Patient safety trilogy: perspectives from clinical engineering.

PubMed

Gieras, Izabella; Sherman, Paul; Minsent, Dennis

2013-01-01

This article examines the role a clinical engineering or healthcare technology management (HTM) department can play in promoting patient safety from three different perspectives: a community hospital, a national government health system, and an academic medical center. After a general overview, Izabella Gieras from Huntington Hospital in Pasadena, CA, leads off by examining the growing role of human factors in healthcare technology, and describing how her facility uses clinical simulations in medical equipment evaluations. A section by Paul Sherman follows, examining patient safety initiatives from the perspective of the Veterans Health Administration with a focus on hazard alerts and recalls. Dennis Minsent from Oregon Health & Science University writes about patient safety from an academic healthcare perspective, and details how clinical engineers can engage in multidisciplinary safety opportunities.

Reliability of the OSCE for Physical and Occupational Therapists

PubMed Central

Sakurai, Hiroaki; Kanada, Yoshikiyo; Sugiura, Yoshito; Motoya, Ikuo; Wada, Yosuke; Yamada, Masayuki; Tomita, Masao; Tanabe, Shigeo; Teranishi, Toshio; Tsujimura, Toru; Sawa, Syunji; Okanishi, Tetsuo

2014-01-01

[Purpose] To examine agreement rates between faculty members and clinical supervisors as OSCE examiners. [Subjects] The study subjects were involved physical and occupational therapists working in clinical environments for 1 to 5 years after graduating from training schools as OSCE examinees, and a physical or occupational therapy faculty member and a clinical supervisor as examiners. Another clinical supervisor acted as a simulated patient. [Methods] The agreement rate between the examiners for each OSCE item was calculated based on Cohen’s kappa coefficient to confirm inter-rater reliability. [Results] The agreement rates for the behavioral aspects of the items were higher in the second than in the first examination. Similar increases were also observed in the agreement rates for the technical aspects until the initiation of each activity; however, the rates decreased during the middle to terminal stages of continuous movements. [Conclusion] The results may reflect the recent implementation of measures for the integration of therapist education in training schools and clinical training facilities. PMID:25202170

Comparative Effectiveness Study to Assess Two Examination Modalities Used to Detect Dental Caries in Preschool Urban Children

PubMed Central

Billings, Ronald J.

2013-01-01

Abstract Background: Dental caries affecting the primary dentition of U.S. children continues to be the most prevalent chronic childhood disease. Preventive screening for dental caries in toddlers by dental professionals is labor-intensive and costly. Studies are warranted to examine innovative screening modalities that reduce cost, are less labor-intensive, and have the potential to identify caries in high-risk children. Subjects and Methods: Two hundred ninety-one children were randomized into two groups: Group 1 received a traditional, visual tactile examination initially and follow up-examinations at 6 and 12 months, and Group 2 received a teledentistry examination initially and follow-up examinations at 6 and 12 months. The mean primary tooth decayed and filled surfaces (dfs) scores were calculated for all children at baseline and 6 and 12 months. Results: At baseline, the mean dfs score for children examined by means of teledentistry was 2.19, and for the children examined by means of the traditional method, the mean was 1.27; the means were not significantly different. At the 12-month examination, the mean dfs score for the children examined by means of teledentistry was 3.02, and for the children examined by means of the clinical method, the mean dfs was 1.70; the means were not significantly different. At 12 months the mean fillings score for the children examined by means of teledentistry was 1.43 and for the children examined by means of the clinical method was 0.51; the means were statistically significantly different (p<0.001). Conclusions: These results suggest that the teledentistry examinations were comparable to clinical examinations when screening for early childhood caries in preschool children. The data further showed that color printouts of teeth with cavities provided to parents of children who received teledentistry screenings promoted oral healthcare utilization, as children from the teledentistry study group received more dental care than children from the clinical study group. PMID:24053114

Direct questioning is more effective than patient-initiated report for the detection of sexually transmitted infections in a primary care HIV clinic in Western Kenya.

PubMed

Woo, Victoria Gah Hay; Cohen, Craig R; Bukusi, Elizabeth A; Huchko, Megan J

2013-02-01

In resource-limited settings, detection of sexually transmitted infections (STIs) often relies on self-reported symptoms to initiate management. We found self-report demonstrated poor sensitivity for STI detection. Adding clinician-initiated questions about symptoms improved detection rates. Vaginal examination further increased sensitivity. Including clinician-initiated screening in resource-limited settings would improve management of treatable STIs.

A clinical report demonstrating the significance of distinguishing a nasopalatine duct cyst from a radicular cyst

PubMed Central

Aparna, Manikkath; Chakravarthy, Arumugam; Acharya, Shashi Rashmi; Radhakrishnan, Raghu

2014-01-01

Endodontic diagnosis is challenging and depends on the organisation of information from the patient history, clinical examination and analysis of the pulp, radiographic and histopathological assessment. A 35-year-old man was endodontically treated for radiolucency in relation to the roots of maxillary central incisors as it was a provisionally diagnosed case of radicular cyst. Since the palatal swelling persisted, the lesion was re-evaluated using relevant diagnostic aids and a diagnosis of nasopalatine duct cyst (NPDC) was made, which was missed during the initial assessment. An erroneous interpretation of cystic radiolucency in relation to maxillary central incisors can often lead to inappropriate treatment planning. This case highlights the relevant aspects in the diagnosis of NPDC when it is mistaken for a radicular cyst and emphasises the need for thorough clinical examination and relevant investigations for periapical radiolucencies of questionable origin before initiating endodontic therapy. PMID:24642171

Sociodemographic profile and predictors of outpatient clinic attendance among HIV-positive patients initiating antiretroviral therapy in Selangor, Malaysia.

PubMed

Abdulrahman, Surajudeen Abiola; Rampal, Lekhraj; Othman, Norlijah; Ibrahim, Faisal; Hayati, Kadir Shahar; Radhakrishnan, Anuradha P

2017-01-01

Inconsistent literature evidence suggests that sociodemographic, economic, and system- and patient-related factors are associated with clinic attendance among the HIV-positive population receiving antiretroviral therapy (ART) around the world. We examined the factors that predict outpatient clinic attendance among a cohort of HIV-positive patients initiating ART in Selangor, Malaysia. This cross-sectional study analyzed secondary data on outpatient clinic attendance and sociodemographic, economic, psychosocial, and patient-related factors among 242 adult Malaysian patients initiating ART in Selangor, Malaysia. Study cohort was enrolled in a parent randomized controlled trial (RCT) in Hospital Sungai Buloh Malaysia between January and December 2014, during which peer counseling, medication, and clinic appointment reminders were provided to the intervention group through short message service (SMS) and telephone calls for 24 consecutive weeks. Data on outpatient clinic attendance were extracted from the hospital electronic medical records system, while other patient-level data were extracted from pre-validated Adult AIDS Clinical Trial Group (AACTG) adherence questionnaires in which primary data were collected. Outpatient clinic attendance was categorized into binary outcome - regular attendee and defaulter categories - based on the number of missed scheduled outpatient clinic appointments within a 6-month period. Multivariate regression models were fitted to examine predictors of outpatient clinic attendance using SPSS version 22 and R software. A total of 224 (93%) patients who completed 6-month assessment were included in the model. Out of those, 42 (18.7%) defaulted scheduled clinic attendance at least once. Missed appointments were significantly more prevalent among females (n=10, 37.0%), rural residents (n=10, 38.5%), and bisexual respondents (n=8, 47.1%). Multivariate binary logistic regression analysis showed that Indian ethnicity (adjusted odds ratio [AOR] =0.235; 95% CI [0.063-0.869]; P =0.030) and heterosexual orientation (AOR =4.199; 95% CI [1.040-16.957]; P =0.044) were significant predictors of outpatient clinic attendance among HIV-positive patients receiving ART in Malaysia. Ethnicity and sexual orientation of Malaysian patients may play a significant role in their level of adherence to scheduled clinic appointments. These factors should be considered during collaborative adherence strategy planning at ART initiation.

Routine pelvic examinations: A descriptive cross-sectional survey of women's attitudes and beliefs after new guidelines.

PubMed

Kling, Juliana M; Vegunta, Suneela; Al-Badri, Mina; Faubion, Stephanie S; Fields, Heather E; Shah, Amit A; Wallace, Mark R; Ruddy, Barbara E; Bryan, Michael J; Temkit, M'hamed; MacLaughlin, Kathy L

2017-01-01

Routine pelvic examinations have been a fundamental part of the annual female examination. The 2014 American College of Physicians (ACP) guideline recommends against routine pelvic examinations in asymptomatic, nonpregnant, average-risk women. Our aim was to evaluate women's attitudes and beliefs about pelvic examinations and how knowledge of the new guidelines contributes to attitudes and beliefs. A descriptive cross-sectional study was performed using a self-administered written survey developed through literature review and pretested and revised on the basis of staff suggestions. Nonpregnant women age≥21years presenting to outpatient clinics at Mayo Clinic in Arizona or Mayo Clinic in Rochester, Minnesota, received the survey. After being asked about pelvic examination practices and beliefs, participants were informed of the ACP guideline, to determine effect on attitudes and beliefs. Demographic characteristics and pertinent medical history questions were collected from participants. In total, 671 women who were predominantly white, married, and educated completed surveys. Participants described pelvic examinations as reassuring, and a majority believed the examinations were useful in detecting ovarian cancer (74.6%), necessary for screening for sexually transmitted infections (STIs) (71.0%), or necessary before initiating contraception (67.0%). After reading the 2014 ACP guideline, significantly fewer women planned to continue yearly pelvic examinations (P<0.001). Despite evidence to the contrary, women believed pelvic examinations were necessary for STI screening, contraception initiation, and ovarian cancer detection. After education on the ACP screening guideline, fewer women planned to continue yearly pelvic examinations. Copyright © 2016 Elsevier Inc. All rights reserved.

An Examination of New York State's Integrated Primary and Mental Health Care Services for Adults with Serious Mental Illness.

PubMed

Scharf, Deborah M; Breslau, Joshua; Hackbarth, Nicole Schmidt; Kusuke, Daniela; Staplefoote, B Lynette; Pincus, Harold Alan

2014-12-30

The poor physical health of adults with serious mental illnesses is a public health crisis. Greater integration of mental health and primary medical care services at the clinic and system levels could address this need. In New York state, there are several ongoing initiatives that promote integrated care for adults with serious mental illness, provided or coordinated by community mental health center staff. This study examines three initiatives. Data were collected by RAND through site visits and surveys of mental health clinic administrators and associated professionals. Results showed that Primary and Behavioral Health Care Integration grantees developed infrastructure that supported a broad scope of primary and preventive health care services; these broad changes appeared to contribute to clinic-wide culture shifts toward integration and shared accountability for consumers' "whole person" health. Clinics participating in the Medicaid Incentive tended to implement only those services for which they could bill, which resulted in newly identified consumer physical health care needs but did not help consumers to connect to physical health care services. Finally, while administrators and providers were optimistic that Medicaid Health Homes have potential to improve access to care for adults with serious mental illness, the newness of the initiative made it difficult to assess the degree to which Health Home networks would meet these goals. We conclude with recommendations to state policymakers, clinical providers, and technical assistance providers and recommendations for future research, all designed to strengthen New York state's integrated care initiatives for adults with serious mental illness.

Examiner Training and Reliability in Two Randomized Clinical Trials of Adult Dental Caries

PubMed Central

Banting, David W.; Amaechi, Bennett T.; Bader, James D.; Blanchard, Peter; Gilbert, Gregg H.; Gullion, Christina M.; Holland, Jan Carlton; Makhija, Sonia K.; Papas, Athena; Ritter, André V.; Singh, Mabi L.; Vollmer, William M.

2013-01-01

Objectives This report describes the training of dental examiners participating in two dental caries clinical trials and reports the inter- and intra- examiner reliability scores from the initial standardization sessions. Methods Study examiners were trained to use a modified ICDAS-II system to detect the visual signs of non-cavitated and cavitated dental caries in adult subjects. Dental caries was classified as no caries (S), non-cavitated caries (D1), enamel caries (D2) and dentine caries (D3). Three standardization sessions involving 60 subjects and 3604 tooth surface calls were used to calculate several measures of examiner reliability. Results The prevalence of dental caries observed in the standardization sessions ranged from 1.4% to 13.5% of the coronal tooth surfaces examined. Overall agreement between pairs of examiners ranged from 0.88 to 0.99. An intra-class coefficient threshold of 0.60 was surpassed for all but one examiner. Inter-examiner unweighted kappa values were low (0.23– 0.35) but weighted kappas and the ratio of observed to maximum kappas were more encouraging (0.42– 0.83). The highest kappa values occurred for the S/D1 vs. D2/D3 two-level classification of dental caries, for which seven of the eight examiners achieved observed to maximum kappa values over 0.90.Intra-examiner reliability was notably higher than inter-examiner reliability for all measures and dental caries classification systems employed. Conclusion The methods and results for the initial examiner training and standardization sessions for two large clinical trials are reported. Recommendations for others planning examiner training and standardization sessions are offered. PMID:22320292

Examiner training and reliability in two randomized clinical trials of adult dental caries.

