched Medline, Embase, CENTRAL, and China Biology Medicine up to October week 1, 2015. Randomized controlled trials of AF patients assigned to NOACs, warfarin, or antiplatelets, with reports of outcomes stratified by the AF type, were included. A fixed-effects model was used if no statistically significant heterogeneity was indicated; otherwise, a random-effects model was used. Six studies of 69,990 nonvalvular AF patients with ≥1 risk factor for stroke were included. Postantithrombotic treatment, paroxysmal AF patients showed lower risks of stroke (risk ratio [RR], 0.72; 95% confidence interval [CI], 0.59–0.87), stroke or systemic embolism (RR, 0.74; 95% CI, 0.63–0.86), and all-cause mortality (RR, 0.75; 95% CI, 0.67–0.83), while the major bleeding risk was comparable (RR, 0.96; 95% CI, 0.85–1.08). We were unable to detect the superiority of anticoagulation over antiplatelets for paroxysmal AF (RR, 0.72; 95% CI, 0.43–1.23), while it was more effective than antiplatelets for sustained AF (RR, 0.42; 95% CI, 0.33–0.54). NOACs showed superior efficacy over warfarin and trended to show reduced major bleeding irrespective of the AF type. The AF type is a predictor for thromboembolism, and might be helpful in stroke risk stratification model in combination with other risk factors. With the appearance of novel anticoagulant and antiplatelet agents, the best antithrombotic choice for paroxysmal AF needs further exploration. PMID:26717376

  11. Evaluation of the optimal positioning of subcutaneous butterfly when administering injectable opioids in cancer patients

    PubMed Central

    MITREA, NICOLETA; MOSOIU, DANIELA; VOSIT-STELLER, JULIE; ROGOZEA, LILIANA

    2016-01-01

    Background and aims The increasing number of cancer patients, together with the development of new palliative care services in Romania, warrants the evaluation of nursing strategies meant to improve the level of comfort of patients who are suffering from advanced cancer. The main objective of the study was to evaluate the optimal positioning of the subcutaneous (sc) butterfly, in accordance with its resistance in the insertion tissue, the local complications that may occur, and the evaluation of the time of resistance at the insertion site (puncture) with the daily frequency of injectable opioid administration. Methods A prospective experimental pilot study was designed and conducted between January and May 2011. Patients admitted to the Hospice Casa Sperantei (Brasov, Romania) with moderate or severe cancer pain, who were receiving subcutaneously opioids, over the age of 18, with normal body index ranging from 18.5 – 22.0, were assigned randomly to one of two groups, after signing the informed consent. In group one, the butterfly was positioned with the needle bevel up – this was considered to be the control group as this modality of inserting the needle is considered standard practice; in group two the butterfly was positioned with the needle bevel down – experimental group. The drugs used for pain relief were sc tramadol for moderate pain and sc morphine for severe pain. Results Our research supported the hypothesis that the occurrence of local complications coincides with the decrease of sc butterfly resistance in time at the place of insertion, and the sc butterfly has a higher rate of resistance in time at the insertion site if the frequency of injectable opioids administration is lower (twice per day). Conclusion The positioning of the butterflies with the bevel down (experimental group) is associated with a longer resistance in time at the site of insertion, and causes fewer local complications compared to the sc butterflies positioned with the bevel

  12. Transforming the Patient Role to Achieve Better Outcomes Through a Patient Empowerment Program: A Randomized Wait-List Control Trial Protocol

    PubMed Central

    Plaksin, Joseph; Zabar, Sondra; Wallach, Andrew; Sawicki, Chester; Kundrod, Sarita; Kalet, Adina

    2016-01-01

    Background In the patient-centered medical home model of health care, both health care providers (HCPs) and patients must understand their respective roles and responsibilities, view the other as a partner, and use communication skills that promote shared decision making. This is particularly necessary in chronic conditions where outcomes depend on behavior change and in underserved populations where the burden of chronic disease is high. Objective The objectives of this study are to determine if a Patient Empowerment Program (PEP) (1) is acceptable to patients and feasible across multiple clinical sites; (2) will increase patient preference for control in medical decision making, improve patient perceptions of patient-HCP communication, and increase patient activation; (3) is associated with an increase in diabetes self-management behaviors; and (4) has an effect on hemoglobin A 1c(HbA 1c) level. Methods This study recruited English-speaking adult patients with type 2 diabetes mellitus from three urban clinical sites in New York City and randomized them to an immediate intervention group that completed the PEP intervention or a deferred intervention group that served as a wait-list control and completed the PEP intervention after 3-4 months. The PEP intervention consists of two facilitated small group sessions. Session 1 focuses on defining HCP and patient roles in the medical encounter by introducing ideal communication behaviors in each role and by providing both positive and negative examples of patient-HCP encounters. Session 2 focuses on practicing communication skills by role-playing with actors who serve as standardized health care providers. After the role play, participants set goals for their own health care and for future interactions with their HCPs. Outcome measures include the Patient Activation Measure; Ask, Understand, Remember Assessment; Krantz Health Opinion Survey; SF-12v2 Health Survey; Diabetes Self-Management Questionnaire; and HbA 1c. These

  13. Multiple-factor analysis of the first radioactive iodine therapy in post-operative patients with differentiated thyroid cancer for achieving a disease-free status

    PubMed Central

    Liu, Na; Meng, Zhaowei; Jia, Qiang; Tan, Jian; Zhang, Guizhi; Zheng, Wei; Wang, Renfei; Li, Xue; Hu, Tianpeng; Upadhyaya, Arun; Zhou, Pingping; Wang, Sen

    2016-01-01

    131I treatment is an important management method for patients with differentiated thyroid cancer (DTC). Unsuccessful 131I ablation drastically affects the prognosis of the patients. This study aimed to analyze potential predictive factors influencing the achievement of a disease-free status following the first 131I therapy. This retrospective review included 315 DTC patients, and multiple factors were analyzed. Tumor size, pathological tumor stage, lymph node (LN) metastasis, distant metastasis, American Thyroid Association recommended risks, pre-ablation thyroglobulin (Tg), and thyroid stimulating hormone (TSH) displayed significant differences between unsuccessful and successful group. Cutoff values of Tg and TSH to predict a successful outcome were 3.525 ng/mL and 99.700 uIU/ml by receiver operating characteristic curves analysis. Binary logistic regression analysis showed that tumor stage T3 or T4, LN metastasis to N1b station, intermediate and high risks, pre-ablation Tg ≥ 3.525 ng/ml and TSH <99.700 μIU/mL were significantly associated with unsuccessful outcomes. Logistic regression equation for achieving a disease-free status could be rendered as: y (successful treatment) = −0.270–0.503 X1 (LN metastasis) −0.236 X2 (Tg) + 0.015 X3 (TSH). This study demonstrated LN metastasis, pre-ablation Tg and TSH were the most powerful predictors for achieving a disease-free status by the first 131I therapy. PMID:27721492

  14. The Adjoint Method for The Optimization of Brachytherapy and Radiotherapy Patient Treatment Planning Procedures Using Monte Carlo Calculations

    SciTech Connect

    D.L. Henderson; S. Yoo; M. Kowalok; T.R. Mackie; B.R. Thomadsen

    2001-10-30

    The goal of this project is to investigate the use of the adjoint method, commonly used in the reactor physics community, for the optimization of radiation therapy patient treatment plans. Two different types of radiation therapy are being examined, interstitial brachytherapy and radiotherapy. In brachytherapy radioactive sources are surgically implanted within the diseased organ such as the prostate to treat the cancerous tissue. With radiotherapy, the x-ray source is usually located at a distance of about 1-metere from the patient and focused on the treatment area. For brachytherapy the optimization phase of the treatment plan consists of determining the optimal placement of the radioactive sources, which delivers the prescribed dose to the disease tissue while simultaneously sparing (reducing) the dose to sensitive tissue and organs. For external beam radiation therapy the optimization phase of the treatment plan consists of determining the optimal direction and intensity of beam, which provides complete coverage of the tumor region with the prescribed dose while simultaneously avoiding sensitive tissue areas. For both therapy methods, the optimal treatment plan is one in which the diseased tissue has been treated with the prescribed dose and dose to the sensitive tissue and organs has been kept to a minimum.

  15. Variability in protein binding of teicoplanin and achievement of therapeutic drug monitoring targets in critically ill patients: lessons from the DALI Study.

    PubMed

    Roberts, J A; Stove, V; De Waele, J J; Sipinkoski, B; McWhinney, B; Ungerer, J P J; Akova, M; Bassetti, M; Dimopoulos, G; Kaukonen, K-M; Koulenti, D; Martin, C; Montravers, P; Rello, J; Rhodes, A; Starr, T; Wallis, S C; Lipman, J

    2014-05-01

    The aims of this study were to describe the variability in protein binding of teicoplanin in critically ill patients as well as the number of patients achieving therapeutic target concentrations. This report is part of the multinational pharmacokinetic DALI Study. Patients were sampled on a single day, with blood samples taken both at the midpoint and the end of the dosing interval. Total and unbound teicoplanin concentrations were assayed using validated chromatographic methods. The lower therapeutic range of teicoplanin was defined as total trough concentrations from 10 to 20 mg/L and the higher range as 10-30 mg/L. Thirteen critically ill patients were available for analysis. The following are the median (interquartile range) total and free concentrations (mg/L): midpoint, total 13.6 (11.2-26.0) and free 1.5 (0.7-2.5); trough, total 11.9 (10.2-22.7) and free 1.8 (0.6-2.6). The percentage free teicoplanin for the mid-dose and trough time points was 6.9% (4.5-15.6%) and 8.2% (5.5-16.4%), respectively. The correlation between total and free antibiotic concentrations was moderate for both the midpoint (ρ = 0.79, P = 0.0021) and trough (ρ = 0.63, P = 0.027). Only 42% and 58% of patients were in the lower and higher therapeutic ranges, respectively. In conclusion, use of standard dosing for teicoplanin leads to inappropriate concentrations in a high proportion of critically ill patients. Variability in teicoplanin protein binding is very high, placing significant doubt on the validity of total concentrations for therapeutic drug monitoring in critically ill patients.

  16. TU-PIS-Exhibit Hall-3: Simultaneous tracking of patient and real time staff dose to optimize interventional workflow

    SciTech Connect

    Boon, S.

    2015-06-15

    The current clinical standard of organ respiratory imaging, 4D-CT, is fundamentally limited by poor soft-tissue contrast and imaging dose. These limitations are potential barriers to beneficial “4D” radiotherapy methods which optimize the target and OAR dose-volume considering breathing motion but rely on a robust motion characterization. Conversely, MRI imparts no known radiation risk and has excellent soft-tissue contrast. MRI-based motion management is therefore highly desirable and holds great promise to improve radiotherapy of moving cancers, particularly in the abdomen. Over the past decade, MRI techniques have improved significantly, making MR-based motion management clinically feasible. For example, cine MRI has high temporal resolution up to 10 f/s and has been used to track and/or characterize tumor motion, study correlation between external and internal motions. New MR technologies, such as 4D-MRI and MRI hybrid treatment machines (i.e. MR-linac or MR-Co60), have been recently developed. These technologies can lead to more accurate target volume determination and more precise radiation dose delivery via direct tumor gating or tracking. Despite all these promises, great challenges exist and the achievable clinical benefit of MRI-based tumor motion management has yet to be fully explored, much less realized. In this proposal, we will review novel MR-based motion management methods and technologies, the state-of-the-art concerning MRI development and clinical application and the barriers to more widespread adoption. Learning Objectives: Discuss the need of MR-based motion management for improving patient care in radiotherapy. Understand MR techniques for motion imaging and tumor motion characterization. Understand the current state of the art and future steps for clinical integration. Henry Ford Health System holds research agreements with Philips Healthcare. Research sponsored in part by a Henry Ford Health System Internal Mentored Grant.

  17. 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

  18. Long-term survival and T-cell kinetics in relapsed/refractory ALL patients who achieved MRD response after blinatumomab treatment.

    PubMed

    Zugmaier, Gerhard; Gökbuget, Nicola; Klinger, Matthias; Viardot, Andreas; Stelljes, Matthias; Neumann, Svenja; Horst, Heinz-A; Marks, Reinhard; Faul, Christoph; Diedrich, Helmut; Reichle, Albrecht; Brüggemann, Monika; Holland, Chris; Schmidt, Margit; Einsele, Hermann; Bargou, Ralf C; Topp, Max S

    2015-12-10

    This long-term follow-up analysis evaluated overall survival (OS) and relapse-free survival (RFS) in a phase 2 study of the bispecific T-cell engager antibody construct blinatumomab in 36 adults with relapsed/refractory B-precursor acute lymphoblastic leukemia (ALL). In the primary analysis, 25 (69%) patients with relapsed/refractory ALL achieved complete remission with full (CR) or partial (CRh) hematologic recovery of peripheral blood counts within the first 2 cycles. Twenty-five patients (69%) had a minimal residual disease (MRD) response (<10(-4) blasts), including 22 CR/CRh responders, 2 patients with hypocellular bone marrow, and 1 patient with normocellular bone marrow but low peripheral counts. Ten of the 36 patients (28%) were long-term survivors (OS ≥30 months). Median OS was 13.0 months (median follow-up, 32.6 months). MRD response was associated with significantly longer OS (Mantel-Byar P = .009). All 10 long-term survivors had an MRD response. Median RFS was 8.8 months (median follow-up, 28.9 months). A plateau for RFS was reached after ∼18 months. Six of the 10 long-term survivors remained relapse-free, including 4 who received allogeneic stem cell transplantation (allo-SCT) as consolidation for blinatumomab and 2 who received 3 additional cycles of blinatumomab instead of allo-SCT. Three long-term survivors had neurologic events or cytokine release syndrome, resulting in temporary blinatumomab discontinuation; all restarted blinatumomab successfully. Long-term survivors had more pronounced T-cell expansion than patients with OS <30 months.

  19. Long-term survival and T-cell kinetics in relapsed/refractory ALL patients who achieved MRD response after blinatumomab treatment

    PubMed Central

    Gökbuget, Nicola; Klinger, Matthias; Viardot, Andreas; Stelljes, Matthias; Neumann, Svenja; Horst, Heinz-A.; Marks, Reinhard; Faul, Christoph; Diedrich, Helmut; Reichle, Albrecht; Brüggemann, Monika; Holland, Chris; Schmidt, Margit; Einsele, Hermann; Bargou, Ralf C.; Topp, Max S.

    2015-01-01

    This long-term follow-up analysis evaluated overall survival (OS) and relapse-free survival (RFS) in a phase 2 study of the bispecific T-cell engager antibody construct blinatumomab in 36 adults with relapsed/refractory B-precursor acute lymphoblastic leukemia (ALL). In the primary analysis, 25 (69%) patients with relapsed/refractory ALL achieved complete remission with full (CR) or partial (CRh) hematologic recovery of peripheral blood counts within the first 2 cycles. Twenty-five patients (69%) had a minimal residual disease (MRD) response (<10−4 blasts), including 22 CR/CRh responders, 2 patients with hypocellular bone marrow, and 1 patient with normocellular bone marrow but low peripheral counts. Ten of the 36 patients (28%) were long-term survivors (OS ≥30 months). Median OS was 13.0 months (median follow-up, 32.6 months). MRD response was associated with significantly longer OS (Mantel-Byar P = .009). All 10 long-term survivors had an MRD response. Median RFS was 8.8 months (median follow-up, 28.9 months). A plateau for RFS was reached after ∼18 months. Six of the 10 long-term survivors remained relapse-free, including 4 who received allogeneic stem cell transplantation (allo-SCT) as consolidation for blinatumomab and 2 who received 3 additional cycles of blinatumomab instead of allo-SCT. Three long-term survivors had neurologic events or cytokine release syndrome, resulting in temporary blinatumomab discontinuation; all restarted blinatumomab successfully. Long-term survivors had more pronounced T-cell expansion than patients with OS <30 months. PMID:26480933

  20. Optimizing mobilization strategies in difficult-to-mobilize patients: The role of plerixafor.

    PubMed

    Goker, Hakan; Etgul, Sezgin; Buyukasik, Yahya

    2015-08-01

    Peripheral blood stem cell collection is currently the most widely used source for hematopoietic autologous transplantation. Several factors such as advanced age, previous chemotherapy, disease and marrow infiltration at the time of mobilization influence the efficacy of CD34(+) progenitor cell mobilization. Despite the safety and efficiency of the standard mobilization protocols (G-CSF ± chemotherapy), there is still a significant amount of mobilization failure rate (10-40%), which necessitate novel agents for effective mobilization. Plerixafor, is a novel agent, has been recently approved for mobilization of hematopoietic stem cells (HSCs). The combination of Plerixafor with G-CSF provides the collection of large numbers of stem cells in fewer apheresis sessions and can salvage those who fail with standard mobilization regimens. The development and optimization of practical algorithms for the use Plerixafor is crucial to make hematopoietic stem cell mobilization more efficient in a cost-effective way. This review is aimed at summarizing how to identify poor mobilizers, and define rational use of Plerixafor for planning mobilization in hard-to-mobilize patients.

  1. Establishing an optimized patient-specific verification program for volumetric modulated arc therapy.

    PubMed

    Serna, Alfredo; Mata, Fernando; Puchades, Vicente

    2013-01-01

    Quality assurance (QA) of volumetric modulated arc therapy (VMAT) increases the workload significantly. We compared the results from 4 verification methods to establish an efficient VMAT QA. Planning for VMAT treatments was carried out for 40 consecutive patients. Pretreatment verifications were carried out with ion chamber array Physikalish-Technische Werkstätten (PTW729), electronic portal dosimetry (EPID), ion chamber measurements, and independent dose calculation with Diamond program. 2D analyses were made using the gamma analysis (3mm distance to agreement and 3% dose difference relative to maximum, 10% dose threshold). Average point dose difference calculated by Eclipse relative to ion chamber measurements and Diamond were 0.1%±0.9% and 0.6%±2.2%, respectively. Average pass rate for PTW729 was 99.2%±1.9% and 98.3%±1.3% for EPID. The total required time (linac occupancy time given in parentheses) for each QA method was: PTW729 43.5 minutes (26.5 minutes), EPID 14.5 minutes (2.5 minutes), ion chamber 34.5 minutes (26.5 minutes), and Diamond 12.0 minutes (0 minute). The results were consistent and allowed us to establish an optimized protocol, considering safety and accuracy as well as workload, consisting of 2 verification methods: EPID 2D analysis and independent dose calculation.

  2. Strategies to optimize treatment adherence in adolescent patients with cystic fibrosis

    PubMed Central

    Bishay, Lara C; Sawicki, Gregory S

    2016-01-01

    While development of new treatments for cystic fibrosis (CF) has led to a significant improvement in survival age, routine daily treatment for CF is complex, burdensome, and time intensive. Adolescence is a period of decline in pulmonary function in CF, and is also a time when adherence to prescribed treatment plans for CF tends to decrease. Challenges to adherence in adolescents with CF include decreased parental involvement, time management and significant treatment burden, and adolescent perceptions of the necessity and value of the treatments prescribed. Studies of interventions to improve adherence are limited and focus on education, without significant evidence of success. Smaller studies on behavioral techniques do not focus on adolescents. Other challenges for improving adherence in adolescents with CF include infection control practices limiting in-person interactions. This review focuses on the existing evidence base on adherence intervention in adolescents with CF. Future directions for efforts to optimize treatment adherence in adolescents with CF include reducing treatment burden, developing patient-driven technology to improve tracking, communication, and online support, and rethinking the CF health services model to include assessment of individualized adherence barriers. PMID:27799838

  3. Detective quantum efficiency: a standard test to ensure optimal detector performance and low patient exposures

    NASA Astrophysics Data System (ADS)

    Escartin, Terenz R.; Nano, Tomi F.; Cunningham, Ian A.

    2016-03-01

    The detective quantum efficiency (DQE), expressed as a function of spatial frequency, describes the ability of an x-ray detector to produce high signal-to-noise ratio (SNR) images. While regulatory and scientific communities have used the DQE as a primary metric for optimizing detector design, the DQE is rarely used by end users to ensure high system performance is maintained. Of concern is that image quality varies across different systems for the same exposures with no current measures available to describe system performance. Therefore, here we conducted an initial DQE measurement survey of clinical x-ray systems using a DQE-testing instrument to identify their range of performance. Following laboratory validation, experiments revealed that the DQE of five different systems under the same exposure level (8.0 μGy) ranged from 0.36 to 0.75 at low spatial frequencies, and 0.02 to 0.4 at high spatial frequencies (3.5 cycles/mm). Furthermore, the DQE dropped substantially with decreasing detector exposure by a factor of up to 1.5x in the lowest spatial frequency, and a factor of 10x at 3.5 cycles/mm due to the effect of detector readout noise. It is concluded that DQE specifications in purchasing decisions, combined with periodic DQE testing, are important factors to ensure patients receive the health benefits of high-quality images for low x-ray exposures.

  4. Establishing an optimized patient-specific verification program for volumetric modulated arc therapy

    SciTech Connect

    Serna, Alfredo; Mata, Fernando; Puchades, Vicente

    2013-10-01

    Quality assurance (QA) of volumetric modulated arc therapy (VMAT) increases the workload significantly. We compared the results from 4 verification methods to establish an efficient VMAT QA. Planning for VMAT treatments was carried out for 40 consecutive patients. Pretreatment verifications were carried out with ion chamber array Physikalish-Technische Werkstätten (PTW729), electronic portal dosimetry (EPID), ion chamber measurements, and independent dose calculation with Diamond program. 2D analyses were made using the gamma analysis (3 mm distance to agreement and 3% dose difference relative to maximum, 10% dose threshold). Average point dose difference calculated by Eclipse relative to ion chamber measurements and Diamond were 0.1%±0.9% and 0.6%±2.2%, respectively. Average pass rate for PTW729 was 99.2%±1.9% and 98.3%±1.3% for EPID. The total required time (linac occupancy time given in parentheses) for each QA method was: PTW729 43.5 minutes (26.5 minutes), EPID 14.5 minutes (2.5 minutes), ion chamber 34.5 minutes (26.5 minutes), and Diamond 12.0 minutes (0 minute). The results were consistent and allowed us to establish an optimized protocol, considering safety and accuracy as well as workload, consisting of 2 verification methods: EPID 2D analysis and independent dose calculation.

  5. 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.

  6. 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

  7. Optimal dose of intravenous oxycodone for attenuating hemodynamic changes after endotracheal intubation in healthy patients

    PubMed Central

    Park, Yong-Hee; Lee, Seung-Hyuk; Lee, Oh Haeng; Kang, Hyun; Shin, Hwa-Yong; Baek, Chong-Wha; Jung, Yong Hun; Woo, Young Cheol

    2017-01-01

    Abstract Background: Intravenous oxycodone has been used as an adjunct to anesthetic agents. This study aimed to assess the optimal dose of intravenous oxycodone for the attenuation of the hemodynamic responses to laryngoscopy and endotracheal intubation. Methods: A prospective, randomized, double-blind study was conducted. Ninety-five patients were randomly divided into 5 groups based on the oxycodone dose: 0, 0.05, 0.1, 0.15, 0.2 mg/kg. After administering the assigned dose of intravenous oxycodone, anesthesia was induced with thiopental. Heart rate (HR) and blood pressure (BP) were measured at baseline, before intubation, and 1, 2, and 3 minutes after intubation. The percentage increase of BP was calculated as (highest BP after intubation − baseline BP)/baseline BP × 100 (%). The percentage increase of HR was calculated in same formula as above. Hypertension was defined as a 15% increase of systolic BP from baseline, and probit analysis was conducted. Results: Hemodynamic data from 86 patients were analyzed. The percentage increase of mean arterial pressure after intubation in groups 0.05, 0.1, 0.15, and 0.2 was significantly different from that in the control (P < 0.001). For HR, the percentage increase was lower than control group when oxycodone was same or more than 0.1 mg/kg (P < 0.05). Using probit analysis, the 95% effective dose (ED95) for preventing hypertension was 0.159 mg/kg (95% confidence interval [CI], 0.122–0.243). In addition, ED50 was 0.020 mg/kg (95% CI, −0.037 to 0.049). However, oxycodone was not effective for maintaining the HR in our study dosage. There were no significant differences in the incidence of hypotension during induction between groups. Conclusions: Using 0.1 mg/kg of intravenous oxycodone is sufficient to attenuate the increase of BP and HR during induction period in healthy patients. The ED95, which was 0.159 mg/kg, can be useful to adjust the dosage of IV oxycodone for maintain stable BP

  8. Optimal design and patient selection for interventional trials using radiogenomic biomarkers: A REQUITE and Radiogenomics consortium statement.

    PubMed

    De Ruysscher, Dirk; Defraene, Gilles; Ramaekers, Bram L T; Lambin, Philippe; Briers, Erik; Stobart, Hilary; Ward, Tim; Bentzen, Søren M; Van Staa, Tjeerd; Azria, David; Rosenstein, Barry; Kerns, Sarah; West, Catharine

    2016-12-01

    The optimal design and patient selection for interventional trials in radiogenomics seem trivial at first sight. However, radiogenomics do not give binary information like in e.g. targetable mutation biomarkers. Here, the risk to develop severe side effects is continuous, with increasing incidences of side effects with higher doses and/or volumes. In addition, a multi-SNP assay will produce a predicted probability of developing side effects and will require one or more cut-off thresholds for classifying risk into discrete categories. A classical biomarker trial design is therefore not optimal, whereas a risk factor stratification approach is more appropriate. Patient selection is crucial and this should be based on the dose-response relations for a specific endpoint. Alternatives to standard treatment should be available and this should take into account the preferences of patients. This will be discussed in detail.