PubMed

Banting, David W; Amaechi, Bennett T; Bader, James D; Blanchard, Peter; Gilbert, Gregg H; Gullion, Christina M; Holland, Jan Carlton; Makhija, Sonia K; Papas, Athena; Ritter, André V; Singh, Mabi L; Vollmer, William M

2011-01-01

This report describes the training of dental examiners participating in two dental caries clinical trials and reports the inter- and intra-examiner reliability scores from the initial standardization sessions. Study examiners were trained to use a modified International Caries Detection and Assessment System II system to detect the visual signs of non-cavitated and cavitated dental caries in adult subjects. Dental caries was classified as no caries (S), non-cavitated caries (D1), enamel caries (D2), and dentine caries (D3). Three standardization sessions involving 60 subjects and 3,604 tooth surface calls were used to calculate several measures of examiner reliability. The prevalence of dental caries observed in the standardization sessions ranged from 1.4 percent to 13.5 percent of the coronal tooth surfaces examined. Overall agreement between pairs of examiners ranged from 0.88 to 0.99. An intra-class coefficient threshold of 0.60 was surpassed for all but one examiner. Inter-examiner unweighted kappa values were low (0.23-0.35), but weighted kappas and the ratio of observed to maximum kappas were more encouraging (0.42-0.83). The highest kappa values occurred for the S/D1 versus D2/D3 two-level classification of dental caries, for which seven of the eight examiners achieved observed to maximum kappa values over 0.90. Intra-examiner reliability was notably higher than inter-examiner reliability for all measures and dental caries classifications employed. The methods and results for the initial examiner training and standardization sessions for two large clinical trials are reported. Recommendations for others planning examiner training and standardization sessions are offered. © 2011 American Association of Public Health Dentistry.

The presence of nonthoracic distracting injuries does not affect the initial clinical examination of the cervical spine in evaluable blunt trauma patients: a prospective observational study.

PubMed

Konstantinidis, Agathoklis; Plurad, David; Barmparas, Galinos; Inaba, Kenji; Lam, Lydia; Bukur, Marko; Branco, Bernardino C; Demetriades, Demetrios

2011-09-01

A distracting injury mandates cervical spine (c-spine) imaging in the evaluable blunt trauma patient who demonstrates no pain or tenderness over the c-spine. The purpose of this study was to examine which distracting injuries can negatively affect the sensitivity of the standard clinical examination of the c-spine. This is a prospective observational study conducted at a Level I Trauma Center from January 1, 2008, to December 31, 2009. After institutional review board approval, all evaluable (Glasgow Coma Scale score ≥13) blunt trauma patients older than 16 years sustaining a c-spine injury were enrolled. A distracting injury was defined as any immediately evident bony or soft tissue injury or a complaint of non-c-spine pain whether or not an actual injury was subsequently diagnosed. Information regarding the initial clinical examination and the presence of a distracting injury was collected from the senior resident or attending trauma surgeon involved in the initial management. During the study period, 101 evaluable patients sustained a c-spine injury. Distracting injuries were present in 88 patients (87.1%). The most common was rib fracture (21.6%), followed by lower extremity fracture (20.5%) and upper extremity fracture (12.5%). Only four (4.0%) patients had no pain or tenderness on the initial examination of the c-spine. All four patients had bruising and tenderness to the upper anterior chest. None of these four patients developed neurologic sequelae or required a surgical stabilization or immobilization. C-spine imaging may not be required in the evaluable blunt trauma patient despite distracting injuries in any body regions that do not involve the upper chest. Further definition of distracting injuries is mandated to avoid unnecessary utilization of resources and to reduce the imaging burden associated with the evaluation of the c-spine.

A Review of "Research-Informed Clinical Practice" in Initial Teacher Education

ERIC Educational Resources Information Center

Burn, Katharine; Mutton, Trevor

2015-01-01

This review examines the kinds of relationship between research and practice that have been envisaged in programmes designed to provide opportunities for beginning teachers to engage in "research-informed clinical practice". Although the terminology varies, scope for inclusion is defined by an intention to facilitate and deepen the…

Ultrasound Detection of Soft Tissue Abscesses Performed by Non-Physician U.S. Army Medical Providers Naïve to Diagnostic Sonography.

PubMed

LaDuke, Mike; Monti, Jon; Cronin, Aaron; Gillum, Bart

2017-03-01

Patients commonly present to emergency rooms and primary care clinics with cellulitic skin infections with or without abscess formation. In military operational units, non-physician medical personnel provide most primary and initial emergency medical care. The objective of this study was to determine if, after minimal training, Army physician assistants and medics could use portable ultrasound (US) machines to detect superficial soft tissue abscesses. This was a single-blinded, randomized, prospective observational study conducted over the course of 2 days at a military installation. Active duty military physician assistants and medics with little or no US experience were recruited as participants. They received a short block of training on abscess detection using both clinical examination skills (inspection/palpation) and US examination. The participants were then asked to provide a yes/no answer regarding abscess presence in a chicken tissue model. Results were analyzed to assess the participants' abilities to detect abscesses, compare the diagnostic accuracy of their clinical examinations with their US examinations, and assess how often US results changed treatment plans initially on the basis of clinical examination findings alone. 22 participants performed a total of 220 clinical examinations and 220 US scans on 10 chicken tissue abscess models. Clinical examination for abscess detection yielded a sensitivity of 73.5% (95% confidence interval [CI], 65.3-80.3%) and a specificity of 77.2% (95% CI, 67.4-84.9%), although US examination for abscess detection yielded a sensitivity of 99.2% (95% CI, 95.4-99.9%) and a specificity of 95.5% (95% CI, 88.5-98.6%). Clinical examination yielded a diagnostic accuracy of 75.0% (95% CI, 68.9-80.3) although US examination yielded a diagnostic accuracy of 97.7% (95% CI, 94.6-99.2%), a difference in accuracy of 22.7% favoring US (p < 0.01). US changed the diagnosis in 56 of 220 cases (25.4% of all cases, p = 0.02). Of these 56 cases, US led to the correct diagnosis 53 of 56 times (94.6%). Non-physician military medical providers can be trained in a very brief period to use US to detect superficial soft tissue abscesses with excellent accuracy. Reprint & Copyright © 2017 Association of Military Surgeons of the U.S.

Relationship between quality improvement processes and clinical performance.

PubMed

Damberg, Cheryl L; Shortell, Stephen M; Raube, Kristiana; Gillies, Robin R; Rittenhouse, Diane; McCurdy, Rodney K; Casalino, Lawrence P; Adams, John

2010-08-01

To examine the association between performance on clinical process measures and intermediate outcomes and the use of chronic care management processes (CMPs), electronic medical record (EMR) capabilities, and participation in external quality improvement (QI) initiatives. Cross-sectional analysis of linked 2006 clinical performance scores from the Integrated Healthcare Association's pay-for-performance program and survey data from the 2nd National Study of Physician Organizations among 108 California physician organizations (POs). Controlling for differences in PO size, organization type (medical group or independent practice association), and Medicaid revenue, we used ordinary least squares regression analysis to examine the association between the use of CMPs, EMR capabilities, and external QI initiatives and performance on the following 3 clinical composite measures: diabetes management, processes of care, and intermediate outcomes (diabetes and cardiovascular). Greater use of CMPs was significantly associated with clinical performance: among POs using more than 5 CMPs, we observed a 3.2-point higher diabetes management score on a performance scale with scores ranging from 0 to 100 (P <.001), while for each 1.0-point increase on the CMP index, we observed a 1.0-point gain in intermediate outcomes (P <.001). Participation in external QI initiatives was positively associated with improved delivery of clinical processes of care: a 1.0-point increase on the QI index translated into a 1.4-point gain in processes-of-care performance (P = .02). No relationship was observed between EMR capabilities and performance. Greater investments in CMPs and QI interventions may help POs raise clinical performance and achieve success under performance-based accountability schemes.

Association Between Complementary and Alternative Medicine Use and Breast Cancer Chemotherapy Initiation: The Breast Cancer Quality of Care (BQUAL) Study.

PubMed

Greenlee, Heather; Neugut, Alfred I; Falci, Laura; Hillyer, Grace Clarke; Buono, Donna; Mandelblatt, Jeanne S; Roh, Janise M; Ergas, Isaac J; Kwan, Marilyn L; Lee, Marion; Tsai, Wei Yann; Shi, Zaixing; Lamerato, Lois; Kushi, Lawrence H; Hershman, Dawn L

2016-09-01

Not all women initiate clinically indicated breast cancer adjuvant treatment. It is important for clinicians to identify women at risk for noninitiation. To determine whether complementary and alternative medicine (CAM) use is associated with decreased breast cancer chemotherapy initiation. In this multisite prospective cohort study (the Breast Cancer Quality of Care [BQUAL] study) designed to examine predictors of breast cancer treatment initiation and adherence, 685 women younger than 70 years with nonmetastatic invasive breast cancer were recruited from Columbia University Medical Center, Kaiser Permanente Northern California, and Henry Ford Health System and enrolled between May 2006 and July 31, 2010. Overall, 306 patients (45%) were clinically indicated to receive chemotherapy per National Comprehensive Cancer Network guidelines. Participants were followed for up to 12 months. Baseline interviews assessed current use of 5 CAM modalities (vitamins and/or minerals, herbs and/or botanicals, other natural products, mind-body self-practice, mind-body practitioner-based practice). CAM use definitions included any use, dietary supplement use, mind-body use, and a CAM index summing the 5 modalities. Chemotherapy initiation was assessed via self-report up to 12 months after baseline. Multivariable logistic regression models examined a priori hypotheses testing whether CAM use was associated with chemotherapy initiation, adjusting for demographic and clinical covariates, and delineating groups by age and chemotherapy indication. A cohort of 685 women younger than 70 years (mean age, 59 years; median age, 59 years) with nonmetastatic invasive breast cancer were recruited and followed for up to 12 months to examine predictors of breast cancer treatment initiation. Baseline CAM use was reported by 598 women (87%). Chemotherapy was initiated by 272 women (89%) for whom chemotherapy was indicated, compared with 135 women (36%) for whom chemotherapy was discretionary. Among women for whom chemotherapy was indicated, dietary supplement users and women with high CAM index scores were less likely than nonusers to initiate chemotherapy (odds ratio [OR], 0.16; 95% CI, 0.03-0.51; and OR per unit, 0.64; 95% CI, 0.46-0.87, respectively). Use of mind-body practices was not related to chemotherapy initiation (OR, 1.45; 95% CI, 0.57-3.59). There was no association between CAM use and chemotherapy initiation among women for whom chemotherapy was discretionary. CAM use was high among patients with early-stage breast cancer enrolled in a multisite prospective cohort study. Current dietary supplement use and higher number of CAM modalities used but not mind-body practices were associated with decreased initiation of clinically indicated chemotherapy. Oncologists should consider discussing CAM with their patients during the chemotherapy decision-making process.

Clinical predictors of vestibulo-ocular dysfunction in pediatric sports-related concussion.

PubMed

Ellis, Michael J; Cordingley, Dean M; Vis, Sara; Reimer, Karen M; Leiter, Jeff; Russell, Kelly

2017-01-01

OBJECTIVE There were 2 objectives of this study. The first objective was to identify clinical variables associated with vestibulo-ocular dysfunction (VOD) detected at initial consultation among pediatric patients with acute sports-related concussion (SRC) and postconcussion syndrome (PCS). The second objective was to reexamine the prevalence of VOD in this clinical cohort and evaluate the effect of VOD on length of recovery and the development of PCS. METHODS A retrospective review was conducted for all patients with acute SRC and PCS who were evaluated at a pediatric multidisciplinary concussion program from September 2013 to May 2015. Acute SRS was defined as presenting < 30 days postinjury, and PCS was defined according to the International Classification of Diseases, 10th Revision criteria and included being symptomatic 30 days or longer postinjury. The initial assessment included clinical history and physical examination performed by 1 neurosurgeon. Patients were assessed for VOD, defined as the presence of more than 1 subjective vestibular and oculomotor complaint (dizziness, diplopia, blurred vision, etc.) and more than 1 objective physical examination finding (abnormal near point of convergence, smooth pursuits, saccades, or vestibulo-ocular reflex testing). Poisson regression analysis was used to identify factors that increased the risk of VOD at initial presentation and the development of PCS. RESULTS Three hundred ninety-nine children, including 306 patients with acute SRC and 93 with PCS, were included. Of these patients, 30.1% of those with acute SRC (65.0% male, mean age 13.9 years) and 43.0% of those with PCS (41.9% male, mean age 15.4 years) met the criteria for VOD at initial consultation. Independent predictors of VOD at initial consultation included female sex, preinjury history of depression, posttraumatic amnesia, and presence of dizziness, blurred vision, or difficulty focusing at the time of injury. Independent predictors of PCS among patients with acute SRC included the presence of VOD at initial consultation, preinjury history of depression, and posttraumatic amnesia at the time of injury. CONCLUSIONS This study identified important potential risk factors for the development of VOD following pediatric SRC. These results provide confirmatory evidence that VOD at initial consultation is associated with prolonged recovery and is an independent predictor for the development of PCS. Future studies examining clinical prediction rules in pediatric concussion should include VOD. Additional research is needed to elucidate the natural history of VOD following SRC and establish evidence-based indications for targeted vestibular rehabilitation.

Treatment initiation and dropout from prolonged exposure and cognitive processing therapy in a VA outpatient clinic.

PubMed

Kehle-Forbes, Shannon M; Meis, Laura A; Spoont, Michele R; Polusny, Melissa A

2016-01-01

Emerging data suggest that few veterans are initiating prolonged exposure (PE) and cognitive processing therapy (CPT) and dropout levels are high among those who do start the therapies. The goal of this study was to use a large sample of veterans seen in routine clinical care to 1) report the percent of eligible and referred veterans who (a) initiated PE/CPT, (b) dropped out of PE/CPT, (c) were early PE/CPT dropouts, 2) examine predictors of PE/CPT initiation, and 3) examine predictors of early and late PE/CPT dropout. We extracted data from the medical records of 427 veterans who were offered PE/CPT following an intake at a Veterans Health Administration (VHA) PTSD Clinical Team. Eighty-two percent (n = 351) of veterans initiated treatment by attending Session 1 of PE/CPT; among those veterans, 38.5% (n = 135) dropped out of treatment. About one quarter of veterans who dropped out were categorized as early dropouts (dropout before Session 3). No significant predictors of initiation were identified. Age was a significant predictor of treatment dropout; younger veterans were more likely to drop out of treatment than older veterans. Therapy type was also a significant predictor of dropout; veterans receiving PE were more likely to drop out late than veterans receiving CPT. Findings demonstrate that dropout from PE/CPT is a serious problem and highlight the need for additional research that can guide the development of interventions to improve PE/CPT engagement and adherence. (c) 2016 APA, all rights reserved).

The biasing effect of clinical history on physical examination diagnostic accuracy.

PubMed

Sibbald, Matthew; Cavalcanti, Rodrigo B

2011-08-01

Literature on diagnostic test interpretation has shown that access to clinical history can both enhance diagnostic accuracy and increase diagnostic error. Knowledge of clinical history has also been shown to enhance the more complex cognitive task of physical examination diagnosis, possibly by enabling early hypothesis generation. However, it is unclear whether clinicians adhere to these early hypotheses in the face of unexpected physical findings, thus resulting in diagnostic error. A sample of 180 internal medicine residents received a short clinical history and conducted a cardiac physical examination on a high-fidelity simulator. Resident Doctors (Residents) were randomised to three groups based on the physical findings in the simulator. The concordant group received physical examination findings consistent with the diagnosis that was most probable based on the clinical history. Discordant groups received findings associated with plausible alternative diagnoses which either lacked expected findings (indistinct discordant) or contained unexpected findings (distinct discordant). Physical examination diagnostic accuracy and physical examination findings were analysed. Physical examination diagnostic accuracy varied significantly among groups (75 ± 44%, 2 ± 13% and 31 ± 47% in the concordant, indistinct discordant and distinct discordant groups, respectively (F(2,177)  = 53, p < 0.0001). Of the 115 Residents who were diagnostically unsuccessful, 33% adhered to their original incorrect hypotheses. Residents verbalised an average of 12 findings (interquartile range: 10-14); 58 ± 17% were correct and the percentage of correct findings was similar in all three groups (p = 0.44). Residents showed substantially decreased diagnostic accuracy when faced with discordant physical findings. The majority of trainees given discordant physical findings rejected their initial hypotheses, but were still diagnostically unsuccessful. These results suggest that overcoming the bias induced by a misleading clinical history may involve two independent steps: rejection of the incorrect initial hypothesis, and selection of the correct diagnosis. Educational strategies focused solely on prompting clinicians to re-examine their hypotheses may be insufficient to reduce diagnostic error. © Blackwell Publishing Ltd 2011.

Calcaneocuboid joint instability: a novel operative technique for anatomic reconstruction.

PubMed

Lohrer, Heinz; Arentz, Sabine

2004-05-01

A case history of a 13-year-old female national top-level gymnast, suffering from calcaneocuboid joint instability, is presented. The procedure was done as an anatomic repair by capsular reefing, which was augmented using a local periosteal flap. Initially, the athlete twisted her ankle. Clinical investigation revealed no sign of a lateral ankle ligament injury, but following this initial examination, recurrent giving-way of the foot occurred. She additionally felt significant but diffuse pain on the lateral side of the foot during loading in training and competition. For 2 months she was unable to run and conservative treatment failed. Diagnosis of a calcaneocuboid instability was established 4 months after the initial lesion by clinical and x-ray stress examination of the calcaneocuboid joint. Open surgery was successfully performed. Early functional posttreatment was done and the patient returned to full high-level gymnastics ability 16 weeks after surgery. Two years later, a similar injury occurred to the opposite calcaneocuboid joint and the same operative procedure again led to full sports ability.

[Clinical analysis of 16 cases frontal, ethmoid sinus cyst with eye symptoms as initial amount].

PubMed

Zhao, Ying; Sun, Yijun; Yang, Lihui; Jia, Wenxue; Wang, Lijun

2013-11-01

To investigate the diagnosis of frontal, ethmoid sinus cyst with eye symptoms as initial amount,and the curative effect of nasal endoscopic operation. To retrospectively analyze clinical data of sixteen patients with frontal, ethmoid sinus cyst from February 2006 to March 2008. Diagnostic accordance rate of paranasal sinus MRI and CT examination In 16 patients is 100%. Fourteen patients' ocular symptoms disappeared after nasal endoscope operation treatment, two of them improved. None of them recurrened after the fol low-up 3-6 years up to now, all the patients had satisfactory curative effect. Paranasal sinuses and or bital cavity have close relationship , patients with sinus lesions always firstly visit Ophthalmology doctor. The results of MRI and CT examination are of great value for diagnosis. Patients with frontal, ethmoid sinus cyst with eye symptoms as initial amount should be early diagnosed. The treatment of nasal endoscope operation is safe, effective and is worth of firstly chosen.

The Pursuit of a Collegial Model of Clinical Practice: The Story of One University

ERIC Educational Resources Information Center

Strieker, Toni S.; Lim, Woong; Hubbard, Daphne; Crovitz, Darren; Gray, Kimberly C.; Holbien, Marie; Steffen, Cherry

2017-01-01

This study addresses the urgent need for change in clinical experiences that better prepare teacher candidates to negotiate the changing landscape of educational and accreditation policies and practices affecting P-12 classrooms. Specifically, the article examines the impact of a comprehensive 4-year initiative to transform traditional student…

Physiotherapy in Primary Care Triage - the effects on utilization of medical services at primary health care clinics by patients and sub-groups of patients with musculoskeletal disorders: a case-control study.

PubMed

Bornhöft, Lena; Larsson, Maria E H; Thorn, Jörgen

2015-01-01

Primary Care Triage is a patient sorting system used in some primary health care clinics (PHCCs) in Sweden where patients with musculoskeletal disorders (MSD) are triaged directly to physiotherapists. The purpose of this study was to investigate whether sorting/triaging patients seeking a PHCC for MSD directly to physiotherapists affects their utilization of medical services at the clinic for the MSD and to determine whether the effects of the triaging system vary for different sub-groups of patients. A retrospective case-control study design was used at two PHCCs. At the intervention clinic, 656 patients with MSD were initially triaged to physiotherapists. At the control clinic, 1673 patients were initially assessed by general practitioners (GPs). The main outcome measures were the number of patients continuing to visit GPs after the initial assessment, the number of patients receiving referrals to specialists/external examinations, doctors' notes for sick-leave or prescriptions for analgesics during one year, all for the original MSD. Significantly fewer patients triaged to physiotherapists required multiple GP visits for the MSD or received MSD-related referrals to specialists/external examinations, sick-leave recommendations or prescriptions during the following year compared to the GP-assessed group. This applies to all sub-groups except for the group with lower extremity disorders, which did not reach significance for either multiple GP visits or sick-leave recommendations. The reduced utilization of medical services by patients with MSD who were triaged to physiotherapists at a PHCC is likely due to altered management of MSD with initial assessment by physiotherapists.

Perceived Control is a Transdiagnostic Predictor of Cognitive-Behavior Therapy Outcome for Anxiety Disorders

PubMed Central

Gallagher, Matthew W.; Naragon-Gainey, Kristin; Brown, Timothy A.

2013-01-01

Perceived control has been proposed to be a general psychological vulnerability factor that confers an elevated risk for developing anxiety disorders, but there is limited research examining perceived control during cognitive-behavioral therapies (CBT). The present study examined whether treatment resulted in improvements in perceived control, and the indirect effects of CBT on changes in symptoms of obsessive-compulsive disorder, social phobia, generalized anxiety disorder, and panic disorder via changes in perceived control. Participants (n = 606) were a large clinical sample presenting for treatment at an outpatient anxiety disorders clinic. Participants completed a series of self-report questionnaires and a structured clinical interview at an intake evaluation and at two follow-up assessments 12 and 24 months later, with the majority of participants initiating CBT between the first two assessments. Results of latent growth curve models indicated that individuals initiating CBT subsequently reported large increases in perceived control and significant indirect effects of treatment on intraindividual changes in each of the four anxiety disorders examined via intraindividual changes in perceived control. These results suggest that the promotion of more adaptive perceptions of control is associated with recovery from anxiety disorders. Furthermore, the consistent finding of indirect effects across the four anxiety disorders examined underscores the transdiagnostic importance of perceived control in predicting CBT outcomes. PMID:24563563

Impact of biologic agents with and without concomitant methotrexate and at reduced doses in older rheumatoid arthritis patients.

PubMed

Zhang, Jie; Xie, Fenglong; Delzell, Elizabeth; Yun, Huifeng; Lewis, James D; Haynes, Kevin; Chen, Lang; Beukelman, Timothy; Saag, Kenneth G; Curtis, Jeffrey R

2015-05-01

To examine whether concomitant methotrexate (MTX) use is associated with better biologic persistence and whether self-administered anti-tumor necrosis factor (anti-TNF) therapies are used at reduced doses in real-world clinical care settings, not just clinical trials. We conducted a retrospective cohort study among rheumatoid arthritis (RA) patients using Medicare claims data from 2006 to 2012. Subjects were new initiators of etanercept, infliximab, adalimumab, abatacept, and tocilizumab with at least 12 months of continuous medical and pharmacy coverage after treatment initiation. We examined the association between concomitant MTX use and persistence on biologic agents using Cox proportional hazards regression, adjusting for demographics and baseline comorbidities. We further identified a subgroup of patients who initiated and were adherent on etanercept or adalimumab for at least 12 months and examined the proportion of patients who subsequently used these therapies at reduced doses continuously for an additional 12, 18, and 24 months. Of 26,510 eligible RA patients, 10,511 initiated biologic monotherapy. Overall, patients who initiated biologic monotherapy were 1.4 (95% confidence interval [95% CI] 1.3-1.5) times more likely to discontinue at 1 year compared to those who initiated combination therapy, and 1.8 (95% CI 1.7-2.0) times more likely if starting infliximab monotherapy. Approximately 10-20% of patients who initiated and adhered to etanercept and adalimumab for ≥12 months subsequently received reduced-dose therapy for an 12 additional months and beyond. In real-world practice, concomitant MTX was associated with improved persistence on biologic therapy, especially for infliximab users; reduced-dose injectable anti-TNF therapy was used by a substantial proportion of RA patients. © 2015, American College of Rheumatology.

Speech-language pathologists and the Common Core Standards initiative: an opportunity for leadership and organizational change.

PubMed

Dunkle, Jennifer; Flynn, Perry

2012-05-01

The Common Core State Standards initiative within public school education is designed to provide uniform guidelines for academic standards, including more explicit language targets. Speech-language pathologists (SLPs) are highly qualified language experts who may find new leadership roles within their clinical practice using the Common Core Standards. However, determining its usage by SLPs in clinical practice needs to be examined. This article seeks to discover the social context of organizations and organizational change in relation to clinical practice. Specifically, this article presents the diffusion of innovations theory to explain how initiatives move from ideas to institutionalization and the importance of social context in which these initiatives are introduced. Next, the values of both SLPs and organizations will be discussed. Finally, this article provides information on how to affect organizational change through the value of an affirmative, socially based theoretical perspective and methodology, appreciative inquiry. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

The value of formal clinical research training in initiating a career as a clinical investigator.

PubMed

Kapoor, Karan; Wu, Bechien U; Banks, Peter A

2011-12-01

The aim of this study was to determine whether formal clinical research training is of value in the initiation of a successful career as a clinical investigator. We conducted a retrospective review of the career choices of all 25 fellows who entered the Academic Clinical Research Track at Brigham and Women's Hospital since its inception in 1995 and examined the impact of formal clinical research training during their fellowship on their career choice. The primary measure of a successful career as a clinical investigator was the obtainment of external funding for clinical research within 3 years of completion of fellowship. Thirteen of the 25 fellows (52%) received a Master of Public Health (MPH) degree at the Harvard School of Public Health during their fellowship. Ten of these 13 fellows (77%) obtained external funding for clinical research within 3 years of completion of their fellowship. None of the 5 fellows who had already obtained an MPH degree prior to their fellowship and none of the 7 fellows who completed a 7-week summer Program in Clinical Effectiveness but did not complete an MPH degree attempted to receive external funding for clinical research within 3 years of completion of their fellowship. We conclude that formal clinical research training culminating in an MPH degree was extremely valuable in the initiation of a successful career as a clinical investigator.