  9. Optimizing the G8 Screening Tool for Older Patients With Cancer: Diagnostic Performance and Validation of a Six-Item Version

    PubMed Central

    Martinez-Tapia, Claudia; Canoui-Poitrine, Florence; Bastuji-Garin, Sylvie; Soubeyran, Pierre; Mathoulin-Pelissier, Simone; Tournigand, Christophe; Paillaud, Elena; Laurent, Marie

    2016-01-01

    Background. A multidimensional geriatric assessment (GA) is recommended in older cancer patients to inventory health problems and tailor treatment decisions accordingly but requires considerable time and human resources. The G8 is among the most sensitive screening tools for selecting patients warranting a full GA but has limited specificity. We sought to develop and validate an optimized version of the G8. Patients and Methods. We used a prospective cohort of cancer patients aged ≥70 years referred to geriatricians for GA (2007–2012: n = 729 [training set]; 2012–2014: n = 414 [validation set]). Abnormal GA was defined as at least one impaired domain across seven validated tests. Multiple correspondence analysis, multivariate logistic regression, and bootstrapped internal validation were performed sequentially. Results. The final model included six independent predictors for abnormal GA: weight loss, cognition/mood, performance status, self-rated health status, polypharmacy (≥6 medications per day), and history of heart failure/coronary heart disease. For the original G8, sensitivity was 87.2% (95% confidence interval, 84.3–89.7), specificity 57.7% (47.3–67.7), and area under the receiver-operating characteristic curve (AUROC) 86.5% (83.5–89.6). The modified G8 had corresponding values of 89.2% (86.5–91.5), 79.0% (69.4–86.6), and 91.6% (89.3; 93.9), with higher AUROC values for all tumor sites and stable properties on the validation set. Conclusion. A modified G8 screening tool exhibited better diagnostic performance with greater uniformity across cancer sites and required only six items. If these features are confirmed in other settings, the modified tool may facilitate selection for a full GA in older patients with cancer. Implications for Practice: Several screening tools have been developed to identify older patients with cancer likely to benefit from a complete geriatric assessment, but none combines appropriate sensitivity and specificity

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

    SciTech Connect

    Modiri, A; Gu, X; Hagan, A; Sawant, 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). In 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

  11. A BCR-ABL1 cutoff of 1.5% at 3 months, determined by the GeneXpert system, predicts an optimal response in patients with chronic myeloid leukemia

    PubMed Central

    García-Gutiérrez, Valentín; Gómez-Casares, María T.; Puerta, José M.; Alonso-Domínguez, Juan M.; Osorio, Santiago; Hernández-Boluda, Juan C.; Collado, Rosa; Ramírez, María J.; Ibáñez, Fátima; Martín, María L.; Rodríguez-Gambarte, Juan D.; Martínez-Laperche, Carolina; Gómez, Montse; Fiallo, Dolly V.; Redondo, Sara; Rodríguez, Alicia; Ruiz-Nuño, Concepción; Steegmann, Juan L.

    2017-01-01

    In chronic myeloid leukemia (CML) patients, 3-month BCR-ABL1 levels have consistently been correlated with further outcomes. Monitoring molecular responses in CML using the GeneXpert (Cepheid) platform has shown an optimal correlation with standardized RQ-PCR (IS) when measuring BCR-ABL1 levels lower than 10%, as it is not accurate for values over 10%. The aim of the present study was to determine the predictive molecular value at three months on different outcome variables using the Xpert BCR-ABL1 MonitorTM assay (Xpert BCR-ABL1). We monitored 125 newly diagnosed consecutive CML patients in the chronic phase (CML-CP) using an automated method: Xpert BCR-ABL1. Only 5% of patients did not achieve an optimal response at 3 months, and the 10% BCR-ABL1 cutoff defined by RQ-PCR (IS) methods was unable to identify significant differences in the probabilities of achieving a complete cytogenetic response (CCyR) (50% vs. 87%, p = 0.1) or a major molecular response (MMR) (60% vs. 80%, p = 0.29) by 12 months. In contrast, a cutoff of 1.5% more accurately identified differences in the probabilities of achieving CCyR (98% vs. 54%, p<0.001) and MMR (88% vs. 56%, p<0.001) by 12 months, as well as probabilities of treatment changes (p = 0.005). Therefore, when using the Xpert BCR-ABL1 assay, a cutoff of 1.5% at 3 months could with high probability identify patients able to achieve an optimal response at 12 months. PMID:28278193

  12. A BCR-ABL1 cutoff of 1.5% at 3 months, determined by the GeneXpert system, predicts an optimal response in patients with chronic myeloid leukemia.

    PubMed

    García-Gutiérrez, Valentín; Gómez-Casares, María T; Puerta, José M; Alonso-Domínguez, Juan M; Osorio, Santiago; Hernández-Boluda, Juan C; Collado, Rosa; Ramírez, María J; Ibáñez, Fátima; Martín, María L; Rodríguez-Gambarte, Juan D; Martínez-Laperche, Carolina; Gómez, Montse; Fiallo, Dolly V; Redondo, Sara; Rodríguez, Alicia; Ruiz-Nuño, Concepción; Steegmann, Juan L; Jiménez-Velasco, Antonio

    2017-01-01

    In chronic myeloid leukemia (CML) patients, 3-month BCR-ABL1 levels have consistently been correlated with further outcomes. Monitoring molecular responses in CML using the GeneXpert (Cepheid) platform has shown an optimal correlation with standardized RQ-PCR (IS) when measuring BCR-ABL1 levels lower than 10%, as it is not accurate for values over 10%. The aim of the present study was to determine the predictive molecular value at three months on different outcome variables using the Xpert BCR-ABL1 MonitorTM assay (Xpert BCR-ABL1). We monitored 125 newly diagnosed consecutive CML patients in the chronic phase (CML-CP) using an automated method: Xpert BCR-ABL1. Only 5% of patients did not achieve an optimal response at 3 months, and the 10% BCR-ABL1 cutoff defined by RQ-PCR (IS) methods was unable to identify significant differences in the probabilities of achieving a complete cytogenetic response (CCyR) (50% vs. 87%, p = 0.1) or a major molecular response (MMR) (60% vs. 80%, p = 0.29) by 12 months. In contrast, a cutoff of 1.5% more accurately identified differences in the probabilities of achieving CCyR (98% vs. 54%, p<0.001) and MMR (88% vs. 56%, p<0.001) by 12 months, as well as probabilities of treatment changes (p = 0.005). Therefore, when using the Xpert BCR-ABL1 assay, a cutoff of 1.5% at 3 months could with high probability identify patients able to achieve an optimal response at 12 months.

  13. Prospective Assessment of Optimal Individual Position (Prone Versus Supine) for Breast Radiotherapy: Volumetric and Dosimetric Correlations in 100 Patients

    SciTech Connect

    Lymberis, Stella C.; Wyngaert, John Keith de; Parhar, Preeti; Chhabra, Arpit M.; Fenton-Kerimian, Maria; Chang Jengwha; Hochman, Tsivia; Guth, Amber; Roses, Daniel; Goldberg, Judith D.; Formenti, Silvia C.

    2012-11-15

    Purpose: Damage to heart and lung from breast radiotherapy is associated with increased cardiovascular mortality and lung cancer development. We conducted a prospective study to evaluate which position is best to spare lung and heart from radiotherapy exposure. Methods and Materials: One hundred consecutive Stage 0-IIA breast cancer patients consented to participate in a research trial that required two computed tomography simulation scans for planning both supine and prone positions. The optimal position was defined as that which best covered the contoured breast and tumor bed while it minimized critical organ irradiation, as quantified by the in-field heart and lung volume. The trial was designed to plan the first 100 patients in each position to study correlations between in-field volumes of organs at risk and dose. Results: Fifty-three left and 47 right breast cancer patients were consecutively accrued to the trial. In all patients, the prone position was optimal for sparing lung volume compared to the supine setup (mean lung volume reduction was 93.5 cc for right and 103.6 cc for left breast cancer patients). In 46/53 (87%) left breast cancer patients best treated prone, in-field heart volume was reduced by a mean of 12 cc and by 1.8 cc for the other 7/53 (13%) patients best treated supine. As predicted, supine-prone differences in in-field volume and mean dose of heart and lung were highly correlated (Spearman's correlation coefficient for left breast cancer patients was 0.90 for heart and 0.94 for lung and 0.92 for right breast cancer patients for lung). Conclusions: Prone setup reduced the amount of irradiated lung in all patients and reduced the amount of heart volume irradiated in 87% of left breast cancer patients. In-field organ volume is a valid surrogate for predicting dose; the trial continued to the planned target of 400.

  14. Innovative Hypofractionated Stereotactic Regimen Achieves Excellent Local Control with No Radiation Necrosis: Promising Results in the Management of Patients with Small Recurrent Inoperable GBM

    PubMed Central

    Pannullo, Susan C.; Minkowitz, Shlomo; Taube, Shoshana; Chang, Jenghwa; Parashar, Bhupesh; Christos, Paul; Wernicke, A.Gabriella

    2016-01-01

    Management of recurrent glioblastoma multiforme (GBM) remains a challenge. Several institutions reported that a single fraction of ≥ 20 Gy for small tumor burden results in excellent local control; however, this is at the expense of a high incidence of radiation necrosis (RN). Therefore, we developed a hypofractionation pattern of 33 Gy/3 fractions, which is a radiobiological equivalent of 20 Gy, with the aim to lower the incidence of RN. We reviewed records of 21 patients with recurrent GBM treated with hypofractionated stereotactic radiation therapy (HFSRT) to their 22 respective lesions. Sixty Gy fractioned external beam radiotherapy was performed as first-line treatment. Median time from primary irradiation to HFSRT was 9.6 months (range: 3.1 – 68.1 months). In HFSRT, a median dose of 33 Gy in 11 Gy fractions was delivered to the 80% isodose line that encompassed the target volume. The median tumor volume was 1.07 cm3 (range: 0.11 – 16.64 cm3). The median follow-up time after HFSRT was 9.3 months (range: 1.7 – 33.6 months). Twenty-one of 23 lesions treated (91.3%) achieved local control while 2/23 (8.7%) progressed. Median time to progression outside of the treated site was 5.2 months (range: 2.2 – 9.6 months). Progression was treated with salvage chemotherapy. Five of 21 patients (23.8%) were alive at the end of this follow-up; two patients remain disease-free. The remaining 16/21 patients (76.2%) died of disease. Treatment was well tolerated by all patients with no acute CTC/RTOG > Grade 2. There was 0% incidence of RN. A prospective trial will be underway to validate these promising results. PMID:27096136

  15. Optimizing antiplatelet therapy for the ACS patient: reacting to clinical trial data from the ISAR-REACT-2 studies.

    PubMed

    Steinhubl, Steven R

    2006-01-01

    Antiplatelet therapy is the cornerstone of treatment for patients with an acute coronary syndrome (ACS). However, patients presenting with possible ACS are a heterogeneous population, and there is a choice of many potential combination antiplatelet therapies, with aspirin, thienopyridines (eg, clopidogrel), and glycoprotein (GP) IIb/IIIa antagonists. The ISAR-REACT-2 trial investigated the optimal application of triple (aspirin 1 thienopyridine 1 GP IIb/IIIa inhibitor) versus dual (aspirin 1 thienopyridine) antiplatelet therapy for patients with ACS undergoing percutaneous coronary intervention. Abciximab was associated with a significant 25% relative reduction in risk for the 30-day combined endpoint of death, myocardial infarction, or urgent target vessel revascularization. All of this benefit was confined to the patients with elevated troponin levels. The data indicate that troponin can be used as a biomarker to identify patients most likely to benefit from the addition of a GP IIb/IIIa antagonist.

  16. 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.

  17. WellStar Paulding Hospital intensive care unit case study: achieving a research-based, patient-centered design using a collaborative process.

    PubMed

    Burns, Georgeann B; Hogue, Vicky

    2014-01-01

    This article describes the processes and tools used by WellStar Paulding Hospital to plan and design a new intensive care unit (ICU) as part of a 108-bed replacement hospital on a new site. Seeking to create a culture of safety centered around patient care, quality, and efficiency, the team used multiple external resources to increase their effectiveness as participants in the design process and to ensure that the new ICU achieves the functional performance goals identified at the beginning of planning and design. Specific focus on evidence-based design was assisted through participation in the Center for Health Design's Pebble Project process as well as the Joint Commission International Safe Health Design Learning Academy Pilot Program.

  18. In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?

    PubMed

    Johnson, Charles H N; Lang, Sommer A; Bilal, Haris; Rammohan, Kandadai S

    2014-06-01

    A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: 'In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain?'. Altogether more than 200 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Subcutaneous emphysema is usually a benign, self-limiting condition only requiring conservative management. Interventions are useful in the context of severe patient discomfort, respiratory distress or persistent air leak. In the absence of any comparative study, it is not possible to choose definitively between infraclavicular incisions, drain insertion and increasing suction on an in situ drain as the best method for managing severe subcutaneous emphysema. All the three techniques described have been shown to provide effective relief. Increasing suction on a chest tube already in situ provided rapid relief in patients developing SE following pulmonary resection. A retrospective study showed resolution in 66%, increasing to 98% in those who underwent video-assisted thoracic surgery with identification and closure of the leak. Insertion of a drain into the subcutaneous tissue also provided rapid sustained relief. Several studies aided drainage by using regular compressive massage. Infraclavicular incisions were also shown to provide rapid relief, but were noted to be more invasive and carried the potential for cosmetic defect. No major complications were illustrated.

  19. Successful achievement of sustained virological response to triple combination therapy containing simeprevir in two patients with chronic hepatitis C who had failed asunaprevir:Daclatasvir combination therapy.

    PubMed

    Ozeki, Itaru; Nakajima, Tomoaki; Yamaguchi, Masakatsu; Kimura, Mutsuumi; Arakawa, Tomohiro; Kuwata, Yasuaki; Ohmura, Takumi; Sato, Takahiro; Hige, Shuhei; Karino, Yoshiyasu; Toyota, Joji

    2016-10-01

    Patients 1 and 2 were treatment-naive women who had genotype 1b chronic hepatitis C. Both had IL-28B genotype TT, and amino acid substitutions of core 70 and 91 were both wild type. Search for the presence of resistance-associated variants (RAV) in non-structural (NS)3 and NS5A regions confirmed wild-type D168 and L31, along with Y93H, in both patients. These patients participated in a Japanese phase III clinical study of asunaprevir and daclatasvir at the age of 52 and 67 years, respectively, and were treated with the combination regimen for 24 weeks. However, both experienced post-treatment relapse, and then treated with triple combination therapy with simeprevir, pegylated interferon (IFN) and ribavirin at the age of 53 and 68 years, respectively, and achieved sustained virological response. A search for RAV prior to simeprevir treatment identified multiple resistance including D168E, Y93H and L31V in both patients. It has been demonstrated that, in many cases, a treatment failure with a combination of asunaprevir and daclatasvir results in acquisition of RAV in NS3 and NS5A regions and that drug-resistant mutants, particularly those in the NS5A region, survive for a long time. In these cases, direct-acting antivirals targeted towards the NS5A region may have a limited efficacy. The present case report is based on an idea that a regimen containing IFN with simeprevir could be a therapeutic option particularly for those who are likely to be highly sensitive and tolerable to IFN.

  20. Optimal volume of injectate for fluoroscopy-guided cervical interlaminar epidural injection in patients with neck and upper extremity pain.

    PubMed

    Park, Jun Young; Kim, Doo Hwan; Lee, Kunhee; Choi, Seong-Soo; Leem, Jeong-Gil

    2016-10-01

    There is no study of optimal volume of contrast medium to use in cervical interlaminar epidural injections (CIEIs) for appropriate spread to target lesions. To determine optimal volume of contrast medium to use in CIEIs. We analyzed the records of 80 patients who had undergone CIEIs. Patients were divided into 3 groups according to the amount of contrast: 3, 4.5, and 6 mL. The spread of medium to the target level was analyzed. Numerical rating scale data were also analyzed. The dye had spread to a point above the target level in 15 (78.9%), 22 (84.6%), and 32 (91.4%) patients in groups 1 to 3, respectively. The dye reached both sides in 14 (73.7%), 18 (69.2%), and 23 (65.7%) patients, and reached the ventral epidural space in 15 (78.9%), 22 (84.6%), and 30 (85.7%) patients, respectively. There were no significant differences of contrast spread among the groups. There were no significant differences in the numerical rating scale scores among the groups during the 3 months. When performing CIEIs, 3 mL medication is sufficient volume for the treatment of neck and upper-extremity pain induced by lower cervical degenerative disease.

  1. Optimal volume of injectate for fluoroscopy-guided cervical interlaminar epidural injection in patients with neck and upper extremity pain

    PubMed Central

    Park, Jun Young; Kim, Doo Hwan; Lee, Kunhee; Choi, Seong-Soo; Leem, Jeong-Gil

    2016-01-01

    Abstract There is no study of optimal volume of contrast medium to use in cervical interlaminar epidural injections (CIEIs) for appropriate spread to target lesions. To determine optimal volume of contrast medium to use in CIEIs. We analyzed the records of 80 patients who had undergone CIEIs. Patients were divided into 3 groups according to the amount of contrast: 3, 4.5, and 6 mL. The spread of medium to the target level was analyzed. Numerical rating scale data were also analyzed. The dye had spread to a point above the target level in 15 (78.9%), 22 (84.6%), and 32 (91.4%) patients in groups 1 to 3, respectively. The dye reached both sides in 14 (73.7%), 18 (69.2%), and 23 (65.7%) patients, and reached the ventral epidural space in 15 (78.9%), 22 (84.6%), and 30 (85.7%) patients, respectively. There were no significant differences of contrast spread among the groups. There were no significant differences in the numerical rating scale scores among the groups during the 3 months. When performing CIEIs, 3 mL medication is sufficient volume for the treatment of neck and upper-extremity pain induced by lower cervical degenerative disease. PMID:27787378

  2. Nonsteroidal Treatment of Atopic Dermatitis in Pediatric Patients with a Ceramide-Dominant Topical Emulsion Formulated with an Optimized Ratio of Physiological Lipids

    PubMed Central

    Del Rosso, James Q.

    2011-01-01

    Atopic dermatitis is the most common chronic inflammatory skin condition seen in the pediatric population. In the United States, the prevalence rate of atopic dermatitis is 10 to 12 percent in children. A nonsteroidal, barrier repair product consisting of an optimal ratio of ceramides, cholesterol, and free-fatty acids has been demonstrated to be efficacious and safe in the treatment of atopic dermatitis in previous clinical trials. This report is a subgroup analysis of the efficacy and safety of this nonsteroidal, ceramide-dominant, physiological lipid-based topical emulsion used among 59 patients, three months to 16 years of age, with mild-to-moderate atopic dermatitis. Treatment success based on an Investigator Global Assessment rating of clear or almost clear was achieved by 58 percent of subjects after use of the ceramide-dominant, physiological lipid barrier repair emulsion for three weeks as monotherapy or in combination with another topical atopic dermatitis treatment. The severity of pruritus decreased markedly from Baseline to Week 3 overall regardless of disease severity at baseline. A large percentage of subjects (71%) reported satisfaction with clinical results. After three weeks of treatment, a significant number of subjects reported less worry about their atopic dermatitis compared to baseline. The results further support other publications that suggest a treatment approach that incorporates an optimized formulation of a skin barrier repair cream as an integral component of initial atopic dermatitis therapy, either as monotherapy or as part of combination topical therapy. PMID:22191005

  3. First-line cART regimen impacts the course of CD8+ T-cell counts in HIV-infected patients that achieve sustained undetectable viral load.

    PubMed Central

    Poizot-Martin, Isabelle; Allavena, Clotilde; Delpierre, Cyrille; Duvivier, Claudine; Obry-Roguet, Véronique; Cano, Carla E.; Guillouet de Salvador, Francine; Rey, David; Dellamonica, Pierre; Cheret, Antoine; Cuzin, Lise; Katlama, Christine; Cabié, André; Hoen, Bruno

    2016-01-01

    Abstract The aim of the study was to investigate the impact of first-line combined antiretroviral therapy (cART) regimen on the course of CD8+ T-cell counts in human immunodeficiency virus (HIV)-infected patients. A retrospective observational study conducted on the French DAT’AIDS Cohort of HIV-infected patients. We selected 605 patients initiating a first-line cART between 2002 and 2009, and which achieved a sustained undetectable HIV plasma viral load (pVL) for at least 12 months without cART modification. The evolution of CD8+ T-cell counts according to cART regimen was assessed. CD8+ T-cell counts were assessed in 572 patients treated with 2NRTIs+1PI/r (n= 297), 2NRTIs+1NNRTI (n= 207) and 3NRTIs (n= 68). In multivariate analysis, after 12 months of follow-up, the 3NRTIs regimen was associated with a significantly smaller decrease of CD8+ T-cell count compared with NNRTI-containing regimens (–10.2 cells/μL in 3NRTIs vs –105.1 cells/μL; P=0.02) but not compared with PI-containing regimens (10.2 vs –60.9 cells/μL; P=0.21). After 24 months, the 3NRTIs regimen was associated with a smaller decrease of CD8+ T-cell count and % compared with PI/r- and NNRTI-containing regimens (0.2 in 3NRTIs vs –9.9 with PI/r-regimens, P=0.001, and vs –11.1 with NNRTI-regimens, p < 0.0001). A focus analysis on 11 patients treated with an INSTI-containing cART regimen during the study period showed after 12 months of follow-up, a median decrease of CD8+ T-cell count of –155 [inter quartile range: –302; –22] cells/μL. Our data highlight the fact that cART regimens have differential effects on CD8 pool down regulation. PMID:27741125

  4. Thin sheets achieve optimal wrapping of liquids

    NASA Astrophysics Data System (ADS)

    Paulsen, Joseph; Démery, Vincent; Davidovitch, Benny; Santangelo, Christian; Russell, Thomas; Menon, Narayanan

    2015-03-01

    A liquid drop can wrap itself in a sheet using capillary forces [Py et al., PRL 98, 2007]. However, the efficiency of ``capillary origami'' at covering the surface of a drop is hampered by the mechanical cost of bending the sheet. Thinner sheets deform more readily by forming small-scale wrinkles and stress-focussing patterns, but it is unclear how coverage efficiency competes with mechanical cost as thickness is decreased, and what wrapping shapes will emerge. We place a thin (~ 100 nm) polymer film on a drop whose volume is gradually decreased so that the sheet covers an increasing fraction of its surface. The sheet exhibits a complex sequence of axisymmetric and polygonal partially- and fully- wrapped shapes. Remarkably, the progression appears independent of mechanical properties. The gross shape, which neglects small-scale features, is correctly predicted by a simple geometric approach wherein the exposed area is minimized. Thus, simply using a thin enough sheet results in maximal coverage.

  5. Innovative practice model to optimize resource utilization and improve access to care for high-risk and BRCA+ patients

    PubMed Central

    Head, Linden; Nessim, Carolyn; Boyd, Kirsty Usher

    2017-01-01

    Background Bilateral prophylactic mastectomy (BPM) has shown breast cancer risk reduction in high-risk/BRCA+ patients. However, priority of active cancers coupled with inefficient use of operating room (OR) resources presents challenges in offering BPM in a timely manner. To address these challenges, a rapid access prophylactic mastectomy and immediate reconstruction (RAPMIR) program was innovated. The purpose of this study was to evaluate RAPMIR with regards to access to care and efficiency. Methods We retrospectively reviewed the cases of all high-risk/BRCA+ patients having had BPM between September 2012 and August 2014. Patients were divided into 2 groups: those managed through the traditional model and those managed through the RAPMIR model. RAPMIR leverages 2 concurrently running ORs with surgical oncology and plastic surgery moving between rooms to complete 3 combined BPMs with immediate reconstruction in addition to 1–2 independent cases each operative day. RAPMIR eligibility criteria included high-risk/BRCA+ status; BPM with immediate, implant-based reconstruction; and day surgery candidacy. Wait times, case volumes and patient throughput were measured and compared. Results There were 16 traditional patients and 13 RAPMIR patients. Mean wait time (days from referral to surgery) for RAPMIR was significantly shorter than for the traditional model (165.4 v. 309.2 d, p = 0.027). Daily patient throughput (4.3 v. 2.8), plastic surgery case volume (3.7 v. 1.6) and surgical oncology case volume (3.0 v. 2.2) were significantly greater in the RAPMIR model than the traditional model (p = 0.003, p < 0.001 and p = 0.015, respectively). Conclusion A multidisciplinary model with optimized scheduling has the potential to improve access to care and optimize resource utilization. PMID:28234588

  6. 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.

  7. Optimal Stroke Prevention in the Geriatric Patient with Atrial Fibrillation: Position Paper of an Interdisciplinary Expert Panel.

    PubMed

    Bahrmann, P; Wehling, M; Ropers, D; Flohr, J; Leischker, A; Röther, J

    2015-10-01

    The present position paper summarises the outcomes of an expert panel discussion held by hospital-based and office-based physicians with ample experience in the treatment of geriatric patients. The optimal approach to stroke prevention in geriatric patients with atrial fibrillation (AF) has not been adequately clarified. Despite their high risk of stroke and clear indication for anticoagulation according to established risk scores, in practice geriatric AF patients often are withheld treatment because of comorbidities and comedications, concerns about low treatment adherence or fear of bleeding events, in particular due to falls. The panel agreed that geriatric patients should receive oral anticoagulation as a rule, unless a comprehensive neurological and geriatric assessment (including clinical examination, gait tests and validated instruments such as Modified Rankin Scale, Mini-mental state examination or Timed Test of Money Counting) provides sound reasons for refraining from treatment. All patients with a history of falls should be thoroughly evaluated for further evaluation of the causes. Patients with CHADS2 score ≥ 2 should receive anticoagulation even if at high risk for falls. The novel oral anticoagulants (NOAC) facilitate management in the geriatric population with AF (no INR monitoring needed, easier bridging during interventions) and have, based on available data, an improved benefit-risk ratio compared to vitamin K antagonists. Drugs with predominantly non-renal elimination are safer in geriatric patients and should be preferred.

  8. KCNN4 and S100A14 act as predictors of recurrence in optimally debulked patients with serous ovarian cancer

    PubMed Central

    Hu, Ting; Sun, Qian; Wu, Jianli; Lin, Xingguang; Luo, Danfeng; Sun, Chaoyang; Wang, Changyu; Zhou, Bo; Li, Na; Xia, Meng; Lu, Hao; Meng, Li; Xu, Xiaoyan; Hu, Junbo; Ma, Ding; Chen, Gang; Zhu, Tao

    2016-01-01

    Approximately 50-75% of patients with serous ovarian carcinoma (SOC) experience recurrence within 18 months after first-line treatment. Current clinical indicators are inadequate for predicting the risk of recurrence. In this study, we used 7 publicly available microarray datasets to identify gene signatures related to recurrence in optimally debulked SOC patients, and validated their expressions in an independent clinic cohort of 127 patients using immunohistochemistry (IHC). We identified a two-gene signature including KCNN4 and S100A14 which was related to recurrence in optimally debulked SOC patients. Their mRNA expression levels were positively correlated and regulated by DNA copy number alterations (CNA) (KCNN4: p=1.918e-05) and DNA promotermethylation (KCNN4: p=0.0179; S100A14: p=2.787e-13). Recurrence prediction models built in the TCGA dataset based on KCNN4 and S100A14 individually and in combination showed good prediction performance in the other 6 datasets (AUC:0.5442-0.9524). The independent cohort supported the expression difference between SOC recurrences. Also, a KCNN4 and S100A14-centered protein interaction subnetwork was built from the STRING database, and the shortest regulation path between them, called the KCNN4-UBA52-KLF4-S100A14 axis, was identified. This discovery might facilitate individualized treatment of SOC. PMID:27270322

  9. Patient dumping, outlier payments, and optimal healthcare payment policy under asymmetric information.

    PubMed

    Takahara, Tsuyoshi

    2016-12-01

    We analyze a rationale for official authorization of patient dumping in the prospective payment policy framework. We show that when the insurer designs the healthcare payment policy to let hospitals dump high-cost patients, there is a trade-off between the disutility of dumped patients (changes in hospitals' rent extraction due to low-severity patients) and the shift in the level of cost reduction efforts for high-severity patients. We also clarify the welfare-improving conditions by allowing hospitals to dump high-severity patients. Finally, we show that if the efficiency of the cost reduction efforts varies extensively and the healthcare payment cost is substantial, or if there are many private hospitals, the patient dumping policy can improve social welfare in a wider environment.