An examination of the usefulness of repeat testing practices in a large hospital clinical chemistry laboratory.

PubMed

Deetz, Carl O; Nolan, Debra K; Scott, Mitchell G

2012-01-01

A long-standing practice in clinical laboratories has been to automatically repeat laboratory tests when values trigger automated "repeat rules" in the laboratory information system such as a critical test result. We examined 25,553 repeated laboratory values for 30 common chemistry tests from December 1, 2010, to February 28, 2011, to determine whether this practice is necessary and whether it may be possible to reduce repeat testing to improve efficiency and turnaround time for reporting critical values. An "error" was defined to occur when the difference between the initial and verified values exceeded the College of American Pathologists/Clinical Laboratory Improvement Amendments allowable error limit. The initial values from 2.6% of all repeated tests (668) were errors. Of these 668 errors, only 102 occurred for values within the analytic measurement range. Median delays in reporting critical values owing to repeated testing ranged from 5 (blood gases) to 17 (glucose) minutes.

[Spontaneous splenic rupture as complication of infective mononucleosis: a clinical case].

PubMed

Delle Monache, Guido; Orlando, Dante; Frassanito, Salvatore; Sciarra, Roberto; Rinaldi, Manlio Tullio

2003-01-01

Spontaneous splenic rupture is a very rare complication of infectious mononucleosis, already described by other authors. In this case report we show the findings occurring in a young man who presented with sudden left thoracic pain and dyspnea. The initial work-up was oriented towards a suspected diagnosis of left spontaneous pneumothorax. Initially, little attention was paid to the clinical history that was characterized by flu-like symptoms during the previous 2 weeks; this, along with a rushed physical examination, could have had dramatic consequences, due to the unavoidable diagnostic delay. A thorough clinical evaluation by Internists, coupled with the essential ultrasonographic diagnostic support, allowed an earlier diagnosis followed by definitive cure, i.e. splenectomy.

Clinical Prediction Making: Examining Influential Factors Related to Clinician Predictions of Recidivism among Juvenile Offenders

ERIC Educational Resources Information Center

Calley, Nancy G.; Richardson, Emily M.

2011-01-01

This study examined factors influencing clinician predictions of recidivism for juvenile offenders, including youth age at initial juvenile justice system involvement, youth age at discharge, program completion status, clinician perception of strength of the therapeutic relationship, and clinician perception of youth commitment to treatment.…

An Examination of the EeTPA Portfolio Assessment and Other Measures of Teacher Preparation and Readiness

ERIC Educational Resources Information Center

Russell, Victoria; Davidson Devall, Kelly F.

2016-01-01

The authors examined the outcomes on several measures of world language teacher preparedness, including university- and state-mandated summative evaluations and the edTPA portfolio assessment, for seven world language teacher candidates during their final semester of clinical practice. The candidates were enrolled in an initial certification…

Follow-up of 100 dogs with acute diarrhoea in a primary care practice.

PubMed

Berset-Istratescu, C M; Glardon, O J; Magouras, I; Frey, C F; Gobeli, S; Burgener, I A

2014-01-01

This study aimed to examine the aetiology of acute diarrhoea and the relapse rate in 100 client-owned dogs presented to a first-opinion clinic. History, physical examination, faecal testing and owner questionnaire data were collected at initial presentation (T0) and at either the time of relapse or at a recheck performed within 3 months. All dogs received treatment according to their clinical signs. Of 96 dogs that completed the study, 37 (38.5%) relapsed during the study period, 21 (21.9%) relapsed within 3 months, and 16 others (16.6%) at 3 months to 1 year after initial examination. Dogs that had undergone a change in housing location within 1 month prior to presentation and dogs <1 year old were significantly more likely to have positive parasitological analyses (P=0.02 and P=0.001, respectively). Pica was a risk factor for relapse (P=0.0002). Copyright © 2013 Elsevier Ltd. All rights reserved.

Biological variability of transferrin saturation and unsaturated iron binding capacity

PubMed Central

Adams, PC; Reboussin, DM; Press, RD; Barton, JC; Acton, RT; Moses, GC; Leiendecker-Foster, C; McLaren, GD; Dawkins, FW; Gordeuk, VR; Lovato, L; Eckfeldt, JH

2007-01-01

Background Transferrin saturation is widely considered the preferred screening test for hemochromatosis. Unsaturated iron binding capacity has similar performance at lower cost. However, the within-person biological variability of both these tests may limit their ability at commonly used cut points to detect HFE C282Y homozygous patients. Methods The Hemochromatosis and Iron Overload Screening (HEIRS) Study screened 101,168 primary care participants for iron overload using tansferrin saturation, unsaturated iron binding capacity, ferritin and HFE C282Y and H63D genotyping. Transferrin saturation and unsaturated iron binding capacity were performed at initial screening and again when selected participants and controls returned for a clinical examination several months later. A missed case was defined as a C282Y homozygote who had transferrin saturation below cut point (45 % women, 50 % men) or unsaturated iron binding capacity above cut point (150 μmol/L women, 125 μmol/L men) at either the initial screening or clinical examination, or both, regardless of serum ferritin. Results There were 209 C282Y previously undiagnosed homozygotes with transferrin saturation and unsaturated iron binding capacity testing done at initial screening and clinical examination. Sixty-eight C282Y homozygotes (33%) would have been missed at these transferrin saturation cut points (19 men, 49 women, median SF 170 μg/L, first and third quartiles 50 and 474 μg/L), and 58 homozygotes (28 %) would have been missed at the unsaturated iron binding capacity cut points (20 men, 38 women, median SF 168 μg/L, quartiles 38 and 454 μg/L). There was no advantage to using fasting samples. Conclusions The within-person biological variability of transferrin saturation and unsaturated iron binding capacity limit their usefulness as an initial screening test for expressing C282Y homozygotes. PMID:17976429

Traditional circumcision during manhood initiation rituals in the Eastern Cape, South Africa: a pre-post intervention evaluation

PubMed Central

Peltzer, Karl; Nqeketo, Ayanda; Petros, George; Kanta, Xola

2008-01-01

Background Circumcisions undertaken in non-clinical settings can have significant risks of serious adverse events, including death. The aim of this study was to test an intervention for safe traditional circumcision in the context of initiation into manhood among the Xhosa, Eastern Cape, South Africa. Methods Traditional surgeons and nurses registered with the health department were trained over five days on ten modules including safe circumcision, infection control, anatomy, post-operative care, detection and early management of complications and sexual health education. Initiates from initiation schools of the trained surgeons and nurses were examined and interviewed on 2nd, 4th, 7th and 14th day after circumcision. Results From 192 initiates physically examined at the 14th day after circumcision by a trained clinical nurse high rates of complications were found: 40 (20.8%) had mild delayed wound healing, 31 (16.2%) had a mild wound infection, 22 (10.5%) mild pain and 20 (10.4%) had insufficient skin removed. Most traditional surgeons and nurses wore gloves during operation and care but did not use the recommended circumcision instrument. Only 12% of the initiates were circumcised before their sexual debut and they reported a great deal of sexual risk behaviour. Conclusion Findings show weak support for scaling up traditional male circumcision. PMID:18284673

Real-world effectiveness of osteoporosis therapies for fracture reduction in post-menopausal women.

PubMed

Yusuf, Akeem A; Cummings, Steven R; Watts, Nelson B; Feudjo, Maurille Tepie; Sprafka, J Michael; Zhou, Jincheng; Guo, Haifeng; Balasubramanian, Akhila; Cooper, Cyrus

2018-03-21

Studies examining real-world effectiveness of osteoporosis therapies are beset by limitations due to confounding by indication. By evaluating longitudinal changes in fracture incidence, we demonstrated that osteoporosis therapies are effective in reducing fracture risk in real-world practice settings. Osteoporosis therapies have been shown to reduce incidence of vertebral and non-vertebral fractures in placebo-controlled randomized clinical trials. However, information on the real-world effectiveness of these therapies is limited. We examined fracture risk reduction in older, post-menopausal women treated with osteoporosis therapies. Using Medicare claims, we identified 1,278,296 women age ≥ 65 years treated with zoledronic acid, oral bisphosphonates, denosumab, teriparatide, or raloxifene. Fracture incidence rates before and after treatment initiation were described to understand patients' fracture risk profile, and fracture reduction effectiveness of each therapy was evaluated as a longitudinal change in incidence rates. Fracture incidence rates increased during the period leading up to treatment initiation and were highest in the 3-month period most proximal to treatment initiation. Fracture incidence rates following treatment initiation were significantly lower than before treatment initiation. Compared with the 12-month pre-index period, there were reductions in clinical vertebral fractures for denosumab (45%; 95% confidence interval [CI] 39-51%), zoledronic acid (50%; 95% CI 47-52%), oral bisphosphonates (24%; 95% CI 22-26%), and teriparatide (72%; 95% CI 69-75%) during the subsequent 12 months. Relative to the first 3 months after initiation, clinical vertebral fractures were reduced for denosumab (51%; 95% CI 42-59%), zoledronic acid (25%; 95% CI 17-32%), oral bisphosphonates (23%; 95% CI 20-26%), and teriparatide (64%; 95% CI 58-69%) during the subsequent 12 months. In summary, reductions in fracture incidence over time were observed in cohorts of patients treated with osteoporosis therapies.

Understanding managerial behaviour during initial steps of a clinical information system adoption

PubMed Central

2011-01-01

Background While the study of the information technology (IT) implementation process and its outcomes has received considerable attention, the examination of pre-adoption and pre-implementation stages of configurable IT uptake appear largely under-investigated. This paper explores managerial behaviour during the periods prior the effective implementation of a clinical information system (CIS) by two Canadian university multi-hospital centers. Methods Adopting a structurationist theoretical stance and a case study research design, the processes by which CIS managers' patterns of discourse contribute to the configuration of the new technology in their respective organizational contexts were longitudinally examined over 33 months. Results Although managers seemed to be aware of the risks and organizational impact of the adoption of a new clinical information system, their decisions and actions over the periods examined appeared rather to be driven by financial constraints and power struggles between different groups involved in the process. Furthermore, they largely emphasized technological aspects of the implementation, with organizational dimensions being put aside. In view of these results, the notion of 'rhetorical ambivalence' is proposed. Results are further discussed in relation to the significance of initial decisions and actions for the subsequent implementation phases of the technology being configured. Conclusions Theoretical and empirically grounded, the paper contributes to the underdeveloped body of literature on information system pre-implementation processes by revealing the crucial role played by managers during the initial phases of a CIS adoption. PMID:21682885

Impact of Biologics With and Without Concomitant MTX and at Reduced Doses in Older Rheumatoid Arthritis Patients

PubMed Central

Zhang, Jie; Xie, Fenglong; Delzell, Elizabeth; Yun, Huifeng; Lewis, James D; Haynes, Kevin; Chen, Lang; Beukelman, Timothy; Saag, Kenneth G; Curtis, Jeffrey R

2014-01-01

Background This study examines whether concomitant methotrexate (MTX) use is associated with better biologic persistence and whether self-administered anti-TNF therapies are used at reduced doses in real-world clinical care settings, not just clinical trials. Methods We conducted a retrospective cohort study among RA patients using Medicare claims data from 2006 to 2012. Subjects were new initiators of etanercept, infliximab, adalimumab, abatacept and tocilizumab with at least 12 months of continuous medical and pharmacy coverage after treatment initiation. We examined the association between concomitant MTX use and persistence on biologics using Cox proportional hazard regression adjusting for demographics and baseline co-morbidities. We further identified a subgroup of patients who initiated and were adherent on etanercept or adalimumab for at least 12 months and examined the proportion of patients who subsequently used these therapies at reduced doses continuously for an additional 12, 18, and 24 months. Results Of 26,510 eligible RA patients, 10,511 initiated biologic monotherapy. Overall, patients initiated biologic monotherapy were 1.4 (95% CI, 1.3–1.5) times more likely to discontinue at 1-year and 1.8 (95% CI, 1.7–2.0) times more likely if starting infliximab monotherapy. Approximately 10–20% of patients who initiated and adhered to etanercept and adalimumab for ≥ 12 months subsequently used reduced-dose therapy for an 12 additional months and beyond. Conclusion In real-world practice, concomitant MTX was associated with improved persistence on biologic therapy, especially for infliximab users; reduced-dose injectable anti-TNF therapy was used by a substantial proportion of RA patients. PMID:25370912

WhatsApp: a telemedicine platform for facilitating remote oral medicine consultation and improving clinical examinations.

PubMed

Petruzzi, Massimo; De Benedittis, Michele

2016-03-01

Increased use of smartphone and related software applications has created a new era in clinical data exchange among patients and clinicians. This study describes use of the smartphone-based application WhatsApp to share clinical oral medicine information. Clinical images and related questions were submitted by general dentists, physicians, dental hygienists, and patients to the authors via WhatsApp. For each submission, a clinical impression was made and categorized as traumatic, infective, neoplastic, autoimmune, or unclassified. Submissions were summarized by sender type, number of photographs per sender, and category of question. Patients were invited to undergo a clinical examination with biopsy, when indicated. The telemedicine impression was compared to the clinicopathologic diagnosis. Three hundred and thirty-nine images were received for 96 patients; 92 (95.8%) patients underwent clinicopathologic examination, and 45 (49%) received a biopsy. General dentists (62%) and dental hygienists (26%) were the most frequent senders. The most common question was related to diagnosis (56%). The telemedicine impression agreed with the clinicopathologic assessment for 82% of cases. Telemedicine applications, such as WhatsApp, can support communication about oral conditions among clinicians and patients. Telemedicine consultation reduced geographic barriers to initial clinical consultation and encouraged the significant majority of patients to pursue expert clinical examination. Copyright © 2016 Elsevier Inc. All rights reserved.

A tracking and verification system implemented in a clinical environment for partial HIPAA compliance

NASA Astrophysics Data System (ADS)

Guo, Bing; Documet, Jorge; Liu, Brent; King, Nelson; Shrestha, Rasu; Wang, Kevin; Huang, H. K.; Grant, Edward G.

2006-03-01

The paper describes the methodology for the clinical design and implementation of a Location Tracking and Verification System (LTVS) that has distinct benefits for the Imaging Department at the Healthcare Consultation Center II (HCCII), an outpatient imaging facility located on the USC Health Science Campus. A novel system for tracking and verification of patients and staff in a clinical environment using wireless and facial biometric technology to monitor and automatically identify patients and staff was developed in order to streamline patient workflow, protect against erroneous examinations and create a security zone to prevent and audit unauthorized access to patient healthcare data under the HIPAA mandate. This paper describes the system design and integration methodology based on initial clinical workflow studies within a clinical environment. An outpatient center was chosen as an initial first step for the development and implementation of this system.

Assuring dental hygiene clinical competence for licensure: a national survey of dental hygiene program directors.

PubMed

Fleckner, Lucinda M; Rowe, Dorothy J

2015-02-01

To conduct a national survey of dental hygiene program directors to gain their opinions of alternative assessments of clinical competency, as qualifications for initial dental hygiene licensure. A 22 question survey, comprised of statements eliciting Likert-scale responses, was developed and distributed electronically to 341 U.S. dental hygiene program directors. Responses were tabulated and analyzed using University of California, San Francisco Qualtrics® computer software. Data were summarized as frequencies of responses to each item on the survey. The response rate was 42% (n=143). The majority of respondents (65%) agreed that graduating from a Commission on Dental Accreditation (CODA)-approved dental hygiene program and passing the national board examination was the best measure to assure competence for initial licensure. The addition of "successfully completing all program's competency evaluations" to the above core qualifications yielded a similar percentage of agreement. Most (73%) agreed that "the variability of live patients as test subjects is a barrier to standardizing the state and regional examinations," while only 29% agreed that the "use of live patients as test subjects is essential to assure competence for initial licensure." The statement that the one-time state and regional examinations have "low validity in reflecting the complex responsibilities of the dental hygienist in practice" had a high (77%) level of agreement. Most dental hygiene program directors agree that graduating from a CODA-approved dental hygiene program and passing the national board examination would ensure that a graduate has achieved clinical competence and readiness to provide comprehensive patient-centered care as a licensed dental hygienist. Copyright © 2015 The American Dental Hygienists’ Association.

Contribution of Transjugular Liver Biopsy in Patients with the Clinical Presentation of Acute Liver Failure

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

Miraglia, Roberto, E-mail: rmiraglia@ismett.edu; Luca, Angelo; Gruttadauria, Salvatore

2006-12-15

Purpose. Acute liver failure (ALF) treated with conservative therapy has a poor prognosis, although individual survival varies greatly. In these patients, the eligibility for liver transplantation must be quickly decided. The aim of this study was to assess the role of transjugular liver biopsy (TJLB) in the management of patients with the clinical presentation of ALF. Methods. Seventeen patients with the clinical presentation of ALF were referred to our institution during a 52 month period. A TJLB was performed using the Cook Quick-Core needle biopsy. Clinical data, procedural complications, and histologic findings were evaluated. Results. Causes of ALF were virusmore » hepatitis B infection in 7 patients, drug toxicity in 4, mushroom in 1, Wilson's disease in 1, and unknown origin in 4. TJLB was technically successful in all patients without procedure-related complications. Tissue specimens were satisfactory for diagnosis in all cases. In 14 of 17 patients the initial clinical diagnosis was confirmed by TJLB; in 3 patients the initial diagnosis was altered by the presence of unknown cirrhosis. Seven patients with necrosis <60% were successfully treated with medical therapy; 6 patients with submassive or massive necrosis ({>=}85%) were treated with liver transplantation. Four patients died, 3 had cirrhosis, and 1 had submassive necrosis. There was a strict statistical correlation (r = 0.972, p < 0.0001) between the amount of necrosis at the frozen section examination and the necrosis found at routine histologic examination. The average time for TJLB and frozen section examination was 80 min. Conclusion. In patients with the clinical presentation of ALF, submassive or massive liver necrosis and cirrhosis are predictors of poor prognosis. TLJB using an automated device and frozen section examination can be a quick and effective tool in clinical decision-making, especially in deciding patient selection and the best timing for liver transplantation.« less

Risk factors for incidence and severity of white spot lesions during treatment with fixed orthodontic appliances.

PubMed

Chapman, Joshua A; Roberts, W Eugene; Eckert, George J; Kula, Katherine S; González-Cabezas, Carlos

2010-08-01

The development of incipient caries, or white spot lesions (WSLs), is a significant clinical problem in orthodontics. The purpose of this study was to retrospectively determine the incidence and severity of WSLs by examining pretreatment and posttreatment digital photographs. A total of 332 consecutive finished patients from a university graduate orthodontic clinic were evaluated. Initial and final digital images were compared to assess WSLs. The facial surfaces of the anterior 8 maxillary teeth were analyzed. The percentage area of WSL per total facial tooth surface was calculated to control for magnification differences. Reliability of the method was assessed by comparison with direct clinical examination data. Patient and operator factors, and treatment complexity and outcomes were evaluated as predictors of WSL incidence and severity. Agreement between direct clinical examination and digital photo data was excellent, with an intraclass correlation coefficient 0.88 and a 0.3% average difference between methods. The incidence of at least 1 WSL on the labial surface of the anterior 8 maxillary teeth was 36%. The order of incidence was lateral incisor (34%), canine (31%), premolar (28%), and central incisor (17%). Risk factors for the development of incipient caries during orthodontic treatment were young age (preadolescent) at the start of treatment, number of poor hygiene citations during treatment, unfavorable clinical outcome score, white ethnic group, and inadequate oral hygiene at the initial pretreatment examination. The use of computer software to evaluate digital photos retrospectively is a valid method for assessing the incidence and severity of WSLs on the maxillary anterior incisors, canines, and premolars. Copyright (c) 2010 American Association of Orthodontists. Published by Mosby, Inc. All rights reserved.

Application of Viscoelastic Fracture Model and Non-uniform Crack Initiation at Clinically Relevant Notches in Crosslinked UHMWPE

PubMed Central

Sirimamilla, P. Abhiram; Furmanski, Jevan; Rimnac, Clare M.

2012-01-01

The mechanism of crack initiation from a clinically relevant notch is not well-understood for crosslinked ultra high molecular weight polyethylene (UHMWPE) used in total joint replacement components. Static mode driving forces, rather than the cyclic mode conditions typically associated with fatigue processes, have been shown to drive crack propagation in this material. Thus, in this study, crack initiation in a notched specimen under a static load was investigated. A video microscope was used to monitor the notch surface of the specimen and crack initiation time was measured from the video by identifying the onset of crack initiation at the notch. Crack initiation was considered using a viscoelastic fracture theory. It was found that the mechanism of crack initiation involved both single layer and a distributed multi-layer phenomenon and that multi-layer crack initiation delayed the crack initiation time for all loading conditions examined. The findings of this study support that the viscoelastic fracture theory governs fracture mechanics in crosslinked UHMWPE. The findings also support that crack initiation from a notch in UHMWPE is a more complex phenomenon than treated by traditional fracture theories for polymers. PMID:23127638

A hypothesis-driven physical examination learning and assessment procedure for medical students: initial validity evidence.

PubMed

Yudkowsky, Rachel; Otaki, Junji; Lowenstein, Tali; Riddle, Janet; Nishigori, Hiroshi; Bordage, Georges

2009-08-01

Diagnostic accuracy is maximised by having clinical signs and diagnostic hypotheses in mind during the physical examination (PE). This diagnostic reasoning approach contrasts with the rote, hypothesis-free screening PE learned by many medical students. A hypothesis-driven PE (HDPE) learning and assessment procedure was developed to provide targeted practice and assessment in anticipating, eliciting and interpreting critical aspects of the PE in the context of diagnostic challenges. This study was designed to obtain initial content validity evidence, performance and reliability estimates, and impact data for the HDPE procedure. Nineteen clinical scenarios were developed, covering 160 PE manoeuvres. A total of 66 Year 3 medical students prepared for and encountered three clinical scenarios during required formative assessments. For each case, students listed anticipated positive PE findings for two plausible diagnoses before examining the patient; examined a standardised patient (SP) simulating one of the diagnoses; received immediate feedback from the SP, and documented their findings and working diagnosis. The same students later encountered some of the scenarios during their Year 4 clinical skills examination. On average, Year 3 students anticipated 65% of the positive findings, correctly performed 88% of the PE manoeuvres and documented 61% of the findings. Year 4 students anticipated and elicited fewer findings overall, but achieved proportionally more discriminating findings, thereby more efficiently achieving a diagnostic accuracy equivalent to that of students in Year 3. Year 4 students performed better on cases on which they had received feedback as Year 3 students. Twelve cases would provide a reliability of 0.80, based on discriminating checklist items only. The HDPE provided medical students with a thoughtful, deliberate approach to learning and assessing PE skills in a valid and reliable manner.

Vocal fold pseudocyst: results of 46 cases undergoing a uniform treatment algorithm.

PubMed

Estes, Christine; Sulica, Lucian

2014-05-01

To describe treatment results and identify predictors of the need for surgical intervention in patients with vocal fold pseudocyst. Retrospective cohort study with longitudinal followup via survey. Clinical records were reviewed for demographic information, VHI-10 score, and degree of severity of dysphonia. Videostroboscopic examinations were evaluated for presence of vocal fold pseudocyst, along with additional clinical variables, including laterality, reactive lesion, paresis, varix, and hemorrhage. Follow-up surveys were sent to all participants to evaluate current VHI-10 score and degree of vocal limitation. Results were analyzed to determine predictors of surgery and recurrence of pathology. Forty-six patients (41F:5M) with pseudocyst (40 unilateral: 6 bilateral) were reviewed. Twenty-three (50%) had reactive lesions, nineteen (41%) had paresis by clinical criteria, 10 (22%) had varices, and 6 (13%) had hemorrhage on examination. All underwent initial behavioral management (2-12 sessions of voice therapy; mean of 8 sessions). Seventeen (37%) eventually required surgical intervention. No demographic or clinical variables proved predictive of surgical intervention. Follow-up surveys were completed by 63% of patients, and 79% agreed with the statement that they were not professionally limited by their voices. This experience supports behavioral management as an initial intervention in patients with pseudocyst, sufficient by itself to restore vocal function in approximately two out of three patients. Neither initial severity nor any of the studied clinical findings predicted the need for surgery. The large majority of patients with pseudocyst are able to be treated effectively without impact in their professional function. © 2013 The American Laryngological, Rhinological and Otological Society, Inc.

Improving the Implementation of Evidence-Based Clinical Practices in Adolescent Reproductive Health Care Services

PubMed Central

Romero, Lisa M.; Middleton, Dawn; Mueller, Trisha; Avellino, Lia; Hallum-Montes, Rachel

2015-01-01

Purpose The purposes of the study were to describe baseline data in the implementation of evidence-based clinical practices among health center partners as part of a community-wide teen pregnancy prevention initiative and to identify opportunities for health center improvement. Methods Health center partner baseline data were collected in the first year (2011) and before program implementation of a 5-year community-wide teen pregnancy prevention initiative. A needs assessment on health center capacity and implementation of evidence-based clinical practices was administered with 51 health centers partners in 10 communities in the United States with high rates of teen pregnancy. Results Health centers reported inconsistent implementation of evidence-based clinical practices in providing reproductive health services to adolescents. Approximately 94.1% offered same-day appointments, 91.1% had infrastructure to reduce cost barriers, 90.2% offered after-school appointments, and 80.4% prescribed hormonal contraception without prerequisite examinations or testing. Approximately three quarters provided visual and audio privacy in examination rooms (76.5%) and counseling areas (74.5%). Fewer offered a wide range of contraceptive methods (67.8%) and took a sexual health history at every visit (54.9%). Only 45.1% reported Quick Start initiation of hormonal contraception, emergency contraception (43.1%), or intrauterine devices (12.5%) were “always” available to adolescents. Conclusions The assessment highlighted opportunities for health center improvement. Strategies to build capacity of health center partners to implement evidence-based clinical practices may lead to accessibility and quality of reproductive health services for adolescents in the funded communities. PMID:26381918

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Prediction of Treatment Entry and Completion in Prison

ERIC Educational Resources Information Center

Gordon, Michael S.; Kinlock, Timothy W.; Couvillion, Kathryn A.; Schwartz, Robert P.; O'Grady, Kevin

2012-01-01

The present report is an intent-to-treat analysis involving secondary data drawn from the first randomized clinical trial of prison-initiated methadone in the United States. This study examined predictors of treatment entry and completion in prison. A sample of 211 adult male prerelease inmates with preincarceration heroin dependence were randomly…

Brodie Abscess

DTIC Science & Technology

2007-10-01

swelling and tenderness to palpation at the medial ankle and the patient was treated for an ankle sprain . The patient returned to clinic due to...lacking an inciting traumatic event and systemic symptoms. While radiographs are the initial diagnostic modality, Magnetic Resonance (MR) imaging...became manifest. History: A 15 year old white male presented to clinic due to six months of right ankle pain. The physical examination revealed mild

Evaluation of common elbow pathologies: a focus on physical examination.