  10. Wall Shear Stress Restoration in Dialysis Patient's Venous Stenosis: Elucidation via 3D CFD and Shape Optimization

    NASA Astrophysics Data System (ADS)

    Mahmoudzadeh Akherat, S. M. Javid; Cassel, Kevin; Hammes, Mary; Boghosian, Michael; Illinois Institute of Technology Team; University of Chicago Team

    2016-11-01

    Venous stenosis developed after the growth of excessive neointimal hyperplasia (NH) in chronic dialysis treatment is a major cause of mortality in renal failure patients. It has been hypothesized that the low wall shear stress (WSS) triggers an adaptive response in patients' venous system that through the growth of neointimal hyperplastic lesions restores WSS and transmural pressure, which also regulates the blood flow rate back to physiologically acceptable values which is violated by dialysis treatment. A strong coupling of three-dimensional CFD and shape optimization analyses were exploited to elucidate and forecast this adaptive response which correlates very well topographically with patient-specific clinical data. Based on the framework developed, a medical protocol is suggested to predict and prevent dialysis treatment failure in clinical practice. Supported by the National Institute of Diabetes and Digestive and Kidney Diseases of the National Institutes of Health (R01 DK90769).

  11. Overall x-ray system simulation model developed for system design and image quality versus patient dose optimization

    NASA Astrophysics Data System (ADS)

    Kroon, Han

    2003-06-01

    We have developed a full-scale image quality (IQ) simulation model as a tool for X-ray system design, image quality optimization and patient dose reduction. The IQ model supports the (de-)composition of system level requirements and simulates several types of automatic X-ray control technique. The model is implemented in LabVIEW. The X-ray system is modeled in distinguishable components and processes, which allows isolation of sub-systems and exclusion of devices. All relevant patient dose and IQ items such as contrast, sharpness, lag and noise are calculated and additionally combined in IQ "figures of merit" (FOM). Some characteristic application examples will be presented: In a general image magnification study we compare magnification techniques, such as geometric enlargement, image intensifier zooming and digital processing. In an optimization study we apply a new IQ FOM that contains not only imaging properties of the system, but also detail information in terms of material, size and thickness. Combining the IQ simulation model with a Pareto trade-off algorithm appears to be a promising optimization approach. In addition to the mentioned employment, the IQ simulation model is also suitable for comparison studies on the performance of flat detectors versus image intensifier television detectors, application related studies and fine tuning of specific settings and adjustments, design of test objects and development of measuring methods.

  12. Patient-derived xenograft platform of OSCC: a renewable human bio-bank for preclinical cancer research and a new co-clinical model for treatment optimization.

    PubMed

    Sun, Shuyang; Zhang, Zhiyuan

    2016-03-01

    Advances in next-generation sequencing and bioinformatics have begun to reveal the complex genetic landscape in human cancer genomes, including oral squamous cell carcinoma (OSCC). Sophisticated preclinical models that fully represent intra- and inter-tumoral heterogeneity are required to understand the molecular diversity of cancer and achieve the goal of personalized therapies. Over the last decade, patient-derived xenograft (PDX) models generated from human tumor samples that can retain the histological and genetic features of their donor tumors have been shown to be the preferred preclinical tool in translational cancer research compared with other conventional preclinical models. Specifically, genetically well-defined PDX models can be applied to accelerate targeted antitumor drug development and biomarker discovery. Recently, we have successfully established and characterized an OSCC PDX panel as part of our tumor bio-bank for translational cancer research. In this paper, we discuss the establishment, characterization, and preclinical applications of the PDX models. In particular, we focus on the classification and applications of the PDX models based on validated annotations, including clinicopathological features, genomic profiles, and pharmacological testing information. We also explore the translational value of this well-annotated PDX panel in the development of co-clinical trials for patient stratification and treatment optimization in the near future. Although various limitations still exist, this preclinical approach should be further tested and improved.

  13. Optimal dosing regimen of biapenem in Chinese patients with lower respiratory tract infections based on population pharmacokinetic/pharmacodynamic modelling and Monte Carlo simulation.

    PubMed

    Dong, Jing; Xiong, Wei; Chen, Yuancheng; Zhao, Yunfeng; Lu, Yang; Zhao, Di; Li, Wenyan; Liu, Yanhui; Chen, Xijing

    2016-03-01

    In this study, a population pharmacokinetic (PPK) model of biapenem in Chinese patients with lower respiratory tract infections (LRTIs) was developed and optimal dosage regimens based on Monte Carlo simulation were proposed. A total of 297 plasma samples from 124 Chinese patients were assayed chromatographically in a prospective, single-centre, open-label study, and pharmacokinetic parameters were analysed using NONMEN. Creatinine clearance (CLCr) was found to be the most significant covariate affecting drug clearance. The final PPK model was: CL (L/h)=9.89+(CLCr-66.56)×0.049; Vc (L)=13; Q (L/h)=8.74; and Vp (L)=4.09. Monte Carlo simulation indicated that for a target of ≥40% T>MIC (duration that the plasma level exceeds the causative pathogen's MIC), the biapenem pharmacokinetic/pharmacodynamic (PK/PD) breakpoint was 4μg/mL for doses of 0.3g every 6h (3-h infusion) and 1.2g (24-h continuous infusion). For a target of ≥80% T>MIC, the PK/PD breakpoint was 4μg/mL for a dose of 1.2g (24-h continuous infusion). The probability of target attainment (PTA) could not achieve ≥90% at the usual biapenem dosage regimen (0.3g every 12h, 0.5-h infusion) when the MIC of the pathogenic bacteria was 4μg/mL, which most likely resulted in unsatisfactory clinical outcomes in Chinese patients with LRTIs. Higher doses and longer infusion time would be appropriate for empirical therapy. When the patient's symptoms indicated a strong suspicion of Pseudomonas aeruginosa or Acinetobacter baumannii infection, it may be more appropriate for combination therapy with other antibacterial agents.

  14. Optimal dose of gemcitabine for the treatment of biliary tract or pancreatic cancer in patients with liver dysfunction.

    PubMed

    Shibata, Takashi; Ebata, Tomoki; Fujita, Ken-ichi; Shimokata, Tomoya; Maeda, Osamu; Mitsuma, Ayako; Sasaki, Yasutsuna; Nagino, Masato; Ando, Yuichi

    2016-02-01

    A clear consensus does not exist about whether the initial dose of gemcitabine, an essential anticancer antimetabolite, should be reduced in patients with liver dysfunction. Adult patients with biliary tract or pancreatic cancer were divided into three groups according to whether they had mild, moderate, or severe liver dysfunction, evaluated on the basis of serum bilirubin and liver transaminase levels at baseline. As anticancer treatment, gemcitabine at a dose of 800 or 1000 mg/m(2) was given as an i.v. infusion once weekly for 3 weeks of a 4-week cycle. The patients were prospectively evaluated for adverse events during the first cycle, and the pharmacokinetics of gemcitabine and its inactive metabolite, difluorodeoxyuridine, were studied to determine the optimal initial dose of gemcitabine as monotherapy according to the severity of liver dysfunction. A total of 15 patients were studied. Liver dysfunction was mild in one patient, moderate in six, and severe in eight. All 15 patients had been undergoing biliary drainage for obstructive jaundice when they received gemcitabine. Grade 3 cholangitis developed in one patient with moderate liver dysfunction who received gemcitabine at the dose level of 1000 mg/m(2). No other patients had severe treatment-related adverse events resulting in the omission or discontinuation of gemcitabine treatment. The plasma concentrations of gemcitabine and difluorodeoxyuridine were similar among the groups. An initial dose reduction of gemcitabine as monotherapy for the treatment of biliary tract or pancreatic cancers is not necessary for patients with hyperbilirubinemia, provided that obstructive jaundice is well managed. (Clinical trial registration no. UMIN000005363.)

  15. Five skills psychiatrists should have in order to provide patients with optimal ethical care.

    PubMed

    Howe, Edmund

    2011-03-01

    Analyses of empirical research and ethical problems require different skills and approaches. This article presents five core skills psychiatrists need to be able to address ethical problems optimally. These include their being able to recognize ethical conflicts and distinguish them from empirical questions, apply all morally relevant values, and know good from bad ethical arguments. Clinical examples of each are provided.

  16. Association between the Achievement of Target Range CKD-MBD Markers and Mortality in Prevalent Hemodialysis Patients in Taiwan by Using the Kidney Disease: Improving Global Outcomes Clinical Guidelines

    PubMed Central

    Cheng, Ben-Chung; Lee, Chih-Hsiung; Chang, Wen-Xiu

    2016-01-01

    Background. This study evaluated the association between achieving target chronic kidney disease-mineral and bone disorder (CKD-MBD) marker levels and mortality in Taiwanese hemodialysis (HD) patients. Target levels were based on the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. Methods. We performed a retrospective medical record review of 1126 HD patients between 2009 and 2013. A logistic regression model was used to evaluate the relationship between achieving target marker levels and the risk for all-cause and cardiovascular (CV) mortality. Reference target ranges were 7.9 ≤ calcium (Ca) ≤ 9.9 mg/dL, 2.4 ≤ phosphate (P) ≤ 4.7 mg/dL, and 144 ≤ intact parathyroid hormone (iPTH) ≤ 648 pg/mL. Results. Achievement of target P levels was associated with a lower risk for all-cause mortality compared to achievement of either target Ca or iPTH levels. Achieving target P + iPTH levels (OR 1.32) was associated with a lower odds ratio for all-cause mortality compared to achieving target Ca + P (OR 1.66) and Ca + iPTH (OR 1.43) levels. Similar trends were observed for CV mortality risk. Conclusions. The present study demonstrated that achieving serum P levels within the KDIGO target range is the most important factor for lowering mortality in HD patients. PMID:28003998

  17. Optimal Follow-up of Patients with Viral Hepatitis Improves the Detection of Early-stage Hepatocellular Carcinoma and the Prognosis of Survival

    PubMed Central

    Oeda, Satoshi; Iwane, Shinji; Takasaki, Mitsuhiro; Furukawa, Naoko E; Otsuka, Taiga; Eguchi, Yuichiro; Anzai, Keizo

    2016-01-01

    Objective To manage patients with viral hepatitis, it is important to screen for hepatitis, conduct a comprehensive examination if such screening is positive, administer antiviral treatment, and conduct surveillance for hepatocellular carcinoma (HCC). The proper execution of this strategy is expected to effectively reduce the number of deaths from viral hepatitis. Such an “optimal” follow-up for HCC surveillance is therefore important. This study aimed to determine the benefits of performing an optimal follow-up of patients with viral hepatitis. Methods The subjects were infected with the hepatitis virus and were initially diagnosed with or treated for HCC from 2004-2012. We retrospectively analyzed the history of a patient's current illness using the hospital discharge summary. To minimize any lead-time bias, we calculated the corrected survival for patients who received an optimal follow-up. Results Of 333 patients, 107 (32.1%) did not receive an optimal follow-up and thus had low cumulative survival rates in comparison to those who did. The median corrected survival was 51.5 months for patients with an optimal follow-up compared with 31.4 months for those without (p=0.011). A multivariate analysis revealed that AFP <35 [odds ratio (OR), 2.054], Child-Pugh A (OR, 2.488), and an optimal follow-up (OR, 4.539) were independent factors associated with the detection of early-stage HCC. Age (OR, 0.939), tumor stage I/II (OR, 6.918), and an optimal follow-up (OR, 3.213) were found to be independent factors associated with receiving curative treatment. Conclusion An optimal follow-up of patients with viral hepatitis independently increased the detection of early-stage HCC and the administration of curative treatment. Patients with an optimal follow-up survived longer than those without. PMID:27725532

  18. Fluid resuscitation of trauma patients: how fast is the optimal rate?

    PubMed

    Mizushima, Yasuaki; Tohira, Hideo; Mizobata, Yasumitsu; Matsuoka, Tetsuya; Yokota, Junichiro

    2005-11-01

    The Advanced Trauma Life Support guidelines recommend an initial rapid infusion of fluid (1-2 L) in trauma and hemorrhage victims as a diagnostic procedure to aid treatment decisions. Although patient response to initial fluid resuscitation is the key to determining therapeutic strategies, the appropriate rate of infusion is not clearly defined. Ninety-nine adult (age >16 years) blunt trauma victims with hypotension were enrolled. Patients were classified into 3 groups according to hemodynamic state after initial fluid resuscitation and requirement of surgical intervention. Total volume and rate of infusion differed significantly between the groups (P < .05). Patients requiring fluid administration at higher rate were all hemodynamically unstable and required immediate surgical intervention. Moreover, rate of infusion was the best predictor of the patients who required immediate surgical intervention. Moderate fluid infusion rate should be considered to allow identification of the patient's response to initial fluid resuscitation.

  19. Optimal Blood Pressure Goals in Patients With Hypertension at High Risk for Cardiovascular Events.

    PubMed

    Aronow, Wilbert S

    2016-01-01

    Existing epidemiologic and clinical trial data suggest that the blood pressure in patients with hypertension at high risk for cardiovascular events because of coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, or heart failure should be reduced to <140/90 mm Hg in patients younger than 80 years and the systolic blood pressure be reduced to 140-145 mm Hg if tolerated in patients aged 80 years and older. Studies from patients with coronary artery disease, diabetes mellitus, chronic kidney disease, stroke, and heart failure will be discussed that support a blood pressure goal of <140/90 mm Hg in patients younger than 80 years at high risk for cardiovascular events.

  20. Prevalence of Obesity and Its Influence on Achievement of Cardiometabolic Therapeutic Goals in Chinese Type 2 Diabetes Patients: An Analysis of the Nationwide, Cross-Sectional 3B Study

    PubMed Central

    Zhou, Xianghai; Ji, Linong; Ran, Xingwu; Su, Benli; Ji, Qiuhe; Pan, Changyu; Weng, Jianping; Ma, Changsheng; Hao, Chuanming; Zhang, Danyi; Hu, Dayi

    2016-01-01

    Background There are few data on the prevalence of obesity and its influence on achieving blood glucose, blood pressure, and blood lipid (3B) goals in Chinese type 2 diabetes outpatients. Methods Patient demographic data, anthropometric measurements, medications, and blood glucose and lipid profiles of 24,512 type 2 diabetes patients from a large, geographically diverse study (CCMR-3B) were analyzed. Using cut-points for body mass index (BMI) and waist circumference (WC) recommended by the Working Group on Obesity in China, overweight and obesity were defined as BMIs of 24–27.9kg/m2 and ≥28.0kg/m2. Central obesity was defined as a waist circumference ≥80cm in women and ≥85cm in men. The 3B therapeutic goals were HbA1c<7.0%, BP<140/90mmHg and LDL-C<2.6mmol/L. Results Overall, 43.0% of type 2 diabetes patients were overweight and 16.7% were obese; 13.3% of overweight and and10.1% of obese patients achieved all the 3B target goals. Overweight or obese patients were less likely to achieve 3B goals than those with normal BMIs. More than a half the overweight or obese patients (69.6%) were centrally obese. Patients with abdominal obesity were less likely to achieve cardiometabolic targets than those without abdominal obesity. In multivariate logistic regression analysis, female, higher BMI and waist circumference, smoking, drinking, sedentary lifestyle, and longer diabetes duration were significantly correlated with failure to achieve 3B control goals. Conclusions Obesity is highly prevalent and associated with poor 3B control in Chinese type 2 diabetes patients. In clinical practice, more attention and resources should focus on weight loss for such patients. PMID:26726883

  1. Survey of experts on therapeutic policies and proposals for the optimal timing for allogeneic peripheral blood stem cell transplantation in transfusion-dependent patients with myelodysplastic syndrome-refractory anemia

    PubMed Central

    Moon, Joon Ho; Lee, Yoo Jin; Park, Sung Woo; Kim, Ji Yoon

    2016-01-01

    Background Most hypomethylating agent (HMA) responders with myelodysplastic syndrome (MDS) eventually need allogeneic stem cell transplantation (SCT) because they often acquire resistance to HMAs within two years of treatment. Considering the nature of MDS and the poor outcomes of SCT when performed after confirming the progression of MDS to acute myeloid leukemia (AML), allogeneic SCT should be performed with caution in patients with low-risk MDS. Methods To address low-risk MDS, the Korean AML/MDS working party group designed a survey for 34 MDS experts in Korea on therapeutic HMA and allogeneic SCT policies for low-risk MDS. The level of consensus was defined as the percentage of agreement among the experts. Results With regard to the optimal time for allogeneic SCT for HMA responders with MDS-RA, 76% experts agreed that allogeneic SCT should be performed when a patient has a low platelet count. With regard to the relapse pattern that was most commonly found during HMA treatment in responding patients with MDS-RA, 54% experts agreed that the most common pattern that indicated HMA failure was the gradual worsening of cytopenia. Conclusion The optimal time to perform allogeneic SCT in RA patients who achieved hematologic complete remission during HMA treatment is when the platelet count decreases. However, these suggestions need to be evaluated in larger future studies. Therefore, careful decisions should be taken at each step of allogeneic SCT to maximize the outcomes for patients with MDS-RA and iron overload. PMID:27104191

  2. Modulation of Physical Activity to Optimize Pain Sensation following an Intra-Articular Corticosteroid Injection in Patients with Knee Osteoarthritis

    PubMed Central

    Dessery, Yoann; Belzile, Étienne L.; Turmel, Sylvie; Doré, Jean; Diallo, Binta

    2014-01-01

    Background. Intra-articular corticosteroid injection is often used to relieve pain caused by knee osteoarthritis. This study aims to assess the impact after an intra-articular corticosteroid injection treatment on objective and subjective measurement of physical function in knee osteoarthritis patients. Methods. Fourteen patients with unilateral knee osteoarthritis participated in this open-label uncontrolled trial. The intra-articular corticosteroid injection was given at the end of the second week. Physical activity was objectively measured by an accelerometer worn by the participants for eight weeks. Symptoms, quality of life and spatiotemporal parameters of gait were assessed every two weeks. Results. From the injection until six weeks later, pain and stiffness were reduced by approximately 60%. Patients' daily physical activity time was significantly improved after injection: participation in light and moderate physical activities increased during four and two weeks, respectively. Conclusions. The beneficial effects after the intra-articular corticosteroid injection are visible in the duration and intensity of the knee osteoarthritis patients' daily physical activity. However, these effects declined gradually two weeks after injection. Modulating the intensity and duration of physical activity would allow patients to optimize pain sensation over a longer period following an intra-articular corticosteroid injection. Trial Registration. This trial was registered with ClinicalTrials: NCT02049879. PMID:25478585

  3. Esophageal capsule endoscopy is not the optimal technique to determine the need for primary prophylaxis in patients with cirrhosis

    PubMed Central

    Krok, Karen L.; Wagennar, Rebecca Rankin; Kantsevoy, Sergey V.

    2016-01-01

    Introduction Capsule endoscopy has been suggested as a potential alternative to endoscopy for detection of esophagogastric varices and severe portal hypertensive gastropathy (PHG). The aim of the study was to determine whether PillCam esophageal capsule endoscopy could replace endoscopy for screening purposes. Material and methods Sixty-two patients with cirrhosis with no previous variceal bleeding had PillCam capsule endoscopy and video endoscopy performed on the same day. Sensitivity, specificity, and positive and negative predictive values (PPV, NPV) of capsule endoscopy were compared to endoscopy for the presence and severity of esophageal and gastric varices, PHG and the need for primary prophylaxis. Patients’ preference was assessed by a questionnaire. Results Four (6%) patients were unable to swallow the capsule. Sensitivity, specificity, PPV and NPV of capsule endoscopy for detecting any esophageal varices (92%, 50%, 92%, 50%), large varices (55%, 91%, 75%, 80%), variceal red signs (58%, 87%, 69%, 80%), PHG (95%, 50%, 95%, 50%), and the need for primary prophylaxis (91%, 57%, 78%, 80%) were not optimal, with only moderate agreement (κ) between capsule and upper GI endoscopy. Had only a capsule endoscopy been performed, 12 (21.4%) patients would have received inappropriate treatment. Capsule endoscopy also failed to detect (0/13) gastric varices. The majority of patients ranked capsule endoscopy as more convenient (69%) and their preferred (61%) method. Conclusions Despite the preference expressed by patients for capsule endoscopy, we believe that upper GI endoscopy should remain the preferred screening method for primary prophylaxis. PMID:27186182

  4. Taking a lesson from patients' recovery strategies to optimize training during robot-aided rehabilitation.

    PubMed

    Colombo, Roberto; Sterpi, Irma; Mazzone, Alessandra; Delconte, Carmen; Pisano, Fabrizio

    2012-05-01

    In robot-assisted neurorehabilitation, matching the task difficulty level to the patient's needs and abilities, both initially and as the relearning process progresses, can enhance the effectiveness of training and improve patients' motivation and outcome. This study presents a Progressive Task Regulation algorithm implemented in a robot for upper limb rehabilitation. It evaluates the patient's performance during training through the computation of robot-measured parameters, and automatically changes the features of the reaching movements, adapting the difficulty level of the motor task to the patient's abilities. In particular, it can select different types of assistance (time-triggered, activity-triggered, and negative assistance) and implement varied therapy practice to promote generalization processes. The algorithm was tuned by assessing the performance data obtained in 22 chronic stroke patients who underwent robotic rehabilitation, in which the difficulty level of the task was manually adjusted by the therapist. Thus, we could verify the patient's recovery strategies and implement task transition rules to match both the patient's and therapist's behavior. In addition, the algorithm was tested in a sample of five chronic stroke patients. The findings show good agreement with the therapist decisions so indicating that it could be useful for the implementation of training protocols allowing individualized and gradual treatment of upper limb disabilities in patients after stroke. The application of this algorithm during robot-assisted therapy should allow an easier management of the different motor tasks administered during training, thereby facilitating the therapist's activity in the treatment of different pathologic conditions of the neuromuscular system.

  5. A quality improvement project to optimize patient outcomes following the maze procedure.

    PubMed

    Henry, Linda L; Ad, Niv; Martin, Lisa; Hunt, Sharon; Crippen, Pamela

    2009-01-01

    Atrial fibrillation (AF) is the most common of all clinically sustained heart arrhythmias with associated morbidities (shortness of breath, fatigue, and stroke). The maze cardiac surgical procedure is a new treatment option available for patients who have medical refractory AF. The purpose of this study was to determine whether a written postdischarge protocol was necessary to improve outcomes following the maze procedure. Only 3 (27%) patients with AF were actively treated by an arrhythmia protocol for restoration of sinus rhythm. Unnecessary pharmacologic management for AF was found in 44 patients with normal sinus rhythm. A postdischarge protocol was developed that improved outcomes.

  6. Optimization of the extent of surgical treatment in patients with stage I in cervical cancer

    NASA Astrophysics Data System (ADS)

    Chernyshova, A. L.; Kolomiets, L. A.; Sinilkin, I. G.; Chernov, V. I.; Lyapunov, A. Yu.

    2016-08-01

    The study included 26 patients with FIGO stage Ia1-Ib1 cervical cancer who underwent fertility-sparing surgery (transabdominaltrachelectomy). To visualize sentinel lymph nodes, lymphoscintigraphy with injection of 99mTc-labelled nanocolloid was performed the day before surgery. Intraoperative identification of sentinel lymph nodes using hand-held gamma probe was carried out to determine the radioactive counts over the draining lymph node basin. The sentinel lymph node detection in cervical cancer patients contributes to the accurate clinical assessment of the pelvic lymph node status, precise staging of the disease and tailoring of surgical treatment to individual patient.

  7. [The surgical tactic optimization in local accumulations of liquid in patients with severe acute pancreatitis].

    PubMed

    Sheĭko, V D; Oganezian, A H

    2013-12-01

    The results of examination and treatment of 56 patients, having local accumulations of liquid (IAL) in severe acute pancreatitis (SAP), were analyzed. Transcutaneous puncture-draining sanation was performed in 47 (83.9%) patients; 7 (12.5%)--were treated without surgical intervention; in 2 (3.6%)--open operative interventions were done. SIRS was revealed in 31 (55.4%) patients, the signs of the LAL infectioning in accordance to the ultrasonographic investigation data, computeric tomography (CT) without SIRS was observed in 2 (93.6%), the compression features--in 45 (80.4%). Application of surgical tactics proposed in accordance to the data of the ultrasonographic monitoring of LAL, the signs of compression and the SIRS presence with determination of contents and infectioning have had permitted to improve the treatment results in patients, suffering SAP.

  8. [Optimization of staged treatment in patients with extensive combined face defects].

    PubMed

    Verbo, E V; Ordzhonikidze, M Z; Filippov, I K

    2015-01-01

    Free autotransplantation of revascularized flaps allow reconstructing soft tissue integrity with simultaneous bone defects elimination in patients with extensive combined face defects, but for eligible reconstruction of facial proportions one may need additional surgical procedures. The study included 161 patients who underwent free autotransplantation of revascularized flaps. Main pitfalls of the method are revealed and reviewed in the paper. When corresponding to deformity type free autotransplantation of revascularized flaps results in full functional and esthetic rehabilitation.