PubMed

Laratta, Joseph; Caldwell, Jon-Michael; Lombardi, Joseph; Levine, William; Ahmad, Christopher

2017-05-01

Elbow tendinopathy accounts for the majority of elbow pathology in patients presenting to upper extremity and sports medicine surgeons. With increased participation in overhead sports in an aging population, the incidence of elbow injuries has risen. A comprehensive knowledge of elbow anatomy and biomechanical function of the elbow complex is prerequisite in the assessment of patients with elbow injuries; however, a thorough understanding of alternative and confounding pathologies is essential for accurate diagnosis. Because tendinopathy, tendonitis, and tendon tears have an anatomic basis for their pathology, a targeted history and meticulous physical examination often yields an accurate clinical diagnosis. The importance of physical examination and provocative examination maneuvers must be stressed in a technologically advanced era where clinical diagnosis is too commonly attained solely by advanced imaging modalities. A revived dedication to the physical examination may enhance our ability to correctly diagnose various pathologies about the elbow. Early and accurate clinical diagnosis is the first step in the proper initiation of treatment modalities and improvement in overall patient outcome.

The effect of pre-service training on post-graduation skill and knowledge retention among mid-level healthcare providers in Mozambique.

PubMed

Feldacker, Caryl; Chicumbe, Sergio; Dgedge, Martinho; Cesar, Freide; Augusto, Gerito; Robertson, Molly; Mbofana, Francisco; O'Malley, Gabrielle

2015-04-16

Mozambique suffers from critical shortages of healthcare workers including non-physician clinicians, Tecnicos de Medicina Geral (TMGs), who are often senior clinicians in rural health centres. The Mozambique Ministry of Health and the International Training and Education Center for Health, University of Washington, Seattle, revised the national curriculum to improve TMG clinical knowledge and skills. To evaluate the effort, data was collected at graduation and 10 months later from pre-revision (initial) and revised curriculum TMGs to determine the following: (1) Did cohorts trained in the revised curriculum score higher on measurements of clinical knowledge, physical exam procedures, and solving clinical case scenarios than those trained in the initial curriculum; (2) Did TMGs in both curricula retain their knowledge over time (from baseline to follow-up); and (3) Did skills and knowledge retention differ over time by curricula? Post-graduation and over time results are presented. t-tests examine differences in scores between curriculum groups. Univariate and multivariate linear regression models assess curriculum-related, demographic, and workplace factors associated with scores on each of three evaluation methods at the p < 0.05 level. Paired t-tests examine within-group changes over time. ANOVA models explore differences between Health Training Institutes (HTIs). Generalized estimating equations determine whether change in scores over time differed by curricula. Mean scores of initial curriculum TMGs at follow-up were 52.7%, 62.6%, and 40.0% on the clinical cases, knowledge test, and physical exam, respectively. Averages were significantly higher among the revised group for clinical cases (60.2%; p < 0.001) and physical exam (47.6%; p < 0.001). HTI was influential on clinical case and physical exam scores. Between graduation and follow-up, clinical case and physical exam scores decreased significantly for initial curriculum students; clinical case scores increased significantly among revised curriculum TMGs. Although curriculum revision had limited effect, marginal improvements in the revised group show promise that these TMGs may have increased ability to synthesize clinical information. Weaknesses in curriculum and practicum implementation likely compromised the effect of curriculum revision. An improvement strategy that includes strengthened TMG training, greater attention to pre-service clinical practice, and post-graduation mentoring may be more advantageous than curriculum revision, alone, to improve care provided by TMGs.

Pre-cART Elevation of CRP and CD4+ T-Cell Immune Activation Associated With HIV Clinical Progression in a Multinational Case-Cohort Study.

PubMed

Balagopal, Ashwin; Asmuth, David M; Yang, Wei-Teng; Campbell, Thomas B; Gupte, Nikhil; Smeaton, Laura; Kanyama, Cecilia; Grinsztejn, Beatriz; Santos, Breno; Supparatpinyo, Khuanchai; Badal-Faesen, Sharlaa; Lama, Javier R; Lalloo, Umesh G; Zulu, Fatima; Pawar, Jyoti S; Riviere, Cynthia; Kumarasamy, Nagalingeswaran; Hakim, James; Li, Xiao-Dong; Pollard, Richard B; Semba, Richard D; Thomas, David L; Bollinger, Robert C; Gupta, Amita

2015-10-01

Despite the success of combination antiretroviral therapy (cART), a subset of HIV-infected patients who initiate cART develop early clinical progression to AIDS; therefore, some cART initiators are not fully benefitted by cART. Immune activation pre-cART may predict clinical progression in cART initiators. A case-cohort study (n = 470) within the multinational Prospective Evaluation of Antiretrovirals in Resource-Limited Settings clinical trial (1571 HIV treatment-naive adults who initiated cART; CD4 T-cell count <300 cells/mm; 9 countries) was conducted. A subcohort of 30 participants per country was randomly selected; additional cases were added from the main cohort. Cases [n = 236 (random subcohort 36; main cohort 200)] had clinical progression (incident WHO stage 3/4 event or death) within 96 weeks after cART initiation. Immune activation biomarkers were quantified pre-cART. Associations between biomarkers and clinical progression were examined using weighted multivariable Cox-proportional hazards models. Median age was 35 years, 45% were women, 49% black, 31% Asian, and 9% white. Median CD4 T-cell count was 167 cells per cubic millimeter. In multivariate analysis, highest quartile C-reactive protein concentration [adjusted hazard ratio (aHR), 2.53; 95% confidence interval (CI): 1.02 to 6.28] and CD4 T-cell activation (aHR, 5.18; 95% CI: 1.09 to 24.47) were associated with primary outcomes, compared with lowest quartiles. sCD14 had a trend toward association with clinical failure (aHR, 2.24; 95% CI: 0.96 to 5.21). Measuring C-reactive protein and CD4 T-cell activation may identify patients with CD4 T-cell counts <300 cells per cubic millimeter at risk for early clinical progression when initiating cART. Additional vigilance and symptom-based screening may be required in this subset of patients even after beginning cART.

Pre-cART Elevation of CRP and CD4+ T-cell Immune Activation Associated with HIV Clinical Progression in a Multinational Case-Cohort Study

PubMed Central

Balagopal, Ashwin; Asmuth, David M.; Yang, Wei-Teng; Campbell, Thomas B.; Gupte, Nikhil; Smeaton, Laura; Kanyama, Cecilia; Grinsztejn, Beatriz; Santos, Breno; Supparatpinyo, Khuanchai; Badal-Faesen, Sharlaa; Lama, Javier R.; Lalloo, Umesh G.; Zulu, Fatima; Pawar, Jyoti S; Riviere, Cynthia; Kumarasamy, Nagalingeswaran; Hakim, James; Li, Xiao-Dong; Pollard, Richard B.; Semba, Richard D.; Thomas, David L.; Bollinger, Robert C.; Gupta, Amita

2015-01-01

Background Despite the success of combination antiretroviral therapy (cART), a subset of HIV-infected patients who initiate cART develop early clinical progression to AIDS; therefore some cART initiators are not fully benefitted by cART. Immune activation pre-cART may predict clinical progression in cART initiators. Methods A case-cohort study (n=470) within the multinational Prospective Evaluation of Antiretrovirals in Resource-Limited Settings (PEARLS) clinical trial (1571 HIV treatment-naïve adults who initiated cART; CD4+ T cell count <300 cells/mm3; nine countries) was conducted. A subcohort of 30 participants/country was randomly selected; additional cases were added from the main cohort. Cases (n=236 [random subcohort–36; main cohort–200]) had clinical progression (incident WHO Stage 3/4 event or death) within 96 weeks following cART initiation. Immune activation biomarkers were quantified pre-cART. Associations between biomarkers and clinical progression were examined using weighted multivariable Cox-proportional hazards models. Results Median age was 35 years, 45% were women, 49% black, 31% Asian, and 9% white. Median CD4+ T-cell count was 167 cells/mm3. In multivariate analysis, highest quartile CRP concentration (adjusted hazards ratio [aHR] 2.53, 95%CI 1.02-6.28) and CD4+ T-cell activation (aHR 5.18, 95CI 1.09-24.47) were associated with primary outcomes, compared to lowest quartiles. sCD14 had a trend towards association with clinical failure (aHR 2.24, 95%CI 0.96–5.21). Conclusions Measuring CRP and CD4+ T-cell activation may identify patients with CD4+ T cell counts < 300 cells/mm3 at risk for early clinical progression when initiating cART. Additional vigilance and symptom-based screening may be required in this subset of patients even after beginning cART. PMID:26017661

International models of investigator-initiated trials: implications for Japan

PubMed Central

Trimble, E. L.; Ledermann, J.; Law, K.; Miyata, T.; Imamura, C. K.; Nam, B.-H.; Kim, Y.H.; Bang, Y.-J.; Michaels, M.; Ardron, D.; Amano, S.; Ando, Y.; Tominaga, T.; Kurokawa, K.; Takebe, N.

2012-01-01

Background Academic/institutional investigator-initiated clinical trials benefit individuals and society by supplementing gaps in industry-sponsored clinical trials. Materials In May 2010, experts from Japan, the Republic of Korea, the UK, and the United States, met at a symposium in Tokyo, Japan, to discuss how policies related to the conduct of clinical trials, which have been shown to be effective, may be applied to other regions of the world. Results In order to increase the availability of anticancer drugs world-wide, nations including Japan should examine the benefits of increasing the number of investigator-initiated clinical trials. These trials represent one of the most effective ways to translate basic scientific knowledge into clinical practice. These trials should be conducted under GCP guidelines and include Investigational New Drug application submissions with the ultimate goal of future drug approval. Conclusions To maximize the effectiveness of these trials, a policy to educate health care professionals, cancer patients and their families, and the public in general on the benefits of clinical trials should be strengthened. Finally, policies that expedite the clinical development of novel cancer drugs which have already been shown to be effective in other countries are needed in many nations including Japan to accelerate drug approval. PMID:22843420

Process, cost, and clinical quality: the initial oral contraceptive visit.

PubMed

McMullen, Michael J; Woolford, Samuel W; Moore, Charles L; Berger, Barry M

2013-01-01

To demonstrate how the analysis of clinical process, cost, and outcomes can identify healthcare improvements that reduce cost without sacrificing quality, using the example of the initial visit associated with oral contraceptive pill use. Cross-sectional study using data collected by HealthMETRICS between 1996 and 2009. Using data collected from 106 sites in 24 states, the unintended pregnancy (UIP) rate, effectiveness of patient education, and unit visit cost were calculated. Staff type providing education and placement of education were recorded. Two-way analysis of variance models were created and tested for significance to identify differences between groups. Sites using nonclinical staff to provide education outside the exam were associated with lower cost, higher education scores, and a UIP rate no different from that of sites using clinical staff. Sites also providing patient education during the physical examination were associated with higher cost, lower education scores, and a UIP rate no lower than that of sites providing education outside of the exam. Through analyzing process, cost, and quality, lower-cost processes that did not reduce clinical quality were identified. This methodology is applicable to other clinical services for identifying low-cost processes that do not result in lower clinical quality. By using nonclinical staff educators to provide education outside of the physical examination, sites could save an average of 32% of the total cost of the visit.

Examination of the Korean Modified Checklist of Autism in Toddlers: Item Response Theory

ERIC Educational Resources Information Center

Seung, HyeKyeung; Ji, Juye; Kim, Soo-Jin; Sung, Inkyung; Youn, Young-Ah; Hong, Gyunghun; Lee, Hyeonjin; Lee, Young Hwan; Lee, Hyunsuk; Youm, Hyun Kyung

2015-01-01

The study examined the clinical utility and psychometric properties of the Korean Modified Checklist of Autism in Toddlers (K-M-CHAT)-2. A sample of 2300 parents of 16- to 36-month-old children was recruited across South Korea. A phone interview was utilized to follow up with participants who initially screened positive for autism spectrum…

Developing a Structured Teaching Plan for Psychiatry Tutors at Oxford University

ERIC Educational Resources Information Center

Al-Taiar, Hasanen

2014-01-01

Purpose: The purpose of this thesis was to examine the teaching ways I undertook in teaching medical students and to examine the use of a structured teaching plan for the academic and clinical tutors in psychiatry. The teaching plan was developed for use, initially by Oxford University Academic tutors at the Department of Psychiatry. In addition,…

[Central nervous tuberculosis in patients non-VIH: seven case reports].

PubMed

Mazodier, K; Bernit, E; Faure, V; Rovery, C; Gayet, S; Seux, V; Donnet, A; Brouqui, P; Disdier, P; Schleinitz, N; Kaplanski, G; Veit, V; Harlé, J-R

2003-02-01

Tuberculosis involving the central nervous system (CNS) is rarely observed in non immuno-compromised hosts. We report herin the various clinical, biological and radiological manifestations observed in 7 patients with CNS tuberculosis. Clinical and biological records of 7 patients with CNS tuberculosis were retrospectively studied. All patients had encephalic CT-scan and MRI in the course of the disease. 5 women and 2 men with a mean age of 38.4 years initially initially presented with headache (n = 6), fever (n = 5), meningeal irritation (n = 3), localizing neurological signs (n = 1). Lumbar punction revealed lymphocytic meningitis (n = 6/7). Mycobacterium tuberculosis or bovis was isolated in 3 patients only. Cerebral tomodensitography or magnetic resonance imaging were initially normal in most of cases (n = 4/7), but discovered in the course of disease basilar meningitis (n = 6), hydrocephalus (n = 6), abcess or tuberculoma (n = 4). In all the patients, initiation of the treatment was complicated by clinical and/or biological deterioration, called paradoxal reaction, leading in all cases to glucocorticoid adjunction, with various final results. Indeed, 4 patients developed neurological sequelae. No patient died. CNS tuberculosis is a rare disease in non immunocompromised patients whose diagnostic may be difficult due to the absence of specific clinical symptoms, negative initial radiological examination, as well as delayed and often negative bacterial isolation. Paradoxal reaction appeared to be frequent despite specific antibiotherapy and underlines the beneficial effects of addictive corticosteroids.

Dysphagia in the elderly.

PubMed

Khan, Abraham; Carmona, Richard; Traube, Morris

2014-02-01

Dysphagia, or difficulty swallowing, is a common problem in the elderly. Based on the initial clinical history and physical examination, the dysphagia is assessed as either primarily oropharyngeal or esophageal in origin. Most oropharyngeal dysphagia is of neurologic origin, and management is coordinated with a clinical swallow specialist in conjunction with an ear, nose, and throat (ENT) physician if warning signs imply malignancy. Several structural and functional esophageal disorders can cause dysphagia. If a patient has likely esophageal dysphagia, a video barium esophagram is a good initial test, and referral to a gastroenterologist is generally warranted leading to appropriate treatment. Copyright © 2014 Elsevier Inc. All rights reserved.

Perceptions of Supervision Processes and Practices in Initial Contract, Tenured, and Distinguished-Rated Teachers as They Relate to Self-Learning and Growth in One Large Suburban School District

ERIC Educational Resources Information Center

Watters, Chad M.

2017-01-01

The purpose of this mixed methods study is to examine the perceptions of supervision practices in initial contract, tenured, and distinguished-rated teachers at the elementary level in one large, suburban school district. This study described teacher perceptions of clinical and alternative supervision practices. Six research questions guided this…

The BIG (brain injury guidelines) project: defining the management of traumatic brain injury by acute care surgeons.

PubMed

Joseph, Bellal; Friese, Randall S; Sadoun, Moutamn; Aziz, Hassan; Kulvatunyou, Narong; Pandit, Viraj; Wynne, Julie; Tang, Andrew; O'Keeffe, Terence; Rhee, Peter

2014-04-01

It is becoming a standard practice that any "positive" identification of a radiographic intracranial injury requires transfer of the patient to a trauma center for observation and repeat head computed tomography (RHCT). The purpose of this study was to define guidelines-based on each patient's history, physical examination, and initial head CT findings-regarding which patients require a period of observation, RHCT, or neurosurgical consultation. In our retrospective cohort analysis, we reviewed the records of 3,803 blunt traumatic brain injury patients during a 4-year period. We classified patients according to neurologic examination results, use of intoxicants, anticoagulation status, and initial head CT findings. We then developed brain injury guidelines (BIG) based on the individual patient's need for observation or hospitalization, RHCT, or neurosurgical consultation. A total of 1,232 patients had an abnormal head CT finding. In the BIG 1 category, no patients worsened clinically or radiographically or required any intervention. BIG 2 category had radiographic worsening in 2.6% of the patients. All patients who required neurosurgical intervention (13%) were in BIG 3. There was excellent agreement between assigned BIG and verified BIG. κ statistic is equal to 0.98. We have proposed BIG based on patient's history, neurologic examination, and findings of initial head CT scan. These guidelines must be used as supplement to good clinical examination while managing patients with traumatic brain injury. Prospective validation of the BIG is warranted before its widespread implementation. Epidemiologic study, level III.

Clinical examination and physical assessment of hip joint-related pain in athletes.

PubMed

Reiman, Michael P; Thorborg, Kristian

2014-11-01

Evidence-based clinical examination and assessment of the athlete with hip joint related pain is complex. It requires a systematic approach to properly differentially diagnose competing potential causes of athletic pain generation. An approach with an initial broad focus (and hence use of highly sensitive tests/measures) that then is followed by utilizing more specific tests/measures to pare down this imprecise differential diagnosis list is suggested. Physical assessment measures are then suggested to discern impairments, activity and participation restrictions for athletes with hip-join related pain, hence guiding the proper treatment approach. 5.

Clinical investigation of second mesiobuccal canals in endodontically treated and retreated maxillary molars.

PubMed

Wolcott, James; Ishley, Dave; Kennedy, Wade; Johnson, Scott; Minnich, Scott

2002-06-01

An examination of 1873 conventionally treated and retreated maxillary first and second molars was made in an attempt to determine the percentage of second mesiobuccal (MB2) canals that could be located routinely and evaluate if there were any significant differences between initial treatments and retreatments. The teeth examined were 1193 first molars and 680 second molars treated consecutively over a 2-yr period by five endodontists. Overall the MB2 canal was found in 724 (61%) first molars and 245 (36%) second molars. The incidence of a MB2 canal in first molar retreatments was 67% compared to a 59% incidence in initial treatments. Whereas in second molars, the retreatment incidence was 44% compared with 35% in initial treatments. The significant difference in the incidence of a MB2 canal between initial treatments and retreatments suggests that failure to find and treat existing MB2 canals will decrease the long-term prognosis.

A 5 yr clinical investigation of second mesiobuccal canals in endodontically treated and retreated maxillary molars.

PubMed

Wolcott, James; Ishley, Dave; Kennedy, Wade; Johnson, Scott; Minnich, Scott; Meyers, John

2005-04-01

An examination of 5616 endodontically treated and retreated maxillary first and second molars was made in an attempt to determine the percentage of MB2 canals that could be located routinely, and evaluate if there were any significant differences between initial treatments and retreatments. The teeth examined were 3578 first molars and 2038 second molars treated consecutively over a 5-yr period by six endodontists. Overall the MB2 canal was found in 2133 (60%) first molars, and 712 (35%) second molars. The incidence of a MB2 canal in first molar retreatments was 66% compared to a 58% incidence in initial treatments. Whereas in second molars the retreatment incidence was 40% compared to 34% in initial treatments. The significant difference in the incidence of a MB2 canal between initial treatments and retreatments suggests that failure to find and treat existing MB2 canals will decrease the long-term prognosis.

Implementation of a clinical pharmacy specialist-managed telephonic hospital discharge follow-up program in a patient-centered medical home.

PubMed

Anderson, Sarah L; Marrs, Joel C; Vande Griend, Joseph P; Hanratty, Rebecca

2013-08-01

The objectives of this retrospective study were to examine the feasibility and characteristics that define successful implementation of a Clinical Pharmacy Specialist (CPS) telephonic hospital discharge follow-up quality improvement initiative, as well as the impact of this initiative. Adult patients who were discharged from a safety-net hospital between July 1, 2010 and June 30, 2011 and who were part of a patient-centered medical home were included in this quality improvement initiative. CPSs attempted to contact 470 patients; of those, 207 received the intervention and 263 did not. Patients in the contacted group were more likely to attend a hospital discharge follow-up appointment (66.2% vs. 44.5%, P<0.01) and had lower rates of 30-day readmission (22 vs. 52, P<0.01) compared to those who were not contacted. Institutions should consider allocating resources for pharmacist-managed posthospital discharge follow-up services because of the potential for positive clinical and financial impact.

Integrating research into clinical internship training bridging the science/practice gap in pediatric psychology.

PubMed

McQuaid, Elizabeth L; Spirito, Anthony

2012-03-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a "capstone experience"; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the "business of science." Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists.

Magnetic resonance imaging of injuries to the ankle joint: can it predict clinical outcome?

PubMed

Zanetti, M; De Simoni, C; Wetz, H H; Zollinger, H; Hodler, J

1997-02-01

To predict clinical outcome after ankle sprains on the basis of magnetic resonance (MR) findings. Twenty-nine consecutive patients (mean age 32.9 years, range 13-60 years) were examined clinically and with MR imaging both after trauma and following standardized conservative therapy. Various MR abnormalities were related to a clinical outcome score. There was a tendency for a better clinical outcome in partial, rather than complete, tears of the anterior talofibular ligament and when there was no fluid within the peroneal tendon sheath at the initial MR examination (P = 0.092 for either abnormality). A number of other MR features did not significantly influence clinical outcome, including the presence of a calcaneofibular ligament lesion and a bone bruise of the talar dome. Clinical outcome after ankle sprain cannot consistently be predicted by MR imaging, although MR imaging may be more accurate when the anterior talofibular ligament is only partially torn and there are no signs of injury to the peroneal tendon sheath.

White matter hyperintensities and cerebral amyloidosis: necessary and sufficient for clinical expression of Alzheimer disease?

PubMed

Provenzano, Frank A; Muraskin, Jordan; Tosto, Giuseppe; Narkhede, Atul; Wasserman, Ben T; Griffith, Erica Y; Guzman, Vanessa A; Meier, Irene B; Zimmerman, Molly E; Brickman, Adam M

2013-04-01

Current hypothetical models emphasize the importance of β-amyloid in Alzheimer disease (AD) pathogenesis, although amyloid alone is not sufficient to account for the dementia syndrome. The impact of small-vessel cerebrovascular disease, visualized as white matter hyperintensities (WMHs) on magnetic resonance imaging scans, may be a key factor that contributes independently to AD presentation. To determine the impact of WMHs and Pittsburgh Compound B (PIB) positron-emission tomography-derived amyloid positivity on the clinical expression of AD. Baseline PIB-positron-emission tomography values were downloaded from the Alzheimer's Disease Neuroimaging Initiative database. Total WMH volume was derived on accompanying structural magnetic resonance imaging data. We examined whether PIB positivity and total WMHs predicted diagnostic classification of patients with AD (n = 20) and control subjects (n = 21). A second analysis determined whether WMHs discriminated between those with and without the clinical diagnosis of AD among those who were classified as PIB positive (n = 28). A third analysis examined whether WMHs, in addition to PIB status, could be used to predict future risk for AD among subjects with mild cognitive impairment (n = 59). The Alzheimer's Disease Neuroimaging Initiative public database. The study involved data from 21 normal control subjects, 59 subjects with mild cognitive impairment, and 20 participants with clinically defined AD from the Alzheimer Disease's Neuroimaging Initiative database. Clinical AD diagnosis and WMH volume. Pittsburgh Compound B positivity and increased total WMH volume independently predicted AD diagnosis. Among PIB-positive subjects, those diagnosed as having AD had greater WMH volume than normal control subjects. Among subjects with mild cognitive impairment, both WMH and PIB status at baseline conferred risk for future diagnosis of AD. White matter hyperintensities contribute to the presentation of AD and, in the context of significant amyloid deposition, may provide a second hit necessary for the clinical manifestation of the disease. As risk factors for the development of WMHs are modifiable, these findings suggest intervention and prevention strategies for the clinical syndrome of AD.

What Do Recruiters Consider Important during the Employment Interview?

ERIC Educational Resources Information Center

Atkins, Carolyn P.; Kent, Robert L.

1988-01-01

Examined recruiters' attitudes regarding various hiring characteristics (communication, job selection, appearance) and their impact during initial campus interviews. Questionnaires were completed by 95 recruiters visiting West Virginia University and representing business/industry, hospitals/clinics, and public education. Results revealed that…

Cognitive function in early HIV infection.

PubMed

Prakash, Aanchal; Hou, Jue; Liu, Lei; Gao, Yi; Kettering, Casey; Ragin, Ann B

2017-04-01

This study aimed to examine cognitive function in acute/early HIV infection over the subsequent 2 years. Fifty-six HIV+ subjects and 21 seronegative participants of the Chicago Early HIV Infection Study were evaluated using a comprehensive neuropsychological assessment at study enrollment and at 2-year follow-up. Cognitive performance measures were compared in the groups using t tests and mixed-effect models. Patterns of relationship with clinical measures were determined between cognitive function and clinical status markers using Spearman's correlations. At the initial timepoint, the HIV group demonstrated significantly weaker performance on measures of verbal memory, visual memory, psychomotor speed, motor speed, and executive function. A similar pattern was found when cognitive function was examined at follow-up and across both timepoints. The HIV subjects had generally weaker performance on psychomotor speed, executive function, motor speed, visual memory, and verbal memory. The rate of decline in cognitive function across the 2-year follow-up period did not differ between groups. Correlations between clinical status markers and cognitive function at both timepoints showed weaker performance associated with increased disease burden. Neurocognitive difficulty in chronic HIV infection may have very early onset and reflect consequences of initial brain viral invasion and neuroinflammation during the intense, uncontrolled viremia of acute HIV infection. Further characterization of the changes occurring in initial stages of infection and the risk and protective factors for cognitive function could inform new strategies for neuroprotection.