  9. The Effect of Physician Continuing Medical Education on Patient-Reported Outcomes for Identifying and Optimally Managing Obstructive Sleep Apnea

    PubMed Central

    Johnson, Sara S.; Castle, Patricia H.; Van Marter, Deborah; Roc, Anne; Neubauer, David; Auerbach, Sanford; DeAguiar, Emma

    2015-01-01

    Study Objective: To evaluate the effect of continuing medical education (CME) activities on patient reported outcomes with regard to (1) screening for excessive sleepiness (ES) and obstructive sleep apnea (OSA) and (2) appropriate referral and treatment. Methods: A total of 725 patients were recruited from 75 providers who either participated or did not participate in Transtheoretical Model (TTM)-based OSA CME activities. Patient reported outcomes from participating (n = 36) and non-participating providers (n = 39) were compared using generalized estimating equations examining random effects of provider as unit of assignment. Results: Patients' reports demonstrate that participating physicians were 1.7 times more likely to initiate discussion of sleep problems than non-participating physicians (t1,411 = 3.71, p = 0.05) and 2.25–2.86 times more likely to administer validated measures for OSA (Epworth Sleepiness Scale and STOP-BANG). Patient reports also indicated that participating clinicians (79.9%) were significantly more likely to recommend seeing a sleep specialist compared to non-participating clinicians (60.7%; t1,348 = 9.1, p < 0.01, OR = 2.6). Furthermore, while 89.4% of participating clinicians recommended a sleep study, only 73.2% of the non-participating physicians recommended one (t1,363 = 11.46, p < 0.001, OR = 3.1). Conclusions: Participation in TTM-based OSA CME activities was associated with improved patient reported outcomes compared to the non-participating clinicians. Citation: Johnson SS, Castle PH, Van Marter D, Roc A, Neubauer D, Auerbach S, DeAguiar E. The effect of physician continuing medical education on patient-reported outcomes for identifying and optimally managing obstructive sleep apnea. J Clin Sleep Med 2015;11(3):197–204. PMID:25845903

  10. SU-E-P-47: Evaluation of Improvement of Esophagus Sparing in SBRT Lung Patients with Biologically Based IMRT Optimization

    SciTech Connect

    Liang, X; Penagaricano, J; Paudel, N; Zhang, X; Morrill, S; Corry, P; Han, E; Hardee, M; Ratanatharathorn, V

    2015-06-15

    Purpose: To study the potential of improving esophageal sparing for stereotactic body radiation therapy (SBRT) lung cancer patients by using biological optimization (BO) compared to conventional dose-volume based optimization (DVO) in treatment planning. Methods: Three NSCLC patients (PTV (62.3cc, 65.1cc, and 125.1cc) adjacent to the heart) previously treated with SBRT were re-planned using Varian Eclipse TPS (V11) using DVO and BO. The prescription dose was 60 Gy in 5 fractions normalized to 95% of the PTV volume. Plans were evaluated by comparing esophageal maximum doses, PTV heterogeneity (HI= D5%/D95%), and Paddick’s conformity (CI) indices. Quality of the plans was assessed by clinically-used IMRT QA procedures. Results: By using BO, the maximum dose to the esophagus was decreased 1384 cGy (34.6%), 502 cGy (16.5%) and 532 cGy (16.2%) in patient 1, 2 and 3 respectively. The maximum doses to spinal cord and the doses to 1000 cc and 1500 cc of normal lung were comparable in both plans. The mean doses (Dmean-hrt) and doses to 15cc of the heart (V15-hrt) were comparable for patient 1 and 2. However for patient 3, with the largest PTV, Dmean-hrt and V15-hrt increased by 62.2 cGy (18.3%) and 549.9 cGy (24.9%) respectively for the BO plans. The mean target HI of BO plans (1.13) was inferior to the DVO plans (1.07). The same trend was also observed for mean CI in BO plans (0.77) versus DVO plans (0.83). The QA pass rates (3%, 3mm) were comparable for both plans. Conclusion: This study demonstrated that the use of biological models in treatment planning optimization can substantially improve esophageal sparing without compromising spinal cord and normal lung doses. However, for the large PTV case (125.1cc) we studied here, Dmean-hrt and V15-hrt increased substantially. The target HI and CI were inferior in the BO plans.

  11. Evaluation and development of an ED management model: an effort to optimize patient-centered care.

    PubMed

    McDonough, Kelly S; Pemberton, Meg

    2013-09-01

    In 2008, the emergency department at Mary Washington Hospital was in the midst of a crisis marked by increasing volumes, increasing numbers of left without being seen (LWBS) patients, falling patient satisfaction numbers and a staff dissatisfied with ED leadership. The existing ED model of charge nurses, a nurse manager, and an administrative director was not working. The single nurse manager could not effectively manage the over 200 staff members he/she was assigned. Based upon the findings from the employee satisfaction survey the inability of the nurse managers to properly manage such large numbers of employees was at the core of the issue. Through benchmarking with a similar healthcare system, an evidence based leadership model was identified, developed, and implemented. The model included the addition of six patient care managers with 24-hour coverage in the department, led to a reduced number of direct reports per manager, and an increased connection with employees. The goal was to engage employees in the effort to provide patient centered, quality care. Residual benefits of our change effort improved the patient satisfaction scores as evidenced by meeting organizational goals within 12 months; goal was exceeded in the following year. Additionally, the walk out rate was reduced 75% over 18 months. The correlation between satisfied employees, patient satisfaction, and reduced walk-outs cannot be ignored. Engaged employees positively impact service and quality.

  12. Optimal management of oropharyngeal and esophageal candidiasis in patients living with HIV infection

    PubMed Central

    Vazquez, Jose A

    2010-01-01

    Mucocutaneous candidiasis is frequently one of the first signs of human immunodeficiency virus (HIV) infection. Over 90% of patients with AIDS will develop oropharyngeal candidiasis (OPC) at some time during their illness. Although numerous antifungal agents are available, azoles, both topical (clotrimazole) and systemic (fluconazole, itraconazole, voriconazole, posaconazole) have replaced older topical antifungals (gentian violet and nystatin) in the management of oropharyngeal candidiasis in these patients. The systemic azoles, are generally safe and effective agents in HIV-infected patients with oropharyngeal candidiasis. A constant concern in these patients is relapse, which is dependent on the degree of immunosuppression commonly seen after topical therapy, rather than with systemic azole therapy. Candida esophagitis (CE) is also an important concern since it occurs in more than 10% of patients with AIDS and can lead to a decrease in oral intake and associated weight loss. Fluconazole has become the most widely used antifungal in the management of mucosal candidiasis. However, itraconazole and posaconazole have similar clinical response rates as fluconazole and are also effective alternative agents. In patients with fluconazole-refractory mucosal candidiasis, treatment options now include itraconazole solution, voriconazole, posaconazole, and the newer echinocandins (caspofungin, micafungin, and anidulafungin). PMID:22096388

  13. Optimizing identification and management of COPD patients – reviewing the role of the community pharmacist

    PubMed Central

    van Boven, Job F. M.; Maguire, Terence; Goyal, Pankaj; Altman, Pablo

    2016-01-01

    The aim of this paper was to propose key steps for community pharmacist integration into a patient care pathway for chronic obstructive pulmonary disease (COPD) management. A literature search was conducted to identify publications focusing on the role of the community pharmacist in identification and management of COPD. The literature search highlighted evidence supporting an important role for pharmacists at each of the four key steps in the patient care pathway for COPD management. Step 1 (primary prevention): pharmacists are ideally placed to provide information on disease awareness and risk prevention campaigns, and to encourage lifestyle interventions, including smoking cessation. Step 2 (early detection/case finding): pharmacists are often the first point of contact between the patient and the healthcare system and can therefore play an important role in the early identification of patients with COPD. Step 3 (management and ongoing support): pharmacists can assist patients by providing advice and education on dosage, inhaler technique, treatment expectations and the importance of adherence, and by supporting self‐management, including recognition and treatment of COPD exacerbations. Step 4 (review and follow‐up): pharmacists can play an important role in monitoring adherence and ongoing inhaler technique in patients with COPD. In summary, pharmacists are ideally positioned to play a vital role in all key stages of an integrated COPD patient care pathway from early disease detection to the support of management plans, including advice and counselling regarding medications, inhaler technique and treatment adherence. Areas requiring additional consideration include pharmacist training, increasing awareness of the pharmacist role, administration and reimbursement, and increasing physician–pharmacist collaboration. PMID:27510273

  14. Population pharmacokinetics of ceftazidime in cystic fibrosis patients analyzed by using a nonparametric algorithm and optimal sampling strategy.

    PubMed Central

    Vinks, A A; Mouton, J W; Touw, D J; Heijerman, H G; Danhof, M; Bakker, W

    1996-01-01

    Postinfusion data obtained from 17 patients with cystic fibrosis participating in two clinical trials were used to develop population models for ceftazidime pharmacokinetics during continuous infusion. Determinant (D)-optimal sampling strategy (OSS) was used to evaluate the benefits of merging four maximally informative sampling times with population modeling. Full and sparse D-optimal sampling data sets were analyzed with the nonparametric expectation maximization (NPEM) algorithm and compared with the model obtained by the traditional standard two-stage approach. Individual pharmacokinetic parameter estimates were calculated by weighted nonlinear least-squares regression and by maximum a posteriori probability Bayesian estimator. Individual parameter estimates obtained with four D-optimally timed serum samples (OSS4) showed excellent correlation with parameter estimates obtained by using full data sets. The parameters of interest, clearance and volume of distribution, showed excellent agreement (R2 = 0.89 and R2 = 0.86). The ceftazidime population models were described as two-compartment kslope models, relating elimination constants to renal function. The NPEM-OSS4 model was described by the equations kel = 0.06516+ (0.00708.CLCR) and V1 = 0.1773 +/- 0.0406 liter/kg where CLCR is creatinine clearance in milliliters per minute per 1.73 m2, V1 is the volume of distribution of the central compartment, and kel is the elimination rate constant. Predictive performance evaluation for 31 patients with data which were not part of the model data sets showed that the NPEM-ALL model performed best, with significantly better precision than that of the standard two-stage model (P < 0.001). Predictions with the NPEM-OSS4 model were as precise as those with the NPEM-ALL model but slightly biased (-2.2 mg/liter; P < 0.01). D-optimal monitoring strategies coupled with population modeling results in useful and cost-effective population models and will be of advantage in clinical

  15. The Effect of Dispositional Optimism on Health Outcomes in Patient with Heart Failure

    DTIC Science & Technology

    2013-03-08

    0.57- 0.90) for non-fatal MI, 0.70 (95%CI: 0.55-0.90) for angina pectoris , and 0.75 (95%CI: 0.62-0.91) for total incident CHD after adjusting for age...Non-fatal MI, angina pectoris , incident CHD Non-fatal MI=0.72 (95%CI: 0.57-0.90), angina = 0.70 (95%CI: 0.55-0.90), incident CHD= 0.75 (95%CI: 0.62...into fatal CHD and nonfatal MI from verified angina showed a similar relationship direction, although high and moderate levels of optimism were only

  16. The impacts of dispositional optimism and psychological resilience on the subjective well-being of burn patients: a structural equation modelling analysis.

    PubMed

    He, Fei; Cao, Rong; Feng, Ziqi; Guan, Hao; Peng, Jiaxi

    2013-01-01

    Burn wounds are severely stressful events that can have a significant impact on the mental health of patients. However, the impact of burns on individuals with different personality traits can be different. The present study aimed to investigate the impact of dispositional optimism on the subjective well-being of burn patients, and mainly focused on the confirmation of the mediator role of psychological resilience. 410 burn patients from five general hospitals in Xi'an accomplished the revised Life Orientation Test, Connor-Davidson Resilience Scale, and Subjective Well-Being (SWB) scale. The results revealed that both dispositional optimism and psychological resilience were significantly correlated with SWB. Structural equation modelling indicated that psychological resilience partially mediated the relationship between dispositional optimism and SWB. The current findings extended prior reports and shed some light on how dispositional optimism influenced SWB. Limitations of the study were considered and suggestions for future studies were also discussed.

  17. Tacrolimus in preventing transplant rejection in Chinese patientsoptimizing use

    PubMed Central

    Li, Chuan-Jiang; Li, Liang

    2015-01-01

    Tacrolimus is a product of fermentation of Streptomyces, and belongs to the family of calcineurin inhibitors. It is a widely used immunosuppressive drug for preventing solid-organ transplant rejection. Compared to cyclosporine, tacrolimus has greater immunosuppressive potency and a lower incidence of side effects. It has been accepted as first-line treatment after liver and kidney transplantation. Tacrolimus has specific features in Chinese transplant patients; its in vivo pharmacokinetics, treatment regimen, dose and administration, and adverse-effect profile are influenced by multiple factors, such as genetics and the spectrum of primary diseases in the Chinese population. We reviewed the clinical experience of tacrolimus use in Chinese liver- and kidney-transplant patients, including the pharmacology of tacrolimus, the immunosuppressive effects of tacrolimus versus cyclosporine, effects of different factors on tacrolimus metabolism on Chinese patients, personalized medicine, clinical safety profile, and patient satisfaction and adherence. This article provides guidance for the rational and efficient use of tacrolimus in Chinese organ-transplant patients. PMID:25609922

  18. Lean Flow: Optimizing Cardiopulmonary Bypass Equipment and Flow for Obese Patients-A Technique Article.

    PubMed

    Blessing, Joshua M; Riley, Jeffrey B

    2017-03-01

    The goal of this chart review was to investigate the use of down-sized cardiopulmonary bypass (CPB) circuits for obese patients. The effects of transitioning from larger to smaller oxygenators, reservoirs, and arteriovenous tubing loops were evaluated through a retrospective review of 2,816 adult non-congenital procedure perfusion records. This technique report and case series is a continuation of our original prescriptive CPB circuit quality improvement project. An algorithm was derived to adjust body surface area (BSA) to lower body mass index (BMI) to provide down-sized extracorporeal circuit components capable of meeting the metabolic needs of the patient. As a result of using smaller circuits, decreased priming volumes led to significantly increased hemoglobin (HB) nadirs (p < .05) leading to significant decreases in homologous donor blood product exposures (p < .05). Patients with large BSAs were supported safely with smaller circuits by using lean body mass (LBM)-adjusted BSA and target blood flow algorithm. Based on this case series, large BMI patients may be safely supported with smaller circuits selected based on BSAs adjusted more toward LBM. Use of smaller circuits in high BMI patients led to higher HB nadirs and less donor blood components during the surgical procedure. Renal function and hospital stay were not affected by this approach.

  19. Oral targeted therapies: managing drug interactions, enhancing adherence and optimizing medication safety in lymphoma patients.

    PubMed

    Liewer, Susanne; Huddleston, Ashley N

    2015-04-01

    The advent of newer, targeted oral chemotherapy medications such as small molecule kinase inhibitors, ibrutinib and idelalisib, has created additional options for the treatment of lymphoma. The targeted nature of these agents offers many patient-identified advantages over older, intravenously administered chemotherapy regimens such as ease of self-administration and an increased sense of independence. However, newer oral agents also present unique challenges not previously experienced with older therapies that may affect safety, efficacy and patient adherence. In this article, we review oral agents for the treatment of lymphoma, how to evaluate and manage drug-drug and drug-food interactions with concomitant oral medications, and issues with patient adherence as well as methods to determine adherence for oral chemotherapy.

  20. Optimal management of elderly cancer patients: usefulness of the Comprehensive Geriatric Assessment

    PubMed Central

    Caillet, Philippe; Laurent, Marie; Bastuji-Garin, Sylvie; Liuu, Evelyne; Culine, Stephane; Lagrange, Jean-Leon; Canoui-Poitrine, Florence; Paillaud, Elena

    2014-01-01

    Background Cancer is common in older patients, who raise specific treatment challenges due to aging-related, organ-specific physiologic changes and the presence in most cases of comorbidities capable of affecting treatment tolerance and outcomes. Identifying comorbid conditions and physiologic changes due to aging allows oncologists to better assess the risk/benefit ratio and to adjust the treatment accordingly. Conducting a Comprehensive Geriatric Assessment (CGA) is one approach developed for this purpose. We reviewed the evidence on the usefulness of CGA for assessing health problems and predicting cancer treatment outcomes, functional decline, morbidity, and mortality in older patients with solid malignancies. Methods We searched Medline for articles published in English between January 1, 2000 and April 14, 2014, and reporting prospective observational or interventional studies of CGA feasibility or effectiveness in patients aged ≥65 years with solid malignancies. We identified studies with at least 100 patients, a multivariate analysis, and assessments of at least five of the following CGA domains: nutrition, cognition, mood, functional status, mobility and falls, polypharmacy, comorbidities, and social environment. Results All types of CGA identified a large number of unrecognized health problems capable of interfering with cancer treatment. CGA results influenced 21%–49% of treatment decisions. All CGA domains were associated with chemotoxicity or survival in at least one study. The abnormalities that most often predicted mortality and chemotoxicity were functional impairment, malnutrition, and comorbidities. Conclusion The CGA uncovers numerous health problems in elderly patients with cancer and can affect treatment decisions. Functional impairment, malnutrition, and comorbidities are independently associated with chemotoxicity and/or survival. Only three randomized published studies evaluated the effectiveness of CGA-linked interventions. Further

  1. Optimal intravenous infusion to decrease the haematocrit level in patient of DHF infection

    NASA Astrophysics Data System (ADS)

    Handayani, D.; Nuraini, N.; Saragih, R.; Wijaya, K. P.; Naiborhu, J.

    2014-02-01

    The optimal control of infusion model for Dengue Hemorrhagic Fever (DHF) infection is formulated here. The infusion model will be presented in form of haematocrit level. The input control aim to normalize the haematocrit level and is expressed as infusion volume on mL/day. The stability near the equilibrium points will be analyzed. Numerical simulation shows the dynamic of each infection compartments which gives a description of within-host dynamic of dengue virus. These results show particularly that infected compartments tend to be vanished in ±15days after the onset of the virus. In fact, without any control added, the haematocrit level will decrease but not up to the normal level. Therefore the effective haematocrit normalization should be done with the treatment control. Control treatment for a fixed time using a control input can bring haematocrit level to normal range 42-47%. The optimal control in this paper is divided into three cases, i.e. fixed end point, constrained input, and tracking haematocrit state. Each case shows different infection condition in human body. However, all cases require that the haematocrit level to be in normal range in fixed final time.

  2. Optimal timing of doses of chenic acid in patients with gall stones.

    PubMed Central

    Maudgal, D P; Bird, R; Northfield, T C

    1979-01-01

    Sixteen patients with gall stones were treated with chenic acid (14-16 mg/kg/day) given at three different times in random order for one month each. Before treatment the mean (+/- SE of mean) cholesterol saturation index (SI) of fasting gall-bladder bile was 1.28 +/- 0.06. During bedtime administration of chenic acid the mean SI fell to 0.78 +/- 0.04, which was significantly lower than that obtained with administration in the morning (0.92 +/- 0.05) or with three divided doses at mealtimes (0.92 +/- 0.04). The bile remained supersaturated in seven patients when they received a single morning dose, in five patients when they received mealtime doses, but in only one patient when a single bedtime dose was given. There was no significant difference in side effects between the three different dose timings, or in the proportion of bile acids present in the bile as chenic acid. This enhanced effect obtained with bedtime administration may be due to the enterohepatic circulation of bile acids being maintained during overnight fasting. PMID:435882

  3. Loco-regional therapies for patients with hepatocellular carcinoma awaiting liver transplantation: Selecting an optimal therapy.

    PubMed

    Byrne, Thomas J; Rakela, Jorge

    2016-06-24

    Hepatocellular carcinoma (HCC) is a common, increasingly prevalent malignancy. For all but the smallest lesions, surgical removal of cancer via resection or liver transplantation (LT) is considered the most feasible pathway to cure. Resection - even with favorable survival - is associated with a fairly high rate of recurrence, perhaps since most HCCs occur in the setting of cirrhosis. LT offers the advantage of removing not only the cancer but the diseased liver from which the cancer has arisen, and LT outperforms resection for survival with selected patients. Since time waiting for LT is time during which HCC can progress, loco-regional therapy (LRT) is widely employed by transplant centers. The purpose of LRT is either to bridge patients to LT by preventing progression and waitlist dropout, or to downstage patients who slightly exceed standard eligibility criteria initially but can fall within it after treatment. Transarterial chemoembolization and radiofrequency ablation have been the most widely utilized LRTs to date, with favorable efficacy and safety as a bridge to LT (and for the former, as a downstaging modality). The list of potentially effective LRTs has expanded in recent years, and includes transarterial chemoembolization with drug-eluting beads, radioembolization and novel forms of extracorporal therapy. Herein we appraise the various LRT modalities for HCC, and their potential roles in specific clinical scenarios in patients awaiting LT.

  4. [Optimal rehabilitation of patients with coronary heart disease in outpatient setting].

    PubMed

    Korzhenkov, N P; Kuzichkina, S F; Shcherbakova, N A; Kukhaleishvili, N R; Iarlykov, I I

    2012-01-01

    The problem of invalid rehabilitation in Russia is an important state task and dictates necessity of design of an effective state program of primary prevention of cardiovascular diseases. Common global practice of medico-social model is based on complex detailed medico-social aid. Rehabilitation of postmyocardial infarction patients consists of three phases (stages): hospital posthospital (readaptation) and postreconvalescent (supportive). The program includes physical, psychological and pharmacological rehabilitation. Departments of readaptation and medico-social rehabilitation provide effective conduction of all kinds of rehabilitation. The Moscow North-East Regional Administration has a rich experience in organization of departments of readaptation and medico-social rehabilitation. The departments practice an individual approach to the patients and work in a close contact with bureaus of medico-social commission of experts. Management of patients by cardiologist, rehabilitation specialist and outpatient clinic's physicians provides uninterrupted staged rehabilitation, timely correction of pharmacotherapy, early patient referral to invasive investigations and treatment of coronary heart disease. A course of rehabilitative measures lasts 2 months. Setting up departments of medico-social rehabilitation in outpatient clinics provides more effective use of money assigned by the state for social support of invalids.

  5. Optimizing information technology to improve sexual health-care delivery: public and patient preferences.

    PubMed

    Ross, J D C; Copas, A; Stephenson, J; Fellows, L; Gilleran, G

    2007-07-01

    Information and communication technology (ICT) has the potential to improve the quality of care and efficiency in sexual health clinics, but its introduction requires input not only from health-care professionals and ICT specialists but also from service users and potential future users. In this study, views on ICT in relation to the delivery of sexual health services were assessed using a structured interview in two groups - a community sample of young people and a clinic sample of existing patients. In all, 542 community interviewees and 202 clinic patients participated. About 75% of respondents had access to the Internet and overall 60% reported that the self-collection of a sexual history on an electronic form was acceptable. Black Caribbean individuals had significantly less access to the Internet and a lower acceptance of electronic data collection. For booking an appointment, the majority of patients reported the telephone (community sample 93%, clinic sample 96%) or attending in person (community sample 77%, clinic sample 54%) to be acceptable, with a smaller proportion choosing email (community sample 10%, clinic sample 27%) or the Internet (community sample 7%, clinic sample 11%). Electronic booking was significantly less acceptable to Black Caribbean respondents. Although new technologies offer the opportunity to improve the quality of sexual health services, patient preferences and differences between groups in access to technology also need to be considered when services are reconfigured.

  6. Loco-regional therapies for patients with hepatocellular carcinoma awaiting liver transplantation: Selecting an optimal therapy

    PubMed Central

    Byrne, Thomas J; Rakela, Jorge

    2016-01-01

    Hepatocellular carcinoma (HCC) is a common, increasingly prevalent malignancy. For all but the smallest lesions, surgical removal of cancer via resection or liver transplantation (LT) is considered the most feasible pathway to cure. Resection - even with favorable survival - is associated with a fairly high rate of recurrence, perhaps since most HCCs occur in the setting of cirrhosis. LT offers the advantage of removing not only the cancer but the diseased liver from which the cancer has arisen, and LT outperforms resection for survival with selected patients. Since time waiting for LT is time during which HCC can progress, loco-regional therapy (LRT) is widely employed by transplant centers. The purpose of LRT is either to bridge patients to LT by preventing progression and waitlist dropout, or to downstage patients who slightly exceed standard eligibility criteria initially but can fall within it after treatment. Transarterial chemoembolization and radiofrequency ablation have been the most widely utilized LRTs to date, with favorable efficacy and safety as a bridge to LT (and for the former, as a downstaging modality). The list of potentially effective LRTs has expanded in recent years, and includes transarterial chemoembolization with drug-eluting beads, radioembolization and novel forms of extracorporal therapy. Herein we appraise the various LRT modalities for HCC, and their potential roles in specific clinical scenarios in patients awaiting LT. PMID:27358775

  7. Patients’ Perceived Control, Therapist’s Presence/Absence, and the Optimization of Biofeedback Learning.

    DTIC Science & Technology

    1985-01-01

    Interpersonal Effects on Psychophysiology .. .. .. ... ... 30 Summary .. .. ... .... ... ... ... .... ... ... 36 Hypothesis...helpfulness, ease in talking and being with him, and warmth as perceived by the patient and measured by questions 13 - 18 of Questionnaire A (Appendix C...therapist present. Specific literature on perceived . control, biofeedback, degree of therapist involvement and interpersonal effects on physiology are

  8. Optimal management of cancer treatment-induced bone loss: considerations for elderly patients.

    PubMed

    Tipples, Karen; Robinson, Anne

    2011-11-01

    Hormone manipulation, commonly used in breast and prostate cancer, can result in significant bone loss. In multiple myeloma (MM), corticosteroids play an important role in therapy but increase the risk of fracture over that expected for any given bone mineral density. These adverse effects on the skeletal system are particularly relevant in the elderly population, in whom osteoporosis can significantly affect not only quality of life but also survival. The associated health and social care costs are becoming increasingly important. Screening with dual energy x-ray absorptiometry (DXA) scans and lifestyle advice on smoking, alcohol and dietary intake are essential parts of the management of patients with cancer treatment-induced bone loss. The value of exercise also cannot be underestimated. A careful drug review should be carried out to eliminate agents that may potentially exacerbate bone toxicity. Therapies to address bone toxicities include bisphosphonates, which have been shown to play an increasingly important role in preventing declines in bone health. The issues of compliance when oral agents are used should not be underestimated. Renal toxicity and osteonecrosis of the jaw are relevant toxicities, especially in the elderly. Cardiac toxicity has not been proven, but there is evidence to suggest that the suppression of bone turnover seen with some, although not all, bisphosphonates is not reversed following cessation of treatment. The implications of this finding need to be borne in mind when treating elderly patients. The possibility of atypical fractures in patients taking bisphosphonates also needs to be given consideration, although this remains a rare complication. Recently, the receptor activator of nuclear factor-κB ligand (RANKL) ligand antibody denosumab has been shown to be of value in fracture prevention, and its subcutaneous route of administration offers a potential advantage. Oncologists should also remember that tamoxifen, which has little

  9. Optimizing body contour in massive weight loss patients: the modified vertical abdominoplasty.

    PubMed

    Costa, Luiz Fernando da; Landecker, Alan; Manta, Anísio Marinho

    2004-12-01

    In morbid obesity, contour deformities of the abdomen are common after bariatric surgery and radical weight loss. Traditional abdominoplasty techniques often fail to maximally improve body contour in these cases because adjacent sites such as the hip rolls and flanks are not treated, leaving the patient with large lateral tissue redundancies and dog-ears. In an attempt to solve these challenging problems, the authors present the modified vertical abdominoplasty technique, a single-stage procedure that involves a combined vertical and transverse approach in which an "en bloc" resection of the redundant tissues is performed without undermining, drainage, or reinforcement of the abdominal wall. The latter is only carried out when diastasis and/or hernias are present, and Marlex mesh may be utilized when indicated. In patients with simultaneous large umbilical hernias and/or excessively long stalks, neoumbilicoplasty is recommended. A significant improvement of abdominal contour was obtained in the vast majority of patients because the resection design offers simultaneous treatment of both vertical and transverse tissue redundancies in the abdomen and neighboring regions, with more harmonic results when compared with purely vertical or transverse approaches. The modified vertical abdominoplasty technique is an easy, fast, and reliable alternative for treating these patients, with less intraoperative bleeding, reduced overall cost, and low morbidity rates. In selected cases, the technique is capable of offering excellent results in terms of contouring and maximizes the overall outcome of treatment protocols for these patients, who can then be integrated into normal life with heightened self-esteem, happiness, and productivity.

  10. Treating mineral metabolism disorders in patients undergoing long hemodialysis: a search for an optimal strategy.

    PubMed

    Jean, Guillaume; Vanel, Thierry; Terrat, Jean-Claude; Hurot, Jean-Marc; Lorriaux, Christie; Mayor, Brice; Chazot, Charles

    2009-10-01

    In hemodialysis (HD) patients, mineral metabolism (MM) disorders have been associated with an increased mortality rate. We report the evolution of MM parameters in a stable HD population undergoing long hemodialysis by performing an annual cross-sectional analysis for every year from 1994 to 2008. The therapeutic strategy has changed: the dialysate calcium concentration has decreased from a mean of 1.7 +/- 0.1 to 1.5 +/- 0.07 mmol/L and has been adapted to parathyroid hormone serum levels (from 1 to 1.75 mmol/L). The use of calcium-based and aluminum-based phosphate binders has decreased and they have been replaced by sevelamer; alfacalcidol has partly been replaced by native vitamin D. The percentage of patients with a parathyroid hormone serum level between 150 and 300 pg/mL has increased from 9% to 67% (P<0.001); the percentage of patients with phosphataemia between 1.15 and 1.78 mmol/L has increased from 39% to 84% (P<0.001). The percentage of those with albumin-corrected calcemia between 2.1 and 2.37 mmol/L has increased from 29% to 61% (P<0.001), and that of patients with a calcium-phosphorous product (Ca x P) level >4.4 mmol/L decreased from 8.8% to 2% (P=0.02). Although patients undergo long and intensive HD treatment, MM disorders are common. However, an appropriate strategy, mostly consisting of native vitamin D supplementation, progressive replacement of calcium-based phosphate binders with non-calcium-based ones, and individualization of dialysis session duration and dialysate calcium concentration, would result in a drastic improvement.

  11. Drug Dosage in Patients with Renal Failure Optimized by Immediate Concurrent Feedback

    PubMed Central

    Falconnier, Ariane D; Haefeli, Walter E; Schoenenberger, Ronald A; Surber, Christian; Martin-Facklam, Meret

    2001-01-01

    OBJECTIVE To examine the impact of immediate concurrent feedback on dose adjustment in patients with renal failure. DESIGN Prospective 12-month study in patients with various degrees of renal failure, with comparison to a retrospective control group. SETTING A 39-bed unit of a university hospital providing primary and tertiary care. PATIENTS Patients with renal failure (estimated creatinine clearance ≤50 mL/min) receiving at least 1 pharmacologically active drug. INTERVENTIONS Education of physicians and immediate concurrent feedback on the ward giving estimated creatinine clearance and dose recommendations for renally eliminated drugs adjusted to individual renal function. MEASUREMENTS AND MAIN RESULTS The percentage of dosage regimens adjusted to renal function and cost assessment of drug therapy were calculated. Overall, 17% of the patients had at least 1 estimated creatinine clearance ≤50 mL/min. In the intervention group, the dose of 81% of renally eliminated drugs was adjusted to renal function, compared with 33% in the control group ( P < .001). The mean difference in cost between standard and adjusted dose of renally eliminated drugs in the intervention and control groups was 5.3 ± 12.3 and 0.75 ± 2.8 Swiss francs (approximately US$3.5 and US$0.5), respectively ( P < .001), accounting for 16.5% and 2.8%, respectively, of daily medication costs of all drugs. CONCLUSIONS The proportion of doses of renally eliminated drugs adjusted to renal function can be substantially increased by immediate concurrent feedback. This saves drug costs and has the potential to prevent adverse drug reactions. PMID:11422633

  12. [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.

  13. A SMART design to optimize treatment strategies for patient and family caregiver outcomes.

    PubMed

    Song, Mi-Kyung; DeVito Dabbs, Annette; Ward, Sandra E

    2016-01-01

    Sequential multiple randomization trial (SMART) designs are experimental designs used to identify treatment strategies that maximize targeted health outcomes. SMART designs are receiving greater attention in nursing and other health disciplines to develop multicomponent interventions that are tailored to the patient's (or family caregiver's) needs and preferences. A SMART design resembles a traditional randomized controlled trial (RCT) design in that it scientifically examines intervention effects with randomization. However, the two designs address very different research inquiries. In this article, we compare traditional RCT designs and SMART designs, describe the adaptive treatment framework that underlies SMART designs and key features of SMART designs, and illustrate the application of a SMART design to develop an adaptive palliative care treatment to improve patient and caregiver outcomes.

  14. Ulipristal Acetate in Myomectomy Optimization in an Infertile Patient with Giant Myomas

    PubMed Central

    Borrás, María Dolores; Rubio, Miriam; Abril, Nuria

    2016-01-01

    The use of ulipristal acetate (UPA) has been recently introduced in the treatment of uterine leiomyomas. This drug has proven useful to control menometrorrhagia and to reduce myoma size. In the case presented here, we show the benefits of UPA treatment in facilitating surgical removal of giant myomas in an infertile patient. In addition to myoma reduction and a better control of preoperative bleeding, the treatment with UPA reduced the duration and complexity of the surgery, as well as the area of uterine wall involved and the resulting scar. No side effects were observed and the patient became pregnant 6 months after the surgery and had a normal pregnancy and delivery. This case report shows the beneficial effects of UPA in the preoperative treatment of myomas which affect uterus function. PMID:27594886

  15. [Potential role of patient-derived tumor xenografts (PDTXs) in the selection of optimal therapeutic strategy].

    PubMed

    Tóvári, József

    2015-12-01

    The rapid selection of the efficient anticancer therapy may decrease the unwanted burden to patients and has financial consequences. Tumor models including xenografts in mice were used previously mostly in the development of new anticancer drugs. Nowadays xenografts from direct patient-derived tumor tissues (PDTT) in immune deficient mice yield better models than experimental tumors originating from cell cultures. The new method enables researchers to observe heterogeneous tumor cells with their surrounding tissue elements and matrices representing the clinical situation in humans much better. The cells in PDTT tumors are alive and functionally active through several generations after serial transplantation. Therefore using these models we may investigate tumor response to different therapies, the selection of resistant cell populations and the formation of metastasis predicting the outcomes in the personalized therapy.

  16. Virological and serological tools to optimize the management of patients with chronic hepatitis B.

    PubMed

    Martinot-Peignoux, Michelle; Marcellin, Patrick

    2016-01-01

    Molecular biology techniques are routinely used to diagnose and monitor treatment in patients with chronic hepatitis B (CHB). These tools can detect and quantify viral genomes and analyse their sequences to determine genotype. The increasing use of these tools to monitor patients has greatly improved the management of CHB infection by maximizing the potential for individualized treatment. HBV genotyping has become increasingly important and provides additional information to predict a response to therapy. More sensitive methods to determine HBV DNA levels are now available and the units of measurements have been standardized. HBsAg levels in serum have been shown to reflect active intrahepatic covalently closed circular DNA (cccDNA) and to have additional value in treatment decisions, especially as an on-treatment marker.

  17. SU-E-T-109: An Investigation of Including Variable Relative Biological Effectiveness in Intensity Modulated Proton Therapy Planning Optimization for Head and Neck Cancer Patients

    SciTech Connect

    Cao, W; Zaghian, M; Lim, G; Randeniya, K; Mohan, R; Titt, U

    2015-06-15

    Purpose: The current practice of considering the relative biological effectiveness (RBE) of protons in intensity modulated proton therapy (IMPT) planning is to use a generic RBE value of 1.1. However, RBE is indeed a variable depending on the dose per fraction, the linear energy transfer, tissue parameters, etc. In this study, we investigate the impact of using variable RBE based optimization (vRBE-OPT) on IMPT dose distributions compared by conventional fixed RBE based optimization (fRBE-OPT). Methods: Proton plans of three head and neck cancer patients were included for our study. In order to calculate variable RBE, tissue specific parameters were obtained from the literature and dose averaged LET values were calculated by Monte Carlo simulations. Biological effects were calculated using the linear quadratic model and they were utilized in the variable RBE based optimization. We used a Polak-Ribiere conjugate gradient algorithm to solve the model. In fixed RBE based optimization, we used conventional physical dose optimization to optimize doses weighted by 1.1. IMPT plans for each patient were optimized by both methods (vRBE-OPT and fRBE-OPT). Both variable and fixed RBE weighted dose distributions were calculated for both methods and compared by dosimetric measures. Results: The variable RBE weighted dose distributions were more homogenous within the targets, compared with the fixed RBE weighted dose distributions for the plans created by vRBE-OPT. We observed that there were noticeable deviations between variable and fixed RBE weighted dose distributions if the plan were optimized by fRBE-OPT. For organs at risk sparing, dose distributions from both methods were comparable. Conclusion: Biological dose based optimization rather than conventional physical dose based optimization in IMPT planning may bring benefit in improved tumor control when evaluating biologically equivalent dose, without sacrificing OAR sparing, for head and neck cancer patients. The research

  18. A survey of patient motion in disorders of consciousness and optimization of its retrospective correction.

    PubMed

    Hoffmann, Malte; Carpenter, T Adrian; Williams, Guy B; Sawiak, Stephen J

    2015-04-01

    Functional magnetic resonance imaging (fMRI) can be seriously impaired by patient motion. The purpose of this study was to characterize the typical motion in a clinical population of patients in disorders of consciousness and compare the performance of retrospective correction with rigid-body realignment as implemented in widely used software packages. 63 subjects were scanned with an fMRI visual checkerboard paradigm using a 3T scanner. Time series were corrected for motion, and the resulting transformations were used to calculate a motion score. SPM, FSL, AFNI and AIR were evaluated by comparing the motion obtained by re-running the tool on the corrected data. A publicly available sample fMRI dataset was modified with the motion detected in each patient with each tool. The performance of each tool was measured by comparing the number of supra-threshold voxels after standard fMRI analysis, both in the sample dataset and in simulated fMRI data. We assessed the effect of user-changeable parameters on motion correction in SPM. We found the equivalent motion in the patient population to be 1.4mm on average. There was no significant difference in performance between SPM, FSL and AFNI. AIR was considerably worse, and took more time to run. We found that in SPM the quality factor and interpolation method have no effect on the cluster size, while higher separation and smoothing reduce it. We showed that the main packages SPM, FSL and AFNI are equally suitable for retrospective motion correction of fMRI time series. We show that typically only 80% of activated voxels are recovered by retrospective motion correction.

  19. Tuning of patient-specific deformable models using an adaptive evolutionary optimization strategy.

    PubMed

    Vidal, Franck P; Villard, Pierre-Frédéric; Lutton, Evelyne

    2012-10-01

    We present and analyze the behavior of an evolutionary algorithm designed to estimate the parameters of a complex organ behavior model. The model is adaptable to account for patient's specificities. The aim is to finely tune the model to be accurately adapted to various real patient datasets. It can then be embedded, for example, in high fidelity simulations of the human physiology. We present here an application focused on respiration modeling. The algorithm is automatic and adaptive. A compound fitness function has been designed to take into account for various quantities that have to be minimized. The algorithm efficiency is experimentally analyzed on several real test cases: 1) three patient datasets have been acquired with the "breath hold" protocol, and 2) two datasets corresponds to 4-D CT scans. Its performance is compared with two traditional methods (downhill simplex and conjugate gradient descent): a random search and a basic real-valued genetic algorithm. The results show that our evolutionary scheme provides more significantly stable and accurate results.

  20. Patient safety is not enough: targeting quality improvements to optimize the health of the population.

    PubMed

    Woolf, Steven H

    2004-01-06

    Ensuring patient safety is essential for better health care, but preoccupation with niches of medicine, such as patient safety, can inadvertently compromise outcomes if it distracts from other problems that pose a greater threat to health. The greatest benefit for the population comes from a comprehensive view of population needs and making improvements in proportion with their potential effect on public health; anything less subjects an excess of people to morbidity and death. Patient safety, in context, is a subset of health problems affecting Americans. Safety is a subcategory of medical errors, which also includes mistakes in health promotion and chronic disease management that cost lives but do not affect "safety." These errors are a subset of lapses in quality, which result not only from errors but also from systemic problems, such as lack of access, inequity, and flawed system designs. Lapses in quality are a subset of deficient caring, which encompasses gaps in therapeutics, respect, and compassion that are undetected by normative quality indicators. These larger problems arguably cost hundreds of thousands more lives than do lapses in safety, and the system redesigns to correct them should receive proportionately greater emphasis. Ensuring such rational prioritization requires policy and medical leaders to eschew parochialism and take a global perspective in gauging health problems. The public's well-being requires policymakers to view the system as a whole and consider the potential effect on overall population health when prioritizing care improvements and system redesigns.

  1. Graded Achievement, Tested Achievement, and Validity

    ERIC Educational Resources Information Center

    Brookhart, Susan M.

    2015-01-01

    Twenty-eight studies of grades, over a century, were reviewed using the argument-based approach to validity suggested by Kane as a theoretical framework. The review draws conclusions about the meaning of graded achievement, its relation to tested achievement, and changes in the construct of graded achievement over time. "Graded…

  2. Analytical and Clinical Validity Study of FirstStepDx PLUS: A Chromosomal Microarray Optimized for Patients with Neurodevelopmental Conditions

    PubMed Central

    Hensel, Charles; Vanzo, Rena; Martin, Megan; Dixon, Sean; Lambert, Christophe; Levy, Brynn; Nelson, Lesa; Peiffer, Andy; Ho, Karen S.; Rushton, Patricia; Serrano, Moises; South, Sarah; Ward, Kenneth; Wassman, Edward

    2017-01-01

    Introduction: Chromosomal microarray analysis (CMA) is recognized as the first-tier test in the genetic evaluation of children with developmental delays, intellectual disabilities, congenital anomalies and autism spectrum disorders of unknown etiology. Array Design: To optimize detection of clinically relevant copy number variants associated with these conditions, we designed a whole-genome microarray, FirstStepDx PLUS (FSDX). A set of 88,435 custom probes was added to the Affymetrix CytoScanHD platform targeting genomic regions strongly associated with these conditions. This combination of 2,784,985 total probes results in the highest probe coverage and clinical yield for these disorders. Results and Discussion: Clinical testing of this patient population is validated on DNA from either non-invasive buccal swabs or traditional blood samples. In this report we provide data demonstrating the analytic and clinical validity of FSDX and provide an overview of results from the first 7,570 consecutive patients tested clinically. We further demonstrate that buccal sampling is an effective method of obtaining DNA samples, which may provide improved results compared to traditional blood sampling for patients with neurodevelopmental disorders who exhibit somatic mosaicism. PMID:28357155

  3. Canagliflozin use in patients with renal impairment-Utility of quantitative clinical pharmacology analyses in dose optimization.

    PubMed

    Khurana, Manoj; Vaidyanathan, Jayabharathi; Marathe, Anshu; Mehrotra, Nitin; Sahajwalla, Chandrahas G; Zineh, Issam; Jain, Lokesh

    2015-06-01

    Canagliflozin (INVOKANA™) is approved as an adjunct to diet and exercise to improve glycemic control in adults with type 2 diabetes mellitus (T2DM). Canagliflozin inhibits renal sodium-glucose co-transporter 2 (SGLT2), thereby, reducing reabsorption of filtered glucose and increasing urinary glucose excretion. Given the mechanism of action of SGLT2 inhibitors, we assessed the interplay between renal function, efficacy (HbA1c reduction), and safety (renal adverse reactions). The focus of this article is to highlight the FDA's quantitative clinical pharmacology analyses that were conducted to support the regulatory decision on dosing in patients with renal impairment (RI). The metrics for assessment of efficacy for T2DM drugs is standard; however, there is no standard method for evaluation of renal effects for diabetes drugs. Therefore, several analyses were conducted to assess the impact of canagliflozin on renal function (as measured by eGFR) based on available data. These analyses provided support for approval of canagliflozin in T2DM patients with baseline eGFR ≥ 45 mL/min/1.73 m(2) , highlighting a data-driven approach to dose optimization. The availability of a relatively rich safety dataset (ie, frequent and early measurements of laboratory markers) in the canagliflozin clinical development program enabled adequate assessment of benefit-risk balance in various patient subgroups based on renal function.

  4. Failure to Achieve a Complete Response to Induction BCG Therapy is Associated with Increased Risk of Disease Worsening and Death in Patients with High Risk Non–Muscle Invasive Bladder Cancer

    PubMed Central

    Lerner, Seth P.; Tangen, Catherine M.; Sucharew, Heidi; Wood, David; Crawford, E. David

    2009-01-01

    Purpose The Southwest Oncology Group conducted a randomized trial of induction BCG with or without maintenance BCG. In these additional retrospective analyses, our goal was to evaluate the association of a complete response (CR) or remaining with no evidence of disease (NED) versus no CR during induction therapy with subsequent survival after adjusting for other potential confounders. Among all patients randomized to maintenance treatment, we also wanted to identify combinations of baseline covariates in order to define prognostic groups for subsequent worsening-free survival. Methods Outcome measures of worsening-free and overall survival were assessed using Kaplan Meier estimates and proportional hazards regression models. For the Classification and Regression Tree (CART) analysis, 434 patients randomized to maintenance vs. no therapy with complete covariate information were included. Results Of the 593 evaluable patients, 341 were not randomized to maintenance BCG. Patients who achieved a prior complete response during induction BCG had a 5-year survival probability of 77% compared to 62% for patients who did not [Hazard ratio (HR) 0.60; 95% confidence interval (CI) 0.44, 0.81; p= 0.0008]. Prior CR retained significance when adjusted for age, gender, prior intravesical chemotherapy, and papillary disease versus CIS (HR=0.63; 95% CI: .46, .86; p=0.003). CART analysis identified 4 prognostic groups. Older patients (≥ 62 years old) previously treated with intravesical chemotherapy who failed to achieve a CR had a 5-fold higher risk of a worsening event relative to those who are younger (< 67 years old) and achieve a CR (HR=5.09; 95% CI: 3.37, 7.68; p<0.0001). Conclusion Failure to achieve a complete response after induction BCG is associated with a significant risk of a worsening event and death for patients with CIS or Ta or T1 bladder cancer at increased risk of recurrence. PMID:18367117

  5. Merging technology and clinical research for optimized post-surgical rehabilitation of lung cancer patients

    PubMed Central

    Brintnall, Ruth Ann; Cooper, Julie

    2016-01-01

    Background The 21st century has ushered in an age of wireless communication and technological breakthroughs providing researchers with opportunities and challenges as they incorporate this technology into their research. This paper presents the challenges our team encountered introducing new technologies and how they were overcome for an intervention for post-thoracotomy non-small cell lung cancer (NSCLC) patients. Methods Our intervention incorporated the Nintendo Wii Fit Plus virtual-reality walking and balance exercise into a home-based rehabilitation program. The intervention is novel and innovative in that the intervention provides light-intensity exercise post-thoracotomy for NSCLC patients immediately after return to home from the hospital. The intervention overcomes the barriers of conventional exercise programs that require travel, conventional exercise equipment, and begin months after surgery. Results When translating new technology to research, researchers need to consider a number of factors that need to be addressed. Institutional Review Boards may need further explanation as to why the technology is safe, potential participants may need to have unfounded concerns explained before enrolling, and the research team needs a plan for introducing the technology to participants with a vast range of skill sets and environments in which they will be using technology. In our study, we addressed each of these factors using varying approaches as we translated how the Wii would be used in a home-based exercise intervention by a highly vulnerable, post-thoracotomy NSCLC population. Conclusions While technology brings with it multiple barriers for successful implementation, our team showed that with proper planning and teamwork, researchers can navigate these issues bringing the full benefit of technology to even the most vulnerable of patient populations. PMID:26889481

  6. Optimal management of severe nausea and vomiting in migraine: improving patient outcomes.

    PubMed

    Láinez, Miguel Ja; García-Casado, Ana; Gascón, Francisco

    2013-10-11

    Migraine is a common and potentially disabling disorder for patients, with wide-reaching implications for health care services, society, and the economy. Nausea and vomiting during migraine attacks are common symptoms that affect at least 60% of patients suffering from migraines. These symptoms are often more disabling than the headache itself, causing a great burden on the patient's life. Nausea and vomiting may delay the use of oral abortive medication or interfere with oral drug absorption. Therefore, they can hinder significantly the management and treatment of migraine (which is usually given orally). The main treatment of pain-associated symptoms of migraine (such as nausea and vomiting) is to stop the migraine attack itself as soon as possible, with the effective drugs at the effective doses, seeking if necessary alternative routes of administration. In some cases, intravenous antiemetic drugs are able to relieve a migraine attack and associated symptoms like nausea and vomiting. We performed an exhaustive PubMed search of the English literature to find studies about management of migraine and its associated symptoms. Search terms were migraine, nausea, and vomiting. We did not limit our search to a specific time period. We focused on clinical efficacy and tolerance of the various drugs and procedures based on data from human studies. We included the best available studies for each discussed drug or procedure. These ranged from randomized controlled trials for some treatments to small case series for others. Recently updated books and manuals on neurology and headache were also consulted. We herein review the efficacy of the different approaches in order to manage nausea and vomiting for migraine patents.

  7. State estimation and optimal long period clinical treatment of HIV seropositive patients.

    PubMed

    Grégio, Juliana M; Caetano, Marco A L; Yoneyama, Takashi

    2009-03-01

    Optimal control theory provides a very interesting quantitative method that can be used to assist the decision making process in several areas of application, such as engineering, biology, economics and sociology. The main idea is to determine the values of the manipulated variables, such as drug doses, so that some cost function is minimized, subject to physical constraints. In this work, the cost function reflects the number of CD4+T cells, viral particles and the drug doses. It is worth noticing that high drug doses are related to more intense side-effects, apart from the impact on the actual cost of the treatment. In a previous paper by the authors, the LQR - Linear Quadratic Regulator approach was proposed for the computation of long period maintenance doses for the drugs, which turns out to be of state feedback form. However, it is not practical to determine all the components of the state vector, due to the fact that infected and uninfected CD4+T cells are not microscopically distinguishable. In order to overcome this difficulty, this work proposes the use of Extended Kalman Filter to estimate the state, even though, because of the nonlinear nature of the involved state equations, the separation principle may not be valid. Extensive simulations were then carried out to investigate numerically if the control strategy consisting of the feedback of estimated states yielded satisfactory clinical results.

  8. Optical modeling toward optimizing monitoring of intestinal perfusion in trauma patients

    SciTech Connect

    Akl, Tony; Wilson, Mark A.; Ericson, Milton Nance; Cote, Gerard L.

    2013-01-01

    Trauma is the number one cause of death for people between the ages 1 and 44 years in the United States. In addition, according to the Centers of Disease Control and Prevention, injury results in over 31 million emergency department visits annually. Minimizing the resuscitation period in major abdominal injuries increases survival rates by correcting impaired tissue oxygen delivery. Optimization of resuscitation requires a monitoring method to determine sufficient tissue oxygenation. Oxygenation can be assessed by determining the adequacy of tissue perfusion. In this work, we present the design of a wireless perfusion and oxygenation sensor based on photoplethysmography. Through optical modeling, the benefit of using the visible wavelengths 470, 525 and 590nm (around the 525nm hemoglobin isobestic point) for intestinal perfusion monitoring is compared to the typical near infrared (NIR) wavelengths (805nm isobestic point) used in such sensors. Specifically, NIR wavelengths penetrate through the thin intestinal wall (~4mm) leading to high background signals. However, these visible wavelengths have two times shorter penetration depth that the NIR wavelengths. Monte-Carlo simulations show that the transmittance of the three selected wavelengths is lower by 5 orders of magnitude depending on the perfusion state. Due to the high absorbance of hemoglobin in the visible range, the perfusion signal carried by diffusely reflected light is also enhanced by an order of magnitude while oxygenation signal levels are maintained. In addition, short source-detector separations proved to be beneficial for limiting the probing depth to the thickness of the intestinal wall.

  9. Rehabilitation of the geriatric surgical patient: predicting needs and optimizing outcomes.

    PubMed

    Biffl, Walter L; Biffl, Susan E

    2015-02-01

    Geriatric surgical and trauma patients often require institutionalization following acute hospitalization, generally related to frailty. The potential need for rehabilitation can be assessed using various tools. Once the likelihood of rehabilitation needs is established, early involvement of the rehabilitation team is warranted. Rehabilitation interventions can be initiated during acute hospitalization, and even in the intensive care unit. The rehabilitation team addresses a tremendous spectrum of issues, and targeted interventions are carried out by various team members. There are many gaps in current knowledge of the benefits of rehabilitation interventions. Understanding common standardized assessment tools is important to assess the literature and advance the field.

  10. Optimizing Management of Patients with Adult T Cell Leukemia-Lymphoma

    PubMed Central

    Yared, Jean A.; Kimball, Amy S.

    2015-01-01

    Adult T cell leukemia-lymphoma is a rare disease with a high mortality rate, and is challenging for the clinician. Early allogeneic stem cell transplant can confer durable remission. As novel therapeutic agents become available to treat T cell malignancies, it is increasingly important that medical oncologists, hematologists, and hematopathologists recognize and accurately diagnose adult T cell leukemia-lymphoma. There is no uniform standard of treatment of adult T cell leukemia-lymphoma, and clinical trials remain critical to improving outcomes. Here we present one management approach based on the recent advances in treatment for adult T cell leukemia-lymphoma patients. PMID:26610571

  11. Role of exercise in optimizing the functional status of patients with nonalcoholic fatty liver disease.

    PubMed

    Gerber, Lynn H; Weinstein, Ali; Pawloski, Lisa

    2014-02-01

    Nonalcoholic fatty liver disease (NAFLD) is frequently concomitant with obesity. This article discusses factors that influence health and functional outcomes of people who develop NAFLD, including increased burden of illness, whole body function, performance, and perception of self-efficacy. Changes in macronutrients, amount of calories consumed, and decreased physical activity all negatively influence patient outcome. The benefits of exercise in this population are also discussed. To be effective, exercise must be performed, regularly and in conjunction with dietary and other behavioral change. Therefore, a lifelong commitment to exercise, activity, and diet are needed if NAFLD is to be successfully treated.

  12. Comparative optimism among patients with coronary heart disease (CHD) is associated with fewer adverse clinical events 12 months later.

    PubMed

    Hevey, David; McGee, Hannah M; Horgan, John H

    2014-04-01

    The current study evaluates the levels of comparative optimism among patients with coronary heart disease (CHD) and examines its relationship to health outcomes 12 months later. 164 patients completed self-report questionnaires at the end of cardiac rehabilitation and the number of adverse clinical events in the following 12 months were recorded. Comparative optimism was assessed in relation to a typical other who has not had cardiac event, a typical other who has had the same cardiac event as the respondent, and a typical member of the cardiac rehabilitation class. Clinical-demographic details and distress were assessed. Participants were comparatively optimistic in all three ratings. Logistic regression (controlling for age, gender, co-morbidities, and distress) revealed that higher levels of adverse events were associated with older age, being male, and lower levels of overall comparative optimism. Comparative optimism was associated with decreased risk of adverse clinical events in the year following cardiac rehabilitation attendance.

  13. Flow in patients with left ventricular thrombus using optimized echo PIV-PTV

    NASA Astrophysics Data System (ADS)

    Sampath, Kaushik; Harfi, Thura T.; George, Richard T.; Katz, Joseph

    2016-11-01

    Applications of echocardiographic particle image velocimetry and particle tracking velocimetry (echo PIV-PTV) for characterizing cardiovascular flows have been expanding. It involves acquisition and processing of time-resolved contrast echocardiograms of in vivo flows seeded with micro bubbles. Here, a set of image enhancement and particle tracking methods are implemented on in-vivo data from five patients with history of past or current confirmed left ventricular thrombus (LVT). Our aim is to correlate the LV mixing with thrombogenicity. For cases with persistent LVT and low cardiac efficiency, results show low velocities around the clot as well as low penetration depth of the jet at the exit from the mitral valve and strength of the associated LV vortex. The speeds increase with increasing kinesis (wall motion) and distance from the clot. Patients with recovering cardiac function and diminishing clot size exhibit improved flow, LV vortex strength and penetration even when their efficiency is lower than normal. Trends of the apical washing are consistent with those predicted by the E-wave propagation index.

  14. Optimizing dosing frequencies for bisphosphonates in the management of postmenopausal osteoporosis: patient considerations

    PubMed Central

    Sunyecz, John

    2008-01-01

    Postmenopausal osteoporosis is common and underrecognized among elderly women. Osteoporotic fractures cause disability and disfigurement and threaten patients’ mobility, independence, and survival. Care for incident fractures in this age group must go beyond orthopedic repair, to assessment and treatment of the underlying bone fragility. Fracture risk can be reduced by vitamin D and calcium supplementation along with antiresorptive drug treatment. First-line osteoporosis pharmacotherapy employs nitrogen-containing bisphosphonates. The inconvenience of daily oral treatment has motivated development of weekly, monthly, and intermittent oral regimens, as well as quarterly and yearly intravenous (iv) regimens. Ibandronate is the first bisphosphonate to have shown direct anti-fracture efficacy with a non-daily regimen; it was approved for once-monthly oral dosing in 2005 and for quarterly iv dosing in 2006. Intermittent oral risedronate and yearly iv zoledronic acid were approved in 2007. Newly available regimens with extended dosing intervals reduce the inconvenience of bisphosphonate therapy and provide patients with a range of options from which to select a maximally sustainable course of treatment. This review discusses the development, efficacy, safety, and tolerability of extended-interval bisphosphonate regimens and examines their potential to improve patient acceptance and long-term success of osteoporosis treatment. PMID:19281054

  15. MALDI-TOF alone versus MALDI-TOF combined with real-time antimicrobial stewardship interventions on time to optimal antimicrobial therapy in patients with positive blood cultures.

    PubMed

    Beganovic, Maya; Costello, Michael; Wieczorkiewicz, Sarah M

    2017-02-22

    Introduction: Matrix-assisted laser desorption ionization time of flight (MALDI-TOF) decreases time to organism identification and improves clinical and financial outcomes. The purpose of this study was to evaluate the impact of MALDI-TOF alone vs MALDI-TOF combined with real-time, pharmacist-driven, antimicrobial stewardship (AMS) intervention on patient outcomes.Methods: This single-center, pre-post quasi-experimental study evaluated hospitalized patients with positive blood cultures identified via MALDI-TOF combined with prospective AMS intervention, compared to a control cohort with MALDI-TOF identification without AMS intervention. AMS intervention included: real-time MALDI-TOF pharmacist notification, and prospective AMS provider feedback. The primary outcome was time to optimal antimicrobial therapy (TTOT).Results: A total of 252 blood cultures were included for final analysis: 126 in each group. MALDI-TOF + AMS intervention significantly reduced overall TTOT (75.17 vs 43.06 h, p <0.001), Gram + contaminant TTOT (48.21 vs 11.75 h, p <0.001), Gram - infection (GNI) TTOT (71.83 vs 35.98 h, p <0.001), and reduced overall hospital LOS (15.03 vs 9.02 days, p 0.021). TTOT for Gram + infection (GPI) was improved (64.04 vs 41.61 h, p 0.082). For GPI: reduced hospital LOS (14.64 vs 10.31 days, p 0.002) and length of antimicrobial therapy 24.30 vs 18.97 days, p 0.018). For GNI: reduced time to microbiologic clearance (51.13 vs 34.51 h, p <0.001), hospital LOS (15.40 vs 7.90 days, p 0.027), and ICU LOS (5.55 vs 1.19 days, p 0.035).Conclusion: In order to achieve optimal outcomes, rapid identification with MALDI-TOF combined with real-time AMS interventions is more impactful than MALDI-TOF alone.

  16. Empagliflozin added to metformin and sulfonylurea therapy in patients with sub-optimally controlled type 2 diabetes mellitus.

    PubMed

    Lewin, Andrew J; Frías, Juan P

    2015-04-01

    The combination of metformin and a sulfonylurea is commonly used in type 2 diabetes mellitus. Many patients on this combination therapy do not achieve or maintain glycemic targets and require the addition of a third antihyperglycemic agent. Among the options are the sodium glucose cotransporter 2 (SGLT2) inhibitors, a recently developed class of medications that effectively improve glycemic control and are associated with reduction in body weight and blood pressure. This article evaluates a 24-week, randomized, placebo-controlled study of the SGLT2 inhibitor empagliflozin, added to metformin plus sulfonylurea regimens. Empagliflozin led to significant reductions in glycated hemoglobin and fasting plasma glucose, as well as body weight and systolic blood pressure. Adverse events typically recorded with SGLT2 inhibitors were observed; notably, genital infections occurred in more patients on empagliflozin than placebo. Overall, empagliflozin was well tolerated. These results indicate that SGLT2 inhibitors can be successfully added to metformin plus sulfonylurea regimens. SGLT2 inhibitors are not the only therapeutic option in this clinical situation; however, based on the secondary effects observed in this and other studies, they appear to be of particular value for patients who are obese or overweight.

  17. Detection of Occult Hepatitis C Virus Infection in Patients Who Achieved a Sustained Virologic Response to Direct-Acting Antiviral Agents for Recurrent Infection After Liver Transplantation.

    PubMed

    Elmasry, Sandra; Wadhwa, Sanya; Bang, Bo-Ram; Cook, Linda; Chopra, Shefali; Kanel, Gary; Kim, Brian; Harper, Tammy; Feng, Zongdi; Jerome, Keith R; Kahn, Jeffrey A; Saito, Takeshi

    2017-02-01

    Occult infection with hepatitis C virus (HCV) is defined as the presence of the HCV genome in either liver tissue or peripheral blood monocytes, despite constant negative results from tests for HCV RNA in serum. We investigated whether patients who maintained a sustained virologic response 12 weeks after therapy (SVR12) with direct-acting antiviral (DAA) agents for recurrent HCV infection after liver transplantation had occult HCV infections. We performed a prospective study of 134 patients with recurrent HCV infection after liver transplantation who were treated with DAAs, with or without ribavirin, from 2014 through 2016 (129 patients achieved an SVR12). In >10% of the patients who achieved SVR12 (n = 14), serum levels of aminotransferases did not normalize during or after DAA therapy, or they normalized transiently but then increased sharply after DAA therapy. Of these 14 patients, 9 were assessed for occult HCV infection by reverse transcription quantitative polymerase chain reaction. This analysis revealed that 55% of these patients (n = 5) had an occult infection, with the detection of negative strand viral genome, indicating viral replication. These findings indicate the presence of occult HCV infection in some patients with abnormal levels of serum aminotransferases, despite SVR12 to DAAs for HCV infection after liver transplantation.

  18. A pharmacodynamic study of the optimal P2Y12 inhibitor regimen for East Asian patients with acute coronary syndrome

    PubMed Central

    Lee, Ji Hyun; Ahn, Sung Gyun; Park, Bonil; Park, Sang Wook; Kang, Yong Seok; Lee, Jun-Won; Youn, Young Jin; Ahn, Min-Soo; Kim, Jang-Young; Yoo, Byung-Su; Lee, Seung-Hwan; Yoon, Junghan

    2015-01-01

    Background/Aims: Newer P2Y12 inhibitors, such as prasugrel and ticagrelor, have greater antiplatelet efficacy but may increase the risk of bleeding. In this study, we compared the pharmacodynamic efficacy of prasugrel and ticagrelor in East Asian patients with acute coronary syndrome (ACS). Methods: We selected 83 ACS patients undergoing percutaneous coronary intervention who were discharged with 90 mg ticagrelor twice daily (n = 24), 10 mg prasugrel daily (n = 39) or 5 mg prasugrel daily (n = 20). After 2 to 4 weeks, on-treatment platelet reactivity (OPR) was assessed in terms of P2Y12 reaction units (PRUs) using the VerifyNow P2Y12 assay (Accumetrics). We compared East Asian (85 < PRU ≤ 275) and Caucasian (85 < PRU ≤ 208) criteria for assessing the therapeutic window of OPR. Results: OPR was lowest in the ticagrelor group, followed by the 10 mg prasugrel and 5 mg prasugrel groups (49.1 ± 29.9 vs. 83.7 ± 57.1 vs. 168.5 ± 60.8, respectively; p < 0.001). The 5 mg prasugrel group had the highest proportion of patients with OPR values within the therapeutic window, followed by the 10 mg prasugrel and ticagrelor groups (90.0% vs. 46.2% vs. 12.5%, respectively; p < 0.001 for East Asian criteria; 60.0% vs. 43.6% vs. 12.5%, respectively; p < 0.001 for Caucasian criteria). Conclusions: Short-term administration of 5 mg prasugrel facilitated maintenance within the therapeutic window of OPR compared with the 10 mg prasugrel and ticagrelor groups. Thus, 5 mg prasugrel daily may be the optimal antiplatelet regimen for stabilized East Asian ACS patients. PMID:26354056

  19. [Optimal use of peritoneal dialysis fluids in type 2 diabetes mellitus patients].

    PubMed

    Ryckelynck, Jean-Philippe; Allard, Catherine; Cousin, Maud; Hurault de Ligny, Bruno; El Haggan, Wael; Lobbedez, Thierry

    2006-01-01

    The glucose side-effects, the main osmotic agent in conventional peritoneal dialysis (PD) solutions, are structural and functional changes of the peritoneal membrane, especially diabetic alterations in the microvasculature. Therefore, hyperpermeability with high small solutes transport and less ultrafiltration necessitates more and more high glucose concentration solutions. Glucose degradation products (PDF) and advanced glycation end-products (AGE) are formed and may induce peritoneal membrane alterations. More biocompatible solutions have to be used with less PDF and physiological pH. Icodextrin containing PD solutions have beneficial effect on sustained ultrafiltration for long dwells in PD, limitating fluid overload common in PD patients above all during peritonitis episodes. Amino acid-based PD solutions contribute to the prevention of malnutrition often observed in the diabetic PD population.

  20. Differences in background characteristics of patients with chronic hepatitis C who achieved sustained virologic response with interferon-free versus interferon-based therapy and the risk of developing hepatocellular carcinoma after eradication of hepatitis C virus in Japan.

    PubMed

    Toyoda, H; Tada, T; Takaguchi, K; Senoh, T; Shimada, N; Hiraoka, A; Michitaka, K; Ishikawa, T; Kumada, T

    2016-12-16

    We compared the background characteristics of patients with chronic hepatitis C who achieved eradication of hepatitis C virus (HCV), that is sustained virologic response (SVR), with interferon (IFN)-based versus IFN-free antiviral therapy in Japan. In addition, we used a previously reported risk assessment model to compare the incidence of hepatocellular carcinoma (HCC) after SVR by treatment type. Pretreatment characteristics of 1533 patients who achieved SVR with IFN-based therapy and 1086 patients with IFN-free therapy from five institutions across Japan were compared. The risk of HCC after SVR was assessed based on pretreatment characteristics, and the incidence of HCC after SVR was estimated in both groups. Age and serum alpha-fetoprotein levels were higher, platelet count was lower, and liver fibrosis was more advanced in patients who achieved SVR with IFN-free therapy compared with IFN-based therapy. The incidence of HCC after SVR in the IFN-free group was estimated to be more than twofold higher than in the IFN-based therapy group (7.29% vs. 3.09%, and 6.23% vs. 3.01% when excluding patients who have underwent curative treatment for HCC). There are large differences in pretreatment characteristics between patients who achieved SVR with IFN-based and IFN-free therapies in Japan, which are associated with differential risk of HCC after SVR. These differences can influence the incidence of HCC after SVR and should be taken into consideration when comparing IFN-based and IFN-free therapies in terms of hepatocarcinogenesis suppression with HCV eradication.

  1. Optimal management of severe nausea and vomiting in migraine: improving patient outcomes

    PubMed Central

    Láinez, Miguel JA; García-Casado, Ana; Gascón, Francisco

    2013-01-01

    Migraine is a common and potentially disabling disorder for patients, with wide-reaching implications for health care services, society, and the economy. Nausea and vomiting during migraine attacks are common symptoms that affect at least 60% of patients suffering from migraines. These symptoms are often more disabling than the headache itself, causing a great burden on the patient’s life. Nausea and vomiting may delay the use of oral abortive medication or interfere with oral drug absorption. Therefore, they can hinder significantly the management and treatment of migraine (which is usually given orally). The main treatment of pain-associated symptoms of migraine (such as nausea and vomiting) is to stop the migraine attack itself as soon as possible, with the effective drugs at the effective doses, seeking if necessary alternative routes of administration. In some cases, intravenous antiemetic drugs are able to relieve a migraine attack and associated symptoms like nausea and vomiting. We performed an exhaustive PubMed search of the English literature to find studies about management of migraine and its associated symptoms. Search terms were migraine, nausea, and vomiting. We did not limit our search to a specific time period. We focused on clinical efficacy and tolerance of the various drugs and procedures based on data from human studies. We included the best available studies for each discussed drug or procedure. These ranged from randomized controlled trials for some treatments to small case series for others. Recently updated books and manuals on neurology and headache were also consulted. We herein review the efficacy of the different approaches in order to manage nausea and vomiting for migraine patents. PMID:24143125

  2. The benefit of consolidation radiotherapy to initial disease bulk in patients with advanced Hodgkin’s disease who achieved complete remission after standard chemotherapy

    PubMed Central

    Bayoumi, Yasser; Al-Homaidi, Abdulaziz; Zaidi, Syed; Tailor, Imran; Motiabi, Ibrahiem; Alshehri, Nawal; Al-Ghazali, Assem; Almudaibigh, Samer

    2015-01-01

    Background/purpose The aim of this study was to evaluate the role of consolidation radiotherapy (RT) in advanced-stage Hodgkin’s disease (HD) with initial bulky sites after radiological complete remission (CR) or partial response (PR) with positron emission tomography-negative (metabolic CR) following standard chemotherapy (ABVD [Adriamycin, bleomycin, vinblastine, and dacarbazine]) six to eight cycles. Patients and methods Adult patients with advanced-stage HD treated at our institute during the period 2006 to 2012 were retrospectively evaluated. One hundred and ninety-two patients with initial bulky disease size (>7 cm) who attained radiological CR/PR and metabolic CR were included in the analysis. One hundred and thirteen patients who received radiotherapy (RT) as consolidation postchemotherapy (RT group) were compared to 79 patients who did not receive RT (non-RT group). Disease-free (DFS) and overall survival (OS) rates were estimated using the Kaplan–Meier method and were compared according to treatment group by the log-rank tests at P ≤0.05 significance level. Results The mean age of the cohort was 33 (range: 14 to 81) years. Eighty-four patients received involved-field radiation and 29 patients received involved-site RT. The RT group had worse prognostic factors compared to the non-RT group. Thirteen (12%) relapses occurred in the RT group, and 19 (24%) relapses occurred in the non-RT group. Nine patients (8%) in the RT group died, compared to eleven patients (14%) in the non-RT group. Second malignancies were seen in only five patients: three patients in the RT group compared to two patients in the non-RT group. At 5 years, overall DFS was 79%±9% and OS was 85%±9%. There was significant statistical difference between the RT group and the non-RT group regarding 5-year DFS: 86%±7% and 74%±9%, respectively (P ≤0.02). However, the 5-year OS was 90%±5% for the RT group and 83%±8% for the non-RT group, with no statistical difference (P ≤0

  3. Development of allogeneic NK cell adoptive transfer therapy in metastatic melanoma patients: in vitro preclinical optimization studies.

    PubMed

    Besser, Michal J; Shoham, Tsipi; Harari-Steinberg, Orit; Zabari, Naama; Ortenberg, Rona; Yakirevitch, Arkadi; Nagler, Arnon; Loewenthal, Ron; Schachter, Jacob; Markel, Gal

    2013-01-01

    Natural killer (NK) cells have long been considered as potential agents for adoptive cell therapy for solid cancer patients. Until today most studies utilized autologous NK cells and yielded disappointing results. Here we analyze various modular strategies to employ allogeneic NK cells for adoptive cell transfer, including donor-recipient HLA-C mismatching, selective activation and induction of melanoma-recognizing lysis receptors, and co-administration of antibodies to elicit antibody-dependent cell cytotoxicity (ADCC). We show that NK cell activation and induction of the relevant lysis receptors, as well as co-administration of antibodies yield substantial anti-cancer effects, which are functionally superior to HLA-C mismatching. Combination of the various strategies yielded improved effects. In addition, we developed various clinically-compatible ex vivo expansion protocols that were optimized according to fold expansion, purity and expression of lysis receptors. The main advantages of employing allogeneic NK cells are accessibility, the ability to use a single donor for many patients, combination with various strategies associated with the mechanism of action, e.g. antibodies and specific activation, as well as donor selection according to HLA or CD16 genotypes. This study rationalizes a clinical trial that combines adoptive transfer of highly potent allogeneic NK cells and antibody therapy.

  4. Preliminary study of optimal measurement location on vibroarthrography for classification of patients with knee osteoarthritis

    PubMed Central

    Ota, Susumu; Ando, Akiko; Tozawa, Yusuke; Nakamura, Takuya; Okamoto, Shogo; Sakai, Takenobu; Hase, Kazunori

    2016-01-01

    [Purpose] The aims of the present study were to investigate the most suitable location for vibroarthrography measurements of the knee joint to distinguish a healthy knee from knee osteoarthritis using Wavelet transform analysis. [Subjects and Methods] Participants were 16 healthy females and 17 females with severe knee osteoarthritis. Vibroarthrography signals were measured on the medial and lateral epicondyles, mid-patella, and tibia using stethoscopes with a microphone while subjects stood up from a seated position. Frequency and knee flexion angles at the peak wavelet coefficient were obtained. [Results] Peak wavelet coefficients at the lateral condyle and tibia were significantly higher in patients with knee osteoarthritis than in the control group. Knee joint angles at the peak wavelet coefficient were smaller (more extension) in the osteoarthritis group compared to the control group. The area under the receiver operating characteristic curve on tibia assessment with the frequency and knee flexion angles was higher than at the other measurement locations (both area under the curve: 0.86). [Conclusion] The tibia is the most suitable location for classifying knee osteoarthritis based on vibroarthrography signals. PMID:27821959

  5. Behavioral Health in the Patient Centered Medical Home (PCMH): An Important Part of Meeting the Quadruple Aim and Achieving Level II & III NCQA PCMH Recognition

    DTIC Science & Technology

    2011-01-24

    Care Behavioral Health Model Focused on all enrolled patients • Embedded with PC team • BHPs & PCMs share patient information • Brings a team-based...enrolled patients • Care Manager and Embedded BHP – Continuity of Care – Stepped Care – Access to all enrollees to BHP in the PCMH – Clinical...available for each Service as funds to hire new BHP in the PCMH comes available. Way Ahead 2011 MHS Conference 21 – It is coming • Funding expected to be

  6. Doppler index and plasma level of atrial natriuretic hormone are improved by optimizing atrioventricular delay in atrioventricular block patients with implanted DDD pacemakers.

    PubMed

    Toda, N; Ishikawa, T; Nozawa, N; Kobayashi, I; Ochiai, H; Miyamoto, K; Sumita, S; Kimura, K; Umemura, S

    2001-11-01

    Doppler index is the sum of isovolumetric contraction time and isovolumetric relaxation time divided by ejection time and has clinical value as an index of combined systolic and diastolic myocardial performance. This crossover study compared the Doppler index and atrial natriuretic hormone (atrial natriuretic peptide) [ANP] between optimal (AV) delay and prolonged AV delay in patients with DDD pacemakers. The study included 14 patients (6 men, 8 women, age 78.4+/-9.3 [SD] years) with AV block with an implanted DDD pacemaker. AV delay was prolonged in a 25-ms, stepwise fashion starting from 125 ms to 250 ms. Pacing rate was set at 70 beats/min. Cardiac output (CO) was assessed by pulsed Doppler echocardiography, and optimal AV delay was defined as the AV delay at which CO was maximum, and an AV delay setting of 250 ms as prolonged AV delay. Plasma level of ANP and Doppler index determined by echocardiography were measured 1 week after programming. AV delay was switched to another AV delay and measurements were repeated after 1 week. Optimal AV delay was 159+/-19 ms. Doppler index was significantly lower at optimal AV delay than at prolonged AV delay (0.68+/-0.26 vs 0.92+/-0.30, P < 0.05). The plasma ANP level was significantly lower at optimal AV delay than at prolonged AV delay (29.0+/-30.7 vs 52.6+/-44.9 pg/mL, P < 0.05). In conclusion, the Doppler index and the plasma ANP level were significantly lower at optimal AV delay than at prolonged AV delay. This study shows the importance of the optimal AV delay setting in patients with an implanted DDD pacemaker, the Doppler index and plasma ANP levels are good indicators for optimizing AV delay.

  7. Potential of a Pharmacogenetic-Guided Algorithm to Predict Optimal Warfarin Dosing in a High-Risk Hispanic Patient

    PubMed Central

    Hernandez-Suarez, Dagmar F.; Claudio-Campos, Karla; Mirabal-Arroyo, Javier E.; Torres-Hernández, Bianca A.; López-Candales, Angel; Melin, Kyle; Duconge, Jorge

    2016-01-01

    Deep abdominal vein thrombosis is extremely rare among thrombotic events secondary to the use of contraceptives. A case to illustrate the clinical utility of ethno-specific pharmacogenetic testing in warfarin management of a Hispanic patient is reported. A 37-year-old Hispanic Puerto Rican, non-gravid female with past medical history of abnormal uterine bleeding on hormonal contraceptive therapy was evaluated for abdominal pain. Physical exam was remarkable for unspecific diffuse abdominal tenderness, and general initial laboratory results—including coagulation parameters—were unremarkable. A contrast-enhanced computed tomography showed a massive thrombosis of the main portal, splenic, and superior mesenteric veins. On admission the patient was started on oral anticoagulation therapy with warfarin at 5 mg/day and low-molecular-weight heparin. The prediction of an effective warfarin dose of 7.5 mg/day, estimated by using a recently developed pharmacogenetic-guided algorithm for Caribbean Hispanics, coincided with the actual patient’s warfarin dose to reach the international normalized ratio target. We speculate that the slow rise in patient’s international normalized ratio observed on the initiation of warfarin therapy, the resulting high risk for thromboembolic events, and the required warfarin dose of 7.5 mg/day are attributable in some part to the presence of the NQO1*2 (g.559C>T, p.P187S) polymorphism, which seems to be significantly associated with resistance to warfarin in Hispanics. By adding genotyping results of this novel variant, the predictive model can inform clinicians better about the optimal warfarin dose in Caribbean Hispanics. The results highlight the potential for pharmacogenetic testing of warfarin to improve patient care. PMID:28210634

  8. Optimal Same-Day Platelet Inhibition in Patients Receiving Drug-Eluting Stents With or Without Previous Maintenance Thienopyridine Therapy: from the Evaluation of Platelet Inhibition in Patients Having A VerifyNow Assay (EPIPHANY) Trial.

    PubMed

    Lee, Michael S; Shlofmitz, Evan; Haag, Elizabeth; Santiago, Lyn; Pollack, Simcha; Reichek, Nathaniel; Shlofmitz, Richard A

    2017-04-01

    We determined if high on-treatment platelet reactivity (HTPR) can be overcome on the day of percutaneous coronary intervention (PCI) in patients with or without previous maintenance thienopyridine therapy. Patients with HTPR, as defined as P2Y12 reaction units (PRU) >230, were switched to an alternate thienopyridine. Patients with HTPR undergoing PCI are at increased risk for ischemic complications. A total of 429 patients undergoing PCI with drug-eluting stents were enrolled. Patients on maintenance thienopyridine (n = 249) with PRU >230 were loaded with the alternative thienopyridine. Patients who were thienopyridine naïve (n = 180) were randomized to clopidogrel 600 (n = 90) or prasugrel 60 mg (n = 90). Patients with HTPR were loaded with the alternative agent. Patients on maintenance clopidogrel (n = 192) had a higher prevalence of HTPR compared with prasugrel (n = 57; 51% vs 4%, p <0.001). Patients on maintenance clopidogrel with HTPR (n = 98) who were loaded with prasugrel achieved PRU ≤230 in 97%. Thienopyridine-naïve patients loaded with clopidogrel had a higher prevalence of HTPR compared with prasugrel (37% vs 3%, p <0.001). Clopidogrel-loaded patients with HTPR (n = 33) who were reloaded with prasugrel achieved PRU ≤230 in 94%. All 3 prasugrel-loaded patients with HTPR treated with clopidogrel achieved PRU ≤230. Two patients experienced 30-day major adverse clinical events. One patient experienced Thrombolysis In Myocardial Infarction major bleeding. In conclusion, HTPR can be overcome in patients with and without previous maintenance thienopyridine therapy by identifying patients with HTPR and switching to an alternate thienopyridine.

  9. Optimization and Reproducibility of Aortic Valve 18F-Fluoride Positron Emission Tomography in Patients With Aortic Stenosis

    PubMed Central

    Cartlidge, Timothy R.G.; Jenkins, William S.A.; Adamson, Philip D.; Robson, Phillip; Lucatelli, Christophe; Van Beek, Edwin J.R.; Prendergast, Bernard; Denison, Alan R.; Forsyth, Laura; Rudd, James H.F.; Fayad, Zahi A.; Fletcher, Alison; Tuck, Sharon; Newby, David E.; Dweck, Marc R.

    2016-01-01

    Background— 18F-Fluoride positron emission tomography (PET) and computed tomography (CT) can measure disease activity and progression in aortic stenosis. Our objectives were to optimize the methodology, analysis, and scan–rescan reproducibility of aortic valve 18F-fluoride PET-CT imaging. Methods and Results— Fifteen patients with aortic stenosis underwent repeated 18F-fluoride PET-CT. We compared nongated PET and noncontrast CT, with a modified approach that incorporated contrast CT and ECG-gated PET. We explored a range of image analysis techniques, including estimation of blood-pool activity at differing vascular sites and a most diseased segment approach. Contrast-enhanced ECG-gated PET-CT permitted localization of 18F-fluoride uptake to individual valve leaflets. Uptake was most commonly observed at sites of maximal mechanical stress: the leaflet tips and the commissures. Scan–rescan reproducibility was markedly improved using enhanced analysis techniques leading to a reduction in percentage error from ±63% to ±10% (tissue to background ratio MDS mean of 1.55, bias −0.05, limits of agreement −0·20 to +0·11). Conclusions— Optimized 18F-fluoride PET-CT allows reproducible localization of calcification activity to different regions of the aortic valve leaflet and commonly to areas of increased mechanical stress. This technique holds major promise in improving our understanding of the pathophysiology of aortic stenosis and as a biomarker end point in clinical trials of novel therapies. Clinical Trial Registration— URL: http://www.clinicaltrials.gov. Unique identifier: NCT02132026. PMID:27733431

  10. Achieving visibility? Use of non-verbal communication in interactions between patients and pharmacists who do not share a common language.

    PubMed

    Stevenson, Fiona

    2014-06-01

    Despite the seemingly insatiable interest in healthcare professional-patient communication, less attention has been paid to the use of non-verbal communication in medical consultations. This article considers pharmacists' and patients' use of non-verbal communication to interact directly in consultations in which they do not share a common language. In total, 12 video-recorded, interpreted pharmacy consultations concerned with a newly prescribed medication or a change in medication were analysed in detail. The analysis focused on instances of direct communication initiated by either the patient or the pharmacist, despite the presence of a multilingual pharmacy assistant acting as an interpreter. Direct communication was shown to occur through (i) the demonstration of a medical device, (ii) the indication of relevant body parts and (iii) the use of limited English. These connections worked to make patients and pharmacists visible to each other and thus to maintain a sense of mutual involvement in consultations within which patients and pharmacists could enact professionally and socially appropriate roles. In a multicultural society this work is important in understanding the dynamics involved in consultations in situations in which language is not shared and thus in considering the development of future research and policy.

  11. Achievements, challenges and unmet needs for haemophilia patients with inhibitors: Report from a symposium in Paris, France on 20 November 2014.

    PubMed

    Dargaud, Y; Pavlova, A; Lacroix-Desmazes, S; Fischer, K; Soucie, M; Claeyssens, S; Scott, D W; d'Oiron, R; Lavigne-Lissalde, G; Kenet, G; Escuriola Ettingshausen, C; Borel-Derlon, A; Lambert, T; Pasta, G; Négrier, C

    2016-01-01

    Over the past 20 years, there have been many advances in haemophilia treatment that have allowed patients to take greater control of their disease. However, the development of factor VIII (FVIII) inhibitors is the greatest complication of the disease and a challenge in the treatment of haemophilia making management of bleeding episodes difficult and surgical procedures very challenging. A meeting to discuss the unmet needs of haemophilia patients with inhibitors was held in Paris on 20 November 2014. Topics discussed were genetic and non-genetic risk factors for the development of inhibitors, immunological aspects of inhibitor development, FVIII products and inhibitor development, generation and functional properties of engineered antigen-specific T regulatory cells, suppression of immune responses to FVIII, prophylaxis in haemophilia patients with inhibitors, epitope mapping of FVIII inhibitors, current controversies in immune tolerance induction therapy, surgery in haemophilia patients with inhibitors and future perspectives for the treatment of haemophilia patients with inhibitors. A summary of the key points discussed is presented in this paper.

  12. [A Case of HPN, In Which QOL Improvement Was Achieved by Combining Continuous Infusion with Once-Weekly Intermittent Infusion - Contribution of Pharmacists to Health Promotion among Home Patients Receiving Infusion Therapy].

    PubMed

    Takeda, Namihiro; Hamana, Tomoko; Oka, Toyoka; Hirohara, Masayoshi; Kushida, Kazuki

    2016-12-01

    Patients receiving parenteral nutrition at home have the following two options: 24-h continuous or intermittent infusion. To date, for patients with impaired glucose tolerance and/or other metabolic disorders or for those with decreased cardiac/ pulmonary/renal function, it is desirable to opt for continuous infusion to minimize the variance in the body's metabolic rate as much as possible. Furthermore, it should be noted that continuous infusion evokes a stronger feeling among patients of being constrained because it restricts their everyday activities. This case witnesses collaborations among the patient's doctor, dispensary's pharmacy, and patient's family. Because ofthe use ofintermittent infusion more or less once per week in addition to continuous infusion, significant improvement in quality of life was achieved, and the patient was able to enjoy taking a short trip. To assist a home patient receiving infusion therapy, it is essential that the pharmacist be equipped with skills to manage risks associated with infusion therapy and have knowledge about insurance to cover incidents concerning infusion fluids or medical materials. It will certainly depend on the degree ofindependence ofpatients and the level ofcare their families can provide; however, should we manage to use a similar medical procedure in at least a few cases in the future, we may be able to contribute to "joie de vivre" in home patients receiving infusion therapy.

  13. Relationships among achieved heart rate, β-blocker dose and long-term outcomes in patients with heart failure with atrial fibrillation

    PubMed Central

    Howlett, Jonathan G; Chiu, Michael H; Southern, Danielle A; Knudtson, Merril; Wilton, Stephen B

    2016-01-01

    Objective Higher β-blocker dose and lower heart rate are associated with decreased mortality in patients with systolic heart failure (HF) and sinus rhythm. However, in the 30% of patients with HF with atrial fibrillation (AF), whether β-blocker dose or heart rate predict mortality is less clear. We assessed the association between β-blocker dose, heart rate and all-cause mortality in patients with HF and AF. Methods We performed a retrospective cohort study in 935 patients (60% men, mean age 74, 44.7% with reduced left ventricular ejection fraction (LVEF)) discharged with concurrent diagnoses of HF and AF. We used Cox models to test independent associations between higher versus lower predischarge heart rate (dichotomised at 70/min) and higher versus lower β-blocker dose (dichotomised at 50% of the evidence-based target), with the primary composite end point of mortality or cardiovascular rehospitalisation over a median of 2.9 years. All analyses were stratified by the presence of left ventricular systolic dysfunction (LVEF≤40%). Results After adjustment for covariates, neither β-blocker dose nor predischarge heart rate was associated with the primary composite end point. However, tachycardia at admission (heart rate >120/min) was associated with a reduced risk of the composite outcome in patients with both reduced LVEF (adjusted HR 0.67, 95% CI 0.52 to 0.88, p<0.01) and preserved LVEF (adjusted HR 0.79, 95% CI 0.64 to 0.98, p=0.04). Conclusions We found no associations between predischarge heart rate or β-blocker dosage and clinical outcomes in patients with recent hospitalisations for HF and AF. PMID:28123760

  14. Facial aesthetic surgical goals in patients of different cultures.

    PubMed

    Rowe-Jones, Julian M

    2014-08-01

    The purpose of facial aesthetic surgery is to improve the patient's psychological well-being. To achieve this, the surgeon must understand the patient's body image and their aesthetic and psychological expectations. These factors must be judged in the context of their cultural background. The patient's cultural values must also be understood to optimize the doctor-patient relationship.

  15. Optimal external laryngeal manipulation versus McCoy blade in active position in patients with poor view of glottis on direct laryngoscopy

    PubMed Central

    Vasudevan, Arumugam; Venkat, Ranjani; Badhe, Ashok Shankar

    2010-01-01

    Successful endotracheal intubation requires a clear view of glottis. Optimal external laryngeal manipulation may improve the view of glottis on direct laryngoscopy with Macintosh blade, but it requires another trained hand. Alternatively, McCoy laryngoscope with elevated tip may be useful. This study has been designed to compare the two techniques in patients with poor view of glottis. Two hundred patients with ‘Grade 2 or more’ view of glottis on direct laryngoscopy with Macintosh blade are included in the study. Optimal external laryngeal manipulation was applied, followed by laryngoscopy with McCoy blade in activated position; and the view was noted in both situations. The two interventions were compared using Chi-square test. The overall changes, in the views, were analyzed with Wilcoxon signed rank test. Both the techniques improved the view of glottis significantly (P<0.05). Optimal external laryngeal manipulation was significantly better than McCoy laryngoscope in active position, especially in patients with Grade 3 or 4 baseline view, poor oropharyngeal class, decreased head extension and decreased submandibular space (odds ratio = 2.36, 3.17, 3.22 and 26.48 respectively). To conclude, optimal external laryngeal manipulation is a better technique than McCoy laryngoscope in patients with poor view of glottis on direct laryngoscopy with Macintosh blade. PMID:20532072

  16. An Assessment of the Contrast Sensitivity in Patients with Ametropic and Anisometropic Amblyopia in Achieving the Corrected Visual Acuity of 1.0.

    PubMed

    Wang, Guipan; Zhao, Congling; Ding, Qiang; Wang, Ping

    2017-02-07

    Both visual acuity (VA) and contrast sensitivity (CS) are important parameters for measuring visual function. In this research, we investigated the CS of patients with ametropic or anisometropic amblyopia, whose corrected visual acuity (CVA) recovered to 1.0. Fifty-five cases with amblyopia and 22 control cases with a normal visual acuity of 1.0 were enrolled. The CS of the patients whose ametropic amblyopia had recovered to a CVA of 1.0 at 18 cpd spatial frequency was still lower than that of the normal control group under both photopic and scotopic conditions (P = 0.001, 0.025), but there were no significant differences at low- and middle-spatial frequencies. The CS of amblyopic eyes of the patients with anisometropic amblyopia was lower than that of the normal control group at the 18 cpd spatial frequency under photopic conditions (P = 0.005), and at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.008, <0.001, 0.004, respectively). The CS between the amblyopic eyes and the sound eyes of patients with anisometropic amblyopia presented significant differences at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.025, 0.045, 0.019, respectively). We suggest that amblyopia treatment should involve not only the correction of VA but also the improvement of CS.

  17. An Assessment of the Contrast Sensitivity in Patients with Ametropic and Anisometropic Amblyopia in Achieving the Corrected Visual Acuity of 1.0

    PubMed Central

    Wang, Guipan; Zhao, Congling; Ding, Qiang; Wang, Ping

    2017-01-01

    Both visual acuity (VA) and contrast sensitivity (CS) are important parameters for measuring visual function. In this research, we investigated the CS of patients with ametropic or anisometropic amblyopia, whose corrected visual acuity (CVA) recovered to 1.0. Fifty-five cases with amblyopia and 22 control cases with a normal visual acuity of 1.0 were enrolled. The CS of the patients whose ametropic amblyopia had recovered to a CVA of 1.0 at 18 cpd spatial frequency was still lower than that of the normal control group under both photopic and scotopic conditions (P = 0.001, 0.025), but there were no significant differences at low- and middle-spatial frequencies. The CS of amblyopic eyes of the patients with anisometropic amblyopia was lower than that of the normal control group at the 18 cpd spatial frequency under photopic conditions (P = 0.005), and at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.008, <0.001, 0.004, respectively). The CS between the amblyopic eyes and the sound eyes of patients with anisometropic amblyopia presented significant differences at the 6 cpd, 12 cpd, and 18 cpd spatial frequencies under scotopic conditions (P = 0.025, 0.045, 0.019, respectively). We suggest that amblyopia treatment should involve not only the correction of VA but also the improvement of CS. PMID:28169333

  18. Achieving therapeutic goals in insulin-using diabetic patients with non-insulin-dependent diabetes mellitus. A weight reduction-exercise-oral agent approach.

    PubMed

    Lucas, C P; Patton, S; Stepke, T; Kinhal, V; Darga, L L; Carroll-Michals, L; Spafford, T R; Kasim, S

    1987-09-18

    Non-insulin-dependent diabetes mellitus (NIDDM) is the most common form of diabetes in the civilized world. Its consequences include microvascular and macrovascular disease, both of which appear to evolve from a common background of obesity and physical inactivity. The current study was undertaken in obese patients with NIDDM to see whether improvements could be made in glycemic control as well as in many cardiovascular risk factors (obesity, hypertension, lipid abnormalities, and physical inactivity) that are typical of this condition. Fifteen obese insulin-using patients with NIDDM (average body mass index, 34.0) were treated with a 500-calorie formula diet for eight to 12 weeks. Administration of insulin and diuretics was discontinued at the onset of the study. A eucaloric diet was begun at eight to 12 weeks and maintained until Week 24. A behaviorally oriented nutrition-exercise program was instituted at the beginning of the study. Glipizide or placebo was added (randomized) at Week 15 if the fasting plasma glucose level in patients exceeded 115 mg/dl. Patients lost an average of 22 pounds over the course of 24 weeks. Frequency and duration of physical activity increased significantly from baseline, as did the maximal oxygen consumption rate. Glycemic control by 15 weeks (without insulin) was similar to baseline (with insulin). With the addition of glipizide at Week 15, both fasting plasma glucose and glucose tolerance improved significantly. This improvement was not observed with placebo. In addition, both systolic and diastolic blood pressure decreased by about 10 mm Hg. There were no significant changes in the levels of serum lipids or glycosylated hemoglobin. In conclusion, a multifaceted intervention program, employing weight reduction, exercise, diet, and glipizide therapy, can be instituted in insulin-using patients with NIDDM, with improvement in glycemic control and in certain risk factors (hypertension, obesity, physical inactivity) for cardiovascular

  19. Leader as achiever.

    PubMed

    Dienemann, Jacqueline

    2002-01-01

    This article examines one outcome of leadership: productive achievement. Without achievement one is judged to not truly be a leader. Thus, the ideal leader must be a visionary, a critical thinker, an expert, a communicator, a mentor, and an achiever of organizational goals. This article explores the organizational context that supports achievement, measures of quality nursing care, fiscal accountability, leadership development, rewards and punishments, and the educational content and teaching strategies to prepare graduates to be achievers.

  20. SNP-array based whole genome homozygosity mapping: a quick and powerful tool to achieve an accurate diagnosis in LGMD2 patients.

    PubMed

    Papić, Lea; Fischer, Dirk; Trajanoski, Slave; Höftberger, Romana; Fischer, Carina; Ströbel, Thomas; Schmidt, Wolfgang M; Bittner, Reginald E; Schabhüttl, Maria; Gruber, Karin; Pieber, Thomas R; Janecke, Andreas R; Auer-Grumbach, Michaela

    2011-01-01

    A large number of novel disease genes have been identified by homozygosity mapping and the positional candidate approach. In this study we used single nucleotide polymorphism (SNP) array-based, whole genome homozygosity mapping as the first step to a molecular diagnosis in the highly heterogeneous muscle disease, limb girdle muscular dystrophy (LGMD). In a consanguineous family, both affected siblings showed homozygous blocks on chromosome 15 corresponding to the LGMD2A locus. Direct sequencing of CAPN3, encoding calpain-3, identified a homozygous deletion c.483delG (p.Ile162SerfsX17). In a sporadic LGMD patient complete absence of caveolin-3 on Western blot was observed. However, a mutation in CAV3 could not be detected. Homozygosity mapping revealed a large homozygous block at the LGMD2I locus, and direct sequencing of FKRP encoding fukutin-related-protein detected the common homozygous c.826 C>A (p.Leu276Ile) mutation. Subsequent re-examination of this patient's muscle biopsy showed aberrant α-dystroglycan glycosylation. In summary, we show that whole-genome homozygosity mapping using low cost SNP arrays provides a fast and non-invasive method to identify disease-causing mutations in sporadic patients or sibs from consanguineous families in LGMD2. Furthermore, this is the first study describing that in addition to PTRF, encoding polymerase I and transcript release factor, FKRP mutations may cause secondary caveolin-3 deficiency.

  1. [Update of planning tables of cholesterol-lowering therapy orientated to achieve LDL therapeutic targets].

    PubMed

    Masana, Luis; Plana, Núria

    2015-01-01

    This is the third update of a planning-table for use in cholesterol-lowering therapy, so as to obtain LDLc objectives. This is an easy to use laptop tool to help choose the best statin or combination therapy (statin plus ezetimibe) depending on the current LDL concentration of the patient, and the LDLc objective to achieve. It is based on a colour code that indicates the drugs that are efficient enough to help patients to achieve their LDL goal. Along with the table, recommendations are given for the best strategy in order to implement the optimal therapy in a maximum of two clinical encounters.

  2. SU-E-T-589: Optimization of Patient Head Angle Position to Spare Hippocampus During the Brain Radiation Therapy

    SciTech Connect

    Cheon, G; Kang, Y; Kang, S; Kim, T; Kim, D; Suh, T

    2015-06-15

    Purpose: Hippocampus is one of the important organs which controls emotions, behaviors, movements the memorizing and learning ability. In the conventional head & neck therapy position, it is difficult to perform the hippocampal-sparing brain radiation therapy. The purpose of this study is to investigate optimal head angle which can save the hippocampal-sparing and organ at risk (OAR) in conformal radiation therapy (CRT), Intensity modulation radiation therapy (IMRT) and helical tomotherapy (HT). Methods: Three types of radiation treatment plans, CRT, IMRT and Tomotherapy plans, were performed for 10 brain tumor patients. The image fusion between CT and MRI data were used in the contour due to the limited delineation of the target and OAR in the CT scan. The optimal condition plan was determined by comparing the dosimetric performance of the each plan with the use of various parameters which include three different techniques (CRT, IMRT, HT) and 4 angle (0, 15, 30, 40 degree). The each treatment plans of three different techniques were compared with the following parameters: conformity index (CI), homogeneity index (HI), target coverage, dose in the OARs, monitor units (MU), beam on time and the normal tissue complication probability (NTCP). Results: HI, CI and target coverage was most excellent in head angle 30 degree among all angle. When compared by modality, target coverage and CI showed good results in IMRT and TOMO than compared to the CRT. HI at the head angle 0 degrees is 1.137±0.17 (CRT), 1.085±0.09 (IMRT) and 1.077±0.06 (HT). HI at the head angle 30 degrees is 1.056±0.08 (CRT), 1.020±0.05 (IMRT) and 1.022±0.07 (HT). Conclusion: The results of our study show that when head angle tilted at 30 degree, target coverage, HI, CI were improved, and the dose delivered to OAR was reduced compared with conventional supine position in brain radiation therapy. This work was supported by the Radiation Technology R&D program (No. 2013M2A2A7043498) and the Mid

  3. Consultation on urological specimens from referred cancer patients using real-time digital microscopy: Optimizing the workflow

    PubMed Central

    Holten-Rossing, Henrik; Larsen, Lise Grupe; Toft, Birgitte Grønkær; Loya, Anand; Vainer, Ben

    2016-01-01

    Introduction: Centralization of cancer treatment entails a reassessment of the diagnostic tissue specimens. Packaging and shipment of glass slides from the local to the central pathology unit means that the standard procedure is time-consuming and that it is difficult to comply with governmental requirements. The aim was to evaluate whether real-time digital microscopy for urological cancer specimens during the primary diagnostic process can replace subsequent physical slide referral and reassessment without compromising diagnostic safety. Methods: From May to October 2014, tissue specimens from 130 patients with urological cancer received at Næstved Hospital's Pathology Department, and expected to be referred for further treatment at cancer unit of a university hospital, were diagnosed using standard light microscopy. In the event of diagnostic uncertainty, the VisionTek digital microscope (Sakura Finetek) was employed. The Pathology Department at Næstved Hospital was equipped with a digital microscope and three consultant pathologists were stationed at Rigshospitalet with workstations optimized for digital microscopy. Representative slides for each case were selected for consultation and live digital consultation took place over the telephone using remote access software. Time of start and finish for each case was logged. For the physically referred cases, time from arrival to sign-out was logged in the national pathology information system, and time spent on microscopy and reporting was noted manually. Diagnosis, number of involved biopsies, grade, and stage were compared between digital microscopy and conventional microscopy. Results: Complete data were available for all 130 cases. Standard procedure with referral of urological cancer specimens took a mean of 8 min 56 s for microscopy, reporting and sign-out per case. For live digital consultations, a mean of 18 min 37 s was spent on each consultation with 4 min 43 s for each case, depending on the number of

  4. OMEGA study: design, baseline data, metabolic syndrome prevalence in a large-scale observational study of hypertensive patients: The Olmesartan Mega Study to Determine the Relationship between Cardiovascular Endpoints and Blood Pressure Goal Achievement study.

    PubMed

    Teramoto, Tamio; Fujita, Toshiro; Kawamori, Ryuzo; Miyazaki, Shigeru; Teramukai, Satoshi; Igarashi, Masao

    2008-11-01

    Elevated systolic blood pressure increases the risk of cardiovascular events, as shown by a number of meta-analyses of large-scale clinical trials. As concerns the prognostic impact of the metabolic syndrome on cardiovascular events, few large-scale studies are available in the Japanese hypertensive population. The prospective, large-scale, observational OMEGA (Olmesartan Mega Study to Determine the Relationship between Cardiovascular Endpoints and Blood Pressure Goal Achievement) study sought to examine the relationship between the incidence of cardiovascular disease (CVD) and achieved blood pressure, metabolic syndrome, lifestyle factors and other risk factors for CVD in patients with hypertension. Of the 15,313 enrolled patients from 2,219 institutions in Japan, we report here the baseline characteristics of the 14,841 eligible patients whose baseline data were collected as of October 31, 2007. Men and women 50 to 79 years old (mean age 65) with physician-diagnosed hypertension were enrolled, and all patients were treated with open-label olmesartan medoxomil (5 to 40 mg daily). The majority of patients (75%) had mild to moderate hypertension. The prevalences of dyslipidemia and diabetes mellitus were 48% and 24%, respectively. The metabolic syndrome was identified in 48% and 19% of the evaluable men and women, respectively, using the criteria of the Japanese Society of Internal Medicine. Men with the metabolic syndrome were at the greatest risk for CVD, and a greater proportion of men than of women had all five metabolic syndrome components. The complete follow-up data from the OMEGA study will provide much-needed information to guide treatment in patients with hypertension and the metabolic syndrome. (Hypertens Res 2008; 31: 2011-2017).

  5. Central sensitization does not identify patients with carpal tunnel syndrome who are likely to achieve short-term success with physical therapy.

    PubMed

    Fernández-de-Las-Peñas, César; Cleland, Joshua A; Ortega-Santiago, Ricardo; de-la-Llave-Rincon, Ana Isabel; Martínez-Perez, Almudena; Pareja, Juan A

    2010-11-01

    The aim of the current study was to identify whether hyperexcitability of the central nervous system is a prognostic factor for individuals with carpal tunnel syndrome (CTS) likely to experience rapid and clinical self-reported improvement following a physical therapy program including soft tissue mobilization and nerve slider neurodynamic interventions. Women presenting with clinical and electrophysiological findings of CTS were involved in a prospective single-arm trial. Participants underwent a standardized examination and then a physical therapy session. The physical therapy sessions included both soft tissue mobilization directed at the anatomical sites of potential median nerve entrapment and a passive nerve slider neurodynamic technique targeted to the median nerve. Pressure pain thresholds (PPT) over the median, radial and ulnar nerves, C5-C6 zygapophyseal joint, carpal tunnel and tibialis anterior muscle were assessed bilaterally. Additionally, thermal detection and pain thresholds were measured over the carpal tunnel and thenar eminence bilaterally to evaluate central nervous system excitability. Subjects were classified as responders (having achieved a successful outcome) or non-responders based on self-perceived recovery. Variables were entered into a stepwise logistic regression model to determine the most accurate variables for determining prognosis. Data from 72 women were included in the analysis, of which 35 experienced a successful outcome (48.6%). Three variables including PPT over the C5-C6 joint affected side <137 kPa, HPT carpal tunnel affected side <39.6º and general health >66 points were identified. If 2 out of 3 variables were present (LR + 14.8), the likelihood of success increased from 48.6 to 93.3%. We identified 3 factors that may be associated with a rapid clinical response to both soft tissue mobilization and nerve slider neurodynamic techniques targeted to the median nerve in women presenting with CTS. Our results support that

  6. What’s the Optimal Lipids Level for Dialysis Patients? A Cohort Study from a Chinese Dialysis Center in a University Hospital

    PubMed Central

    Yang, Wen- Ling

    2016-01-01

    Background With lipid level being a major contributing factor for cardiovascular health, the high cardiovascular mortality among dialysis patients has raised substantial concerns in regard to the optimal lipid level in these patient population. Objective To explore the optimal lipid level for the survival of dialysis patients. Methods The lipid profile was measured for each patient. All participants were followed throughout the course of the study. Cox proportional hazards analysis was performed to analyze the prognostic value of lipid level on the survival of these patients. Results In our study that included 311 stable maintenance dialysis patients, 54.98% of the participants had LDL-C level ≥100 mg/dl and 82.91% of the patients with triglycerides ≥200 mg/dl had non-HDL level ≥130 mg/dl. During the follow-up period of 48.0 (18.0, 55.5) months, 149 (47.91%) participants died. Among those who died, 59 patients died of cardiovascular disease (CVD) and 33 patients died of ischemic CVD (12.0, 4.7, and 2.7 events per 100 patient-years, respectively). Patients with LDL-C 100–130 mg/dl or non-HDL 130–160 mg/dl had a lower all-cause mortality rate than those who did not meet these criteria. After adjusting for the traditional and ESRD-related risk factors, non-HDL was found to be the independent risk factor for the all-cause mortality. Compared to those patients with non-HDL 130–160 mg/dl, patients with non-HDL <100 mg/dl, 100–130 mg/dl, 160–190 mg/dl, or ≥190 mg/dl all had higher all-cause mortality: HR (95% CI) 3.207 (1.801, 5.713), 2.493 (1.485, 4.184), 2.476 (1.423, 4.307), and 1.917 (1.099, 3.345), respectively. There were no differences in nutrition, comorbidity, and inflammation indices among the patients with different non-HDL groups. However, patients with non-HDL of 130–160 mg/dl had the lowest corrected calcium and calcium phosphate product values as compared with other non-HDL groups. Conclusion Our study demonstrated that non-HDL 130–160

  7. SU-E-T-256: Optimizing the Combination of Targeted Radionuclide Therapy Agents Using a Multi-Scale Patient-Specific Monte Carlo Dosimetry Platform

    SciTech Connect

    Besemer, A; Bednarz, B; Titz, B; Grudzinski, J; Weichert, J; Hall, L

    2014-06-01

    Purpose: Combination targeted radionuclide therapy (TRT) is appealing because it can potentially exploit different mechanisms of action from multiple radionuclides as well as the variable dose rates due to the different radionuclide half-lives. The work describes the development of a multiobjective optimization algorithm to calculate the optimal ratio of radionuclide injection activities for delivery of combination TRT. Methods: The ‘diapeutic’ (diagnostic and therapeutic) agent, CLR1404, was used as a proof-of-principle compound in this work. Isosteric iodine substitution in CLR1404 creates a molecular imaging agent when labeled with I-124 or a targeted radiotherapeutic agent when labeled with I-125 or I-131. PET/CT images of high grade glioma patients were acquired at 4.5, 24, and 48 hours post injection of 124I-CLR1404. The therapeutic 131I-CLR1404 and 125ICLR1404 absorbed dose (AD) and biological effective dose (BED) were calculated for each patient using a patient-specific Monte Carlo dosimetry platform. The optimal ratio of injection activities for each radionuclide was calculated with a multi-objective optimization algorithm using the weighted sum method. Objective functions such as the tumor dose heterogeneity and the ratio of the normal tissue to tumor doses were minimized and the relative importance weights of each optimization function were varied. Results: For each optimization function, the program outputs a Pareto surface map representing all possible combinations of radionuclide injection activities so that values that minimize the objective function can be visualized. A Pareto surface map of the weighted sum given a set of user-specified importance weights is also displayed. Additionally, the ratio of optimal injection activities as a function of the all possible importance weights is generated so that the user can select the optimal ratio based on the desired weights. Conclusion: Multi-objective optimization of radionuclide injection activities

  8. Perioperative optimal blood pressure as determined by ultrasound tagged near infrared spectroscopy and its association with postoperative acute kidney injury in cardiac surgery patients

    PubMed Central

    Hori, Daijiro; Hogue, Charles; Adachi, Hideo; Max, Laura; Price, Joel; Sciortino, Christopher; Zehr, Kenton; Conte, John; Cameron, Duke; Mandal, Kaushik

    2016-01-01

    OBJECTIVES Perioperative blood pressure management by targeting individualized optimal blood pressure, determined by cerebral blood flow autoregulation monitoring, may ensure sufficient renal perfusion. The purpose of this study was to evaluate changes in the optimal blood pressure for individual patients, determined during cardiopulmonary bypass (CPB) and during early postoperative period in intensive care unit (ICU). A secondary aim was to examine if excursions below optimal blood pressure in the ICU are associated with risk of cardiac surgery-associated acute kidney injury (CSA-AKI). METHODS One hundred and ten patients undergoing cardiac surgery had cerebral blood flow monitored with a novel technology using ultrasound tagged near infrared spectroscopy (UT-NIRS) during CPB and in the first 3 h after surgery in the ICU. The correlation flow index (CFx) was calculated as a moving, linear correlation coefficient between cerebral flow index measured using UT-NIRS and mean arterial pressure (MAP). Optimal blood pressure was defined as the MAP with the lowest CFx. Changes in optimal blood pressure in the perioperative period were observed and the association of blood pressure excursions (magnitude and duration) below the optimal blood pressure [area under the curve (AUC) < OptMAP mmHgxh] with incidence of CSA-AKI (defined using Kidney Disease: Improving Global Outcomes criteria) was examined. RESULTS Optimal blood pressure during early ICU stay and CPB was correlated (r = 0.46, P < 0.0001), but was significantly higher in the ICU compared with during CPB (75 ± 8.7 vs 71 ± 10.3 mmHg, P = 0.0002). Thirty patients (27.3%) developed CSA-AKI within 48 h after the surgery. AUC < OptMAP was associated with CSA-AKI during CPB [median, 13.27 mmHgxh, interquartile range (IQR), 4.63–20.14 vs median, 6.05 mmHgxh, IQR 3.03–12.40, P = 0.008], and in the ICU (13.72 mmHgxh, IQR 5.09–25.54 vs 5.65 mmHgxh, IQR 1.71–13.07, P = 0.022). CONCLUSIONS Optimal blood pressure during

  9. Optimal Cutoff Levels of More Sensitive Cardiac Troponin Assays for the Early Diagnosis of Myocardial Infarction in Patients With Renal Dysfunction

    PubMed Central

    Twerenbold, Raphael; Wildi, Karin; Jaeger, Cedric; Gimenez, Maria Rubini; Reiter, Miriam; Reichlin, Tobias; Walukiewicz, Astrid; Gugala, Mathias; Krivoshei, Lian; Marti, Nadine; Moreno Weidmann, Zoraida; Hillinger, Petra; Puelacher, Christian; Rentsch, Katharina; Honegger, Ursina; Schumacher, Carmela; Zurbriggen, Felicitas; Freese, Michael; Stelzig, Claudia; Campodarve, Isabel; Bassetti, Stefano; Osswald, Stefan

    2015-01-01

    Background— It is unknown whether more sensitive cardiac troponin (cTn) assays maintain their clinical utility in patients with renal dysfunction. Moreover, their optimal cutoff levels in this vulnerable patient population have not previously been defined. Methods and Results— In this multicenter study, we examined the clinical utility of 7 more sensitive cTn assays (3 sensitive and 4 high-sensitivity cTn assays) in patients presenting with symptoms suggestive of acute myocardial infarction. Among 2813 unselected patients, 447 (16%) had renal dysfunction (defined as Modification of Diet in Renal Disease–estimated glomerular filtration rate <60 mL·min−1·1.73 m−2). The final diagnosis was centrally adjudicated by 2 independent cardiologists using all available information, including coronary angiography and serial levels of high-sensitivity cTnT. Acute myocardial infarction was the final diagnosis in 36% of all patients with renal dysfunction. Among patients with renal dysfunction and elevated baseline cTn levels (≥99th percentile), acute myocardial infarction was the most common diagnosis for all assays (range, 45%–80%). In patients with renal dysfunction, diagnostic accuracy at presentation, quantified by the area under the receiver-operator characteristic curve, was 0.87 to 0.89 with no significant differences between the 7 more sensitive cTn assays and further increased to 0.91 to 0.95 at 3 hours. Overall, the area under the receiver-operator characteristic curve in patients with renal dysfunction was only slightly lower than in patients with normal renal function. The optimal receiver-operator characteristic curve–derived cTn cutoff levels in patients with renal dysfunction were significantly higher compared with those in patients with normal renal function (factor, 1.9–3.4). Conclusions— More sensitive cTn assays maintain high diagnostic accuracy in patients with renal dysfunction. To ensure the best possible clinical use, assay

  10. Comparing Science Achievement Constructs: Targeted and Achieved

    ERIC Educational Resources Information Center

    Ferrara, Steve; Duncan, Teresa

    2011-01-01

    This article illustrates how test specifications based solely on academic content standards, without attention to other cognitive skills and item response demands, can fall short of their targeted constructs. First, the authors inductively describe the science achievement construct represented by a statewide sixth-grade science proficiency test.…

  11. Which Achievement Gap?

    ERIC Educational Resources Information Center

    Anderson, Sharon; Medrich, Elliott; Fowler, Donna

    2007-01-01

    From the halls of Congress to the local elementary school, conversations on education reform have tossed around the term "achievement gap" as though people all know precisely what that means. As it's commonly used, "achievement gap" refers to the differences in scores on state or national achievement tests between various…

  12. Optimized polymerase chain reaction-based single-strand conformation polymorphism analysis of p53 gene applied to Bulgarian patients with invasive breast cancer.

    PubMed

    Krasteva, M E; Garanina, Z; Georgieva, E I

    2003-11-01

    During the last few decades a substantial amount of evidence has accumulated proving that the abrogation of the normal p53 pathway is a critical step in the initiation and progression of tumors. Decoding the genetic mechanisms involved in carcinogenesis requires screening for consistent genetic tumor alterations, including those concerning the p53 gene. Thus, practical, efficient, and inexpensive techniques for accurate determination of p53 mutational status are needed. Polymerase chain reaction/single-strand conformation polymorphism (PCR-SSCP) analysis is considered to be a useful tool to investigate the role of the p53 gene in the development and progression of human cancers. The sensitivity of the method can be increased considerably by varying the experimental conditions. Here we demonstrate a scheme of PCR-SSCP optimization for detection of p53 gene mutations of patients with various cancers. Optimal conditions for PCRSSCP of p53 exons 4-9 are reported. Such PCR-SSCP optimization could allow an increase in the sensitivity and reproducibility of the technique and facilitates screening of large series of patients to assess the clinical significance of p53 mutations in human cancers. Using the optimized PCR-SSCP analysis we screened Bulgarian patients with invasive breast cancer for p53 gene mutations and registered a 33.33% frequency of mutations. To date, there are no data concerning the p53 status of Bulgarian breast cancer patients. Screening for p53 gene mutations enables an accurate and routine determination of the p53 status of patients with cancer and may be applied in clinical oncology to cancer diagnosis, prediction of prognosis and response to treatment.

  13. Prospective Optimization.

    PubMed

    Sejnowski, Terrence J; Poizner, Howard; Lynch, Gary; Gepshtein, Sergei; Greenspan, Ralph J

    2014-05-01

    Human performance approaches that of an ideal observer and optimal actor in some perceptual and motor tasks. These optimal abilities depend on the capacity of the cerebral cortex to store an immense amount of information and to flexibly make rapid decisions. However, behavior only approaches these limits after a long period of learning while the cerebral cortex interacts with the basal ganglia, an ancient part of the vertebrate brain that is responsible for learning sequences of actions directed toward achieving goals. Progress has been made in understanding the algorithms used by the brain during reinforcement learning, which is an online approximation of dynamic programming. Humans also make plans that depend on past experience by simulating different scenarios, which is called prospective optimization. The same brain structures in the cortex and basal ganglia that are active online during optimal behavior are also active offline during prospective optimization. The emergence of general principles and algorithms for goal-directed behavior has consequences for the development of autonomous devices in engineering applications.

  14. Prospective Optimization

    PubMed Central

    Sejnowski, Terrence J.; Poizner, Howard; Lynch, Gary; Gepshtein, Sergei; Greenspan, Ralph J.

    2014-01-01

    Human performance approaches that of an ideal observer and optimal actor in some perceptual and motor tasks. These optimal abilities depend on the capacity of the cerebral cortex to store an immense amount of information and to flexibly make rapid decisions. However, behavior only approaches these limits after a long period of learning while the cerebral cortex interacts with the basal ganglia, an ancient part of the vertebrate brain that is responsible for learning sequences of actions directed toward achieving goals. Progress has been made in understanding the algorithms used by the brain during reinforcement learning, which is an online approximation of dynamic programming. Humans also make plans that depend on past experience by simulating different scenarios, which is called prospective optimization. The same brain structures in the cortex and basal ganglia that are active online during optimal behavior are also active offline during prospective optimization. The emergence of general principles and algorithms for goal-directed behavior has consequences for the development of autonomous devices in engineering applications. PMID:25328167

  15. Calibrating the High Density Magnetic Port within Tissue Expanders to Achieve more Accurate Dose Calculations for Postmastectomy Patients with Immediate Breast Reconstruction

    NASA Astrophysics Data System (ADS)

    Jones, Jasmine; Zhang, Rui; Heins, David; Castle, Katherine

    In postmastectomy radiotherapy, an increasing number of patients have tissue expanders inserted subpectorally when receiving immediate breast reconstruction. These tissue expanders are composed of silicone and are inflated with saline through an internal metallic port; this serves the purpose of stretching the muscle and skin tissue over time, in order to house a permanent implant. The issue with administering radiation therapy in the presence of a tissue expander is that the port's magnetic core can potentially perturb the dose delivered to the Planning Target Volume, causing significant artifacts in CT images. Several studies have explored this problem, and suggest that density corrections must be accounted for in treatment planning. However, very few studies accurately calibrated commercial TP systems for the high density material used in the port, and no studies employed fusion imaging to yield a more accurate contour of the port in treatment planning. We compared depth dose values in the water phantom between measurement and TPS calculations, and we were able to overcome some of the inhomogeneities presented by the image artifact by fusing the KVCT and MVCT images of the tissue expander together, resulting in a more precise comparison of dose calculations at discrete locations. We expect this method to be pivotal in the quantification of dose distribution in the PTV. Research funded by the LS-AMP Award.

  16. The electronic medical office: optimizing solutions.

    PubMed

    Kirschenbaum, Ira H; Mabrey, Jay D; Wood, George W; Alexander, A Herbert; Rhoades, Charles E; Alexander, Ian J; Golladay, Gregory J; Wheeless, Clifford

    2008-01-01

    Optimizing the care for patients in the orthopaedic clinical setting involves a wide range of issues. Surgical techniques, preoperative and postoperative care, long-term outcomes follow-up, continuing education, and patient communication are a few of the important areas that surgeons deal with on a regular basis. Successful management of this information has an impact on clinical outcomes, direct patient care, financial decisions, and management of the surgeon's time. The development of a comprehensive electronic medical office is a powerful and probably necessary tool to successfully manage such information and achieve the goals of an effective and safe orthopaedic practice.

  17. Addition of hydrochlorothiazide to angiotensin receptor blocker therapy can achieve a lower sodium balance with no acceleration of intrarenal renin angiotensin system in patients with chronic kidney disease

    PubMed Central

    Fuwa, Daisuke; Fukuda, Michio; Ogiyama, Yoshiaki; Sato, Ryo; Mizuno, Masashi; Miura, Toshiyuki; Abe-Dohmae, Sumiko; Michikawa, Makoto; Kobori, Hiroyuki; Ohte, Nobuyuki

    2016-01-01

    Objective Angiotensin receptor blockers (ARBs) produce a lower sodium (Na) balance, and the natriuretic effect is enhanced under Na deprivation, despite falls in blood pressure (BP) and glomerular filtration rate (GFR). Methods The effect of additional hydrochlorothiazide (HCTZ; 12.5 mg/day) to ARB treatment (valsartan; 80 mg/day) on glomerulotubular Na balance was evaluated in 23 patients with chronic kidney disease. Results Add-on HCTZ decreased GFR, tubular Na load, and tubular Na reabsorption (tNa), although 24-hour urinary Na excretion (UNaV) remained constant. Daily urinary angiotensinogen excretion (UAGTV, 152±10→82±17 μg/g Cre) reduced (p=0.02). Changes in tubular Na load (r2=0.26) and tNa (r2=0.25) correlated with baseline 24-hour UAGTV. Changes in filtered Na load correlated with changes in nighttime systolic BP (r2=0.17), but not with changes in daytime systolic BP. The change in the tNa to filtered Na load ratio was influenced by the change in daytime UNaV (β=−0.67, F=16.8), rather than the change in nighttime UNaV. Conclusions Lower Na balance was produced by add-on HCTZ to ARB treatment without an increase of intra-renal renin-angiotensin system activity, leading to restoration of nocturnal hypertension. A further study is needed to demonstrate that the reduction of UAGTV by additional diuretics to ARBs prevents the progression of nephropathy or cardiovascular events. PMID:27283968

  18. [Optimization of accounting for radiation exposure of patients as a basis for assessing the risk of stochastic effects due to medical X-ray diagnostic irradiation].

    PubMed

    Kalinina, M V; Zhukova, T V; Kononenko, N A

    2013-01-01

    The work is devoted to optimization of the control and accounting for radiation exposure of patients in the X-ray examinations by means of improving existing forms of state statistical survey (form #3-DOZ.). The analysis of the radiation exposure of patients in medical institutions of the Rostov region for the period of 2005-2011 was carried out. It is proposed to exclude the information about the individual patient doses received by calculation; differentiate a group of "adult patients' on age and gender, selecting the reproductive age, discriminate as a separate category of dose-generating, intervention methods of research that will allow to more accurately calculate the risk of the development of stochastic effects of the medical radiation exposure to population.

  19. Practical tips and tricks in cardiovascular computed tomography: patient preparation for optimization of cardiovascular CT data acquisition.

    PubMed

    Halliburton, Sandra Simon; Abbara, Suhny

    2007-07-01

    The acquisition of diagnostic cardiovascular computed tomography (CT) images requires careful preparation of the patient before scanning. Guidelines for patient preparation are largely dictated by scanner capabilities and the technical limits they impose on patient-specific characteristics. The objective of this paper is to highlight procedures for patient screening, premedication, instruction, positioning, and electrocardiographic (ECG) lead placement. Awareness of scanner limitations and adherence to patient preparation guidelines can significantly improve CT image quality and diagnostic yield.

  20. The effect of post-discharge educational intervention on patients in achieving objectives in modifiable risk factors six months after discharge following an episode of acute coronary syndrome, (CAM-2 Project): a randomized controlled trial

    PubMed Central

    2010-01-01

    Objectives We investigated whether an intervention mainly consisting of a signed agreement between patient and physician on the objectives to be reached, improves reaching these secondary prevention objectives in modifiable cardiovascular risk factors six-months after discharge following an acute coronary syndrome. Background There is room to improve mid-term adherence to clinical guidelines' recommendations in coronary heart disease secondary prevention, specially non-pharmacological ones, often neglected. Methods In CAM-2, patients discharged after an acute coronary syndrome were randomly assigned to the intervention or the usual care group. The primary outcome was reaching therapeutic objectives in various secondary prevention variables: smoking, obesity, blood lipids, blood pressure control, exercise and taking of medication. Results 1757 patients were recruited in 64 hospitals and 1510 (762 in the intervention and 748 in the control group) attended the six-months follow-up visit. After adjustment for potentially important variables, there were, between the intervention and control group, differences in the mean reduction of body mass index (0.5 vs. 0.2; p < 0.001) and waist circumference (1.6 cm vs. 0.6 cm; p = 0.05), proportion of patients who exercise regularly and those with total cholesterol below 175 mg/dl (64.7% vs. 56.5%; p = 0.001). The reported intake of medications was high in both groups for all the drugs considered with no differences except for statins (98.1% vs. 95.9%; p = 0.029). Conclusions At least in the short term, lifestyle changes among coronary heart disease patients are achievable by intensifying the responsibility of the patient himself by means of a simple and feasible intervention. PMID:21092191

  1. Comparison of PCSK9 Inhibitor Evolocumab vs Ezetimibe in Statin-Intolerant Patients: Design of the Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin-Intolerant Subjects 3 (GAUSS-3) Trial.

    PubMed

    Nissen, Steven E; Dent-Acosta, Ricardo E; Rosenson, Robert S; Stroes, Erik; Sattar, Naveed; Preiss, David; Mancini, G B John; Ballantyne, Christie M; Catapano, Alberico; Gouni-Berthold, Ioanna; Stein, Evan A; Xue, Allen; Wasserman, Scott M; Scott, Rob; Thompson, Paul D

    2016-03-01

    Statins are the accepted standard for lowering low-density lipoprotein cholesterol (LDL-C). However, 5% to 10% of statin-treated patients report intolerance, mostly due to muscle-related adverse effects. Challenges exist to objective identification of statin-intolerant patients. Evolocumab is a monoclonal antibody that binds proprotein convertase subtilisin/kexin type 9 (PCSK9), resulting in marked LDL-C reduction. We report the design of Goal Achievement After Utilizing an Anti-PCSK9 Antibody in Statin-Intolerant Subjects 3 (GAUSS-3), a phase 3, multicenter, randomized, double-blind, ezetimibe-controlled study to compare effectiveness of 24 weeks of evolocumab 420 mg monthly vs ezetimibe 10 mg daily in hypercholesterolemic patients unable to tolerate an effective statin dose. The study incorporates a novel atorvastatin-controlled, double-blind, crossover phase to objectively identify statin intolerance. Eligible patients had LDL-C above the National Cholesterol Education Project Adult Treatment Panel III target level for the appropriate coronary heart disease risk category and were unable to tolerate ≥3 statins or 2 statins (one of which was atorvastatin ≤10 mg/d) or had a history of marked creatine kinase elevation accompanied by muscle symptoms while on 1 statin. This trial has 2 co-primary endpoints: mean percent change from baseline in LDL-C at weeks 22 and 24 and percent change from baseline in LDL-C at week 24. Key secondary efficacy endpoints include change from baseline in LDL-C, percent of patients attaining LDL-C <70 mg/dL (1.81 mmol/L), and percent change from baseline in total cholesterol, non-high-density lipoprotein cholesterol, and apolipoprotein B. Recruitment of 511 patients was completed on November 28, 2014.

  2. Factors Associated With Optimal Long-Term Cosmetic Results in Patients Treated With Accelerated Partial Breast Irradiation Using Balloon-Based Brachytherapy

    SciTech Connect

    Vicini, Frank A.; Keisch, Martin; Shah, Chirag; Goyal, Sharad; Khan, Atif J.; Beitsch, Peter D.; Lyden, Maureen; Haffty, Bruce G.

    2012-06-01

    Purpose: To evaluate factors associated with optimal cosmetic results at 72 months for early-stage breast cancer patients treated with Mammosite balloon-based accelerated partial breast irradiation (APBI). Methods and Materials: A total of 1,440 patients (1,449 cases) with early-stage breast cancer undergoing breast-conserving therapy were treated with balloon-based brachytherapy to deliver APBI (34 Gy in 3.4-Gy fractions). Cosmetic outcome was evaluated at each follow-up visit and dichotomized as excellent/good (E/G) or fair/poor (F/P). Follow-up was evaluated at 36 and 72 months to establish long-term cosmesis, stability of cosmesis, and factors associated with optimal results. Results: The percentage of evaluable patients with excellent/good (E/G) cosmetic results at 36 months and more than 72 months were 93.3% (n = 708/759) and 90.4% (n = 235/260). Factors associated with optimal cosmetic results at 72 months included: larger skin spacing (p = 0.04) and T1 tumors (p = 0.02). Using multiple regression analysis, the only factors predictive of worse cosmetic outcome at 72 months were smaller skin spacing (odds ratio [OR], 0.89; confidence interval [CI], 0.80-0.99) and tumors greater than 2 cm (OR, 4.96, CI, 1.53-16.07). In all, 227 patients had both a 36-month and a 72-month cosmetic evaluation. The number of patients with E/G cosmetic results decreased only slightly from 93.4% at 3 years to 90.8% (p = 0.13) at 6 years, respectively. Conclusions: APBI delivered with balloon-based brachytherapy produced E/G cosmetic results in 90.4% of cases at 6 years. Larger tumors (T2) and smaller skin spacing were found to be the two most important independent predictors of cosmesis.

  3. Living donor liver transplantation for hepatocellular carcinoma achieves better outcomes

    PubMed Central

    Lin, Chih-Che

    2016-01-01

    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

  4. 'No delays achiever'.

    PubMed

    2007-05-01

    The latest version of the NHS Institute for Innovation and Improvement's 'no delays achiever', a web based tool created to help NHS organisations achieve the 18-week target for GP referrals to first treatment, is available at www.nodelaysachiever.nhs.uk.

  5. Vicarious Achievement Orientation.

    ERIC Educational Resources Information Center

    Leavitt, Harold J.; And Others

    This study tests hypotheses about achievement orientation, particularly vicarious achievement. Undergraduate students (N=437) completed multiple-choice questionnaires, indicating likely responses of one person to the success of another. The sex of succeeder and observer, closeness of relationship, and setting (medical school or graduate school of…

  6. Heritability of Creative Achievement

    ERIC Educational Resources Information Center

    Piffer, Davide; Hur, Yoon-Mi

    2014-01-01

    Although creative achievement is a subject of much attention to lay people, the origin of individual differences in creative accomplishments remain poorly understood. This study examined genetic and environmental influences on creative achievement in an adult sample of 338 twins (mean age = 26.3 years; SD = 6.6 years). Twins completed the Creative…

  7. Confronting the Achievement Gap

    ERIC Educational Resources Information Center

    Gardner, David

    2007-01-01

    This article talks about the large achievement gap between children of color and their white peers. The reasons for the achievement gap are varied. First, many urban minorities come from a background of poverty. One of the detrimental effects of growing up in poverty is receiving inadequate nourishment at a time when bodies and brains are rapidly…

  8. Achievement-Based Resourcing.

    ERIC Educational Resources Information Center

    Fletcher, Mike; And Others

    1992-01-01

    This collection of seven articles examines achievement-based resourcing (ABR), the concept that the funding of educational institutions should be linked to their success in promoting student achievement, with a focus on the application of ABR to postsecondary education in the United Kingdom. The articles include: (1) "Introduction" (Mick…

  9. States Address Achievement Gaps.

    ERIC Educational Resources Information Center

    Christie, Kathy

    2002-01-01

    Summarizes 2 state initiatives to address the achievement gap: North Carolina's report by the Advisory Commission on Raising Achievement and Closing Gaps, containing an 11-point strategy, and Kentucky's legislation putting in place 10 specific processes. The North Carolina report is available at www.dpi.state.nc.us.closingthegap; Kentucky's…

  10. Gear optimization

    NASA Technical Reports Server (NTRS)

    Vanderplaats, G. N.; Chen, Xiang; Zhang, Ning-Tian

    1988-01-01

    The use of formal numerical optimization methods for the design of gears is investigated. To achieve this, computer codes were developed for the analysis of spur gears and spiral bevel gears. These codes calculate the life, dynamic load, bending strength, surface durability, gear weight and size, and various geometric parameters. It is necessary to calculate all such important responses because they all represent competing requirements in the design process. The codes developed here were written in subroutine form and coupled to the COPES/ADS general purpose optimization program. This code allows the user to define the optimization problem at the time of program execution. Typical design variables include face width, number of teeth and diametral pitch. The user is free to choose any calculated response as the design objective to minimize or maximize and may impose lower and upper bounds on any calculated responses. Typical examples include life maximization with limits on dynamic load, stress, weight, etc. or minimization of weight subject to limits on life, dynamic load, etc. The research codes were written in modular form for easy expansion and so that they could be combined to create a multiple reduction optimization capability in future.

  11. 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.

  12. Optimizing drug therapy in patients with cardiovascular disease: the impact of pharmacist-managed pharmacotherapy clinics in a primary care setting.

    PubMed

    Geber, Jean; Parra, David; Beckey, Nick P; Korman, Lisa

    2002-06-01

    We evaluated the effectiveness of pharmacist-managed pharmacotherapy clinics in implementing and maximizing therapy with agents known to reduce the morbidity and mortality associated with cardiovascular disease. This was a retrospective chart review of 150 patients who were treated for coronary artery disease in primary care clinics. Appropriate treatment of hypercholesterolem