Emergency recompression: clinical audit of service delivery at a national level.

PubMed

Ross, John As; Sayer, Martin Dj

2009-03-01

Clinical audit is an essential element to the maintenance or improvement of delivery of any medical service. During the development phase of a National Recompression Registration Service for Scotland, clinical audit was initiated to provide a standardised tool to monitor the quality of outcome with respect to the severity of presentation. A functional audit process was an essential consideration for planned future measurement of treatment efficacy at local (single hyperbaric unit) and national (multiple hyperbaric units) scales. The audit process was designed to be undemanding, robust and informative, irrespective of the experience of treatment centre and of the clinician in charge of treatment. The clinical records from 104 cases of divers with decompression illness were used to derive and evaluate measures of severity and clinical outcome that could be used for audit and quality assurance. The various measures of disease severity were examined against clinical outcome and days spent in care after admission to a hyperbaric unit. An initial version of the clinical audit format that was developed from this process is presented.

Clinical characteristics of Helicobacter pylori-negative drug-negative peptic ulcer bleeding

PubMed Central

Chung, Woo Chul; Jeon, Eun Jung; Kim, Dae Bum; Sung, Hea Jung; Kim, Yeon-Ji; Lim, Eun Sun; Kim, Min-ah; Oh, Jung Hwan

2015-01-01

AIM: To investigate the clinical characteristics and outcomes of idiopathic Helicobacter pylori (H. pylori)-negative and drug-negative] peptic ulcer bleeding (PUB). METHODS: A consecutive series of patients who experienced PUB between 2006 and 2012 was retrospectively analyzed. A total of 232 patients were enrolled in this study. The patients were divided into four groups according to the etiologies of PUB: idiopathic, H. pylori-associated, drug-induced and combined (H. pylori-associated and drug-induced) types. We compared the clinical characteristics and outcomes between the groups. When the silver stain or rapid urease tests were H. pylori-negative, we obtained an additional biopsy specimen by endoscopic re-examination and performed an H. pylori antibody test 6-8 wk after the initial endoscopic examination. For a diagnosis of idiopathic PUB, a negative result of an H. pylori antibody test was confirmed. In all cases, re-bleeding was confirmed by endoscopic examination. For the risk assessment, the Blatchford and the Rockall scores were calculated for all patients. RESULTS: For PUB, the frequency of H. pylori infection was 59.5% (138/232), whereas the frequency of idiopathic cases was 8.6% (20/232). When idiopathic PUB was compared to H. pylori-associated PUB, the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis during the hospital stay (30% vs 7.4%, P = 0.02). When idiopathic PUB was compared to drug-induced PUB, the patients in the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis upon admission (30% vs 2.7%, P < 0.01). When drug-induced PUB was compared to H. pylori-associated PUB, the patients in the drug-induced PUB were older (68.49 ± 14.76 years vs 47.83 ± 15.15 years, P < 0.01) and showed a higher proportion of gastric ulcer (77% vs 49%, P < 0.01). However, the Blatchford and the Rockall scores were not significantly different between the two groups. Among the patients who experienced drug-induced PUB, no significant differences were found with respect to clinical characteristics, irrespective of H. pylori infection. CONCLUSION: Idiopathic PUB has unique clinical characteristics such as re-bleeding after initial hemostasis upon admission. Therefore, these patients need to undergo close surveillance upon admission. PMID:26229405

Clinical characteristics of Helicobacter pylori-negative drug-negative peptic ulcer bleeding.

PubMed

Chung, Woo Chul; Jeon, Eun Jung; Kim, Dae Bum; Sung, Hea Jung; Kim, Yeon-Ji; Lim, Eun Sun; Kim, Min-Ah; Oh, Jung Hwan

2015-07-28

To investigate the clinical characteristics and outcomes of idiopathic Helicobacter pylori (H. pylori)-negative and drug-negative] peptic ulcer bleeding (PUB). A consecutive series of patients who experienced PUB between 2006 and 2012 was retrospectively analyzed. A total of 232 patients were enrolled in this study. The patients were divided into four groups according to the etiologies of PUB: idiopathic, H. pylori-associated, drug-induced and combined (H. pylori-associated and drug-induced) types. We compared the clinical characteristics and outcomes between the groups. When the silver stain or rapid urease tests were H. pylori-negative, we obtained an additional biopsy specimen by endoscopic re-examination and performed an H. pylori antibody test 6-8 wk after the initial endoscopic examination. For a diagnosis of idiopathic PUB, a negative result of an H. pylori antibody test was confirmed. In all cases, re-bleeding was confirmed by endoscopic examination. For the risk assessment, the Blatchford and the Rockall scores were calculated for all patients. For PUB, the frequency of H. pylori infection was 59.5% (138/232), whereas the frequency of idiopathic cases was 8.6% (20/232). When idiopathic PUB was compared to H. pylori-associated PUB, the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis during the hospital stay (30% vs 7.4%, P = 0.02). When idiopathic PUB was compared to drug-induced PUB, the patients in the idiopathic PUB group showed a higher rate of re-bleeding after initial hemostasis upon admission (30% vs 2.7%, P < 0.01). When drug-induced PUB was compared to H. pylori-associated PUB, the patients in the drug-induced PUB were older (68.49 ± 14.76 years vs 47.83 ± 15.15 years, P < 0.01) and showed a higher proportion of gastric ulcer (77% vs 49%, P < 0.01). However, the Blatchford and the Rockall scores were not significantly different between the two groups. Among the patients who experienced drug-induced PUB, no significant differences were found with respect to clinical characteristics, irrespective of H. pylori infection. Idiopathic PUB has unique clinical characteristics such as re-bleeding after initial hemostasis upon admission. Therefore, these patients need to undergo close surveillance upon admission.

Acute thoracolumbar pain due to cholecystitis: a case study.

PubMed

Carter, Chris T

2015-01-01

This article describes and discusses the case of an adult female with cholecystitis characterized on initial presentation as acute thoracolumbar pain. A 34-year-old female presented for care with a complaint of acute right sided lower thoracic and upper lumbar pain with associated significant hyperalgesia and muscular hypertonicity. The patient was examined, referred, and later diagnosed by use of ultrasound imaging. Despite many initial physical examination findings of musculoskeletal dysfunction, this case demonstrates the significance of visceral referred pain, viscerosomatic hyperalgesia & hypertonicity, and how these neurological processes can mimic mechanical pain syndromes. A clinical neurological discussion of cholecystitis visceral pain and referred viscerosomatic phenomena is included.

[A school-level longitudinal study of clinical performance examination scores].

PubMed

Park, Jang Hee

2015-06-01

This school-level longitudinal study examined 7 years of clinical performance data to determine differences (effects) in students and annual changes within a school and between schools; examine how much their predictors (characteristics) influenced the variation in student performance; and calculate estimates of the schools' initial status and growth. A school-level longitudinal model was tested: level 1 (between students), level 2 (annual change within a school), and level 3 (between schools). The study sample comprised students who belonged to the CPX Consortium (n=5,283 for 2005~2008 and n=4,337 for 2009~2011). Despite a difference between evaluation domains, the performance outcomes were related to individual large-effect differences and small-effect school-level differences. Physical examination, clinical courtesy, and patient education were strongly influenced by the school effect, whereas patient-physician interaction was not affected much. Student scores are influenced by the school effect (differences), and the predictors explain the variation in differences, depending on the evaluation domain.

Nonsurgically managed patients with degenerative spondylolisthesis: a 10- to 18-year follow-up study.

PubMed

Matsunaga, S; Ijiri, K; Hayashi, K

2000-10-01

Controversy exists concerning the indications for surgery and choice of surgical procedure for patients with degenerative spondylolisthesis. The goals of this study were to determine the clinical course of nonsurgically managed patients with degenerative spondylolisthesis as well as the indications for surgery. A total of 145 nonsurgically managed patients with degenerative spondylolisthesis were examined annually for a minimum of 10 years follow-up evaluation. Radiographic changes, changes in clinical symptoms, and functional prognosis were surveyed. Progressive spondylolisthesis was observed in 49 patients (34%). There was no correlation between changes in clinical symptoms and progression of spondylolisthesis. The intervertebral spaces of the slipped segments were decreased significantly in size during follow-up examination in patients in whom no progression was found. Low-back pain improved following a decrease in the total intervertebral space size. A total of 84 (76%) of 110 patients who had no neurological deficits at initial examination remained without neurological deficit after 10 years of follow up. Twenty-nine (83%) of the 35 patients who had neurological symptoms, such as intermittent claudication or vesicorectal disorder, at initial examination and refused surgery experienced neurological deterioration. The final prognosis for these patients was very poor. Low-back pain was improved by restabilization. Conservative treatment is useful for patients who have low-back pain with or without pain in the lower extremities. Surgical intervention is indicated for patients with neurological symptoms including intermittent claudication or vesicorectal disorder, provided that a good functional outcome can be achieved.

Clinical research in small genomically stratified patient populations.

PubMed

Martin-Liberal, J; Rodon, J

2017-07-01

The paradigm of early drug development in cancer is shifting from 'histology-oriented' to 'molecularly oriented' clinical trials. This change can be attributed to the vast amount of tumour biology knowledge generated by large international research initiatives such as The Cancer Genome Atlas (TCGA) and the use of next generation sequencing (NGS) techniques developed in recent years. However, targeting infrequent molecular alterations entails a series of special challenges. The optimal molecular profiling method, the lack of standardised biological thresholds, inter- and intra-tumor heterogeneity, availability of enough tumour material, correct clinical trials design, attrition rate, logistics or costs are only some of the issues that need to be taken into consideration in clinical research in small genomically stratified patient populations. This article examines the most relevant challenges inherent to clinical research in these populations. Moreover, perspectives from the Academia point of view are reviewed as well as initiatives to be taken in forthcoming years. Copyright © 2017 Elsevier Ltd. All rights reserved.

Early detection and treatment of sexually transmitted disease in pregnant adolescents of low socioeconomic status.

PubMed

Matson, S C; Pomeranz, A J; Kamps, K A

1993-10-01

This study evaluated the prevalence of sexually transmitted disease (STD) in adolescents presenting to a primary pediatric care clinic (PPCC) for the diagnosis of pregnancy and our ability to eradicate identified infections. We followed 168 pregnant adolescents of low socioeconomic status from their original pregnancy diagnosis until their first prenatal clinic visit. We collected screening cervical cultures for Neisseria gonorrhoeae and Chlamydia trachomatis by completing a pelvic examination on 91 patients at our PPCC. At the PPCC visit, 29% were positive for gonorrhea, chlamydia, or both. Screening tests for these infections were collected on all patients at the initial prenatal clinic visit. The risk for presenting to the prenatal clinic with a STD was significantly greater in patients not screened and treated for STD at the PPCC. Average delay from diagnosis to first prenatal clinic visit was 35.7 days. Thus, in this adolescent population, primary care providers are missing an important therapeutic opportunity by failing to identify and treat STD at initial diagnosis of pregnancy.

Missing the mark: Current practices in teaching the male urogenital examination to Canadian undergraduate medical students

PubMed Central

McAlpine, Kristen; Steele, Stephen

2016-01-01

Introduction: The urogenital physical examination is an important aspect of patient encounters in various clinical settings. Introductory clinical skills sessions are intended to provide support and alleviate students’ anxiety when learning this sensitive exam. The techniques each Canadian medical school uses to guide their students through the initial urogenital examination has not been previously reported. Methods: This study surveyed pre-clerkship clinical skills program directors at the main campus of English-speaking Canadian medical schools regarding the curriculum they use to teach the urogenital examination. Results: A response rate of 100% was achieved, providing information on resources and faculty available to students, as well as the manner in which students were evaluated. Surprisingly, over one-third of the Canadian medical schools surveyed failed to provide a setting in which students perform a urogenital examination on a patient in their pre-clinical years. Additionally, there was no formal evaluation of this skill set reported by almost 50% of Canadian medical schools prior to clinical training years. Conclusions: To ensure medical students are confident and accurate in performing a urogenital examination, it is vital they be provided the proper resources, teaching, and training. As we progress towards a competency-based curriculum, it is essential that increased focus be placed on patient encounters in undergraduate training. Further research to quantify students’ exposure to the urogenital examination during clinical years would be of interest. Without this commitment by Canadian medical schools, we are doing a disservice not only to the medical students, but also to our patient population. PMID:27878052

Missing the mark: Current practices in teaching the male urogenital examination to Canadian undergraduate medical students.

PubMed

McAlpine, Kristen; Steele, Stephen

2016-08-01

The urogenital physical examination is an important aspect of patient encounters in various clinical settings. Introductory clinical skills sessions are intended to provide support and alleviate students' anxiety when learning this sensitive exam. The techniques each Canadian medical school uses to guide their students through the initial urogenital examination has not been previously reported. This study surveyed pre-clerkship clinical skills program directors at the main campus of English-speaking Canadian medical schools regarding the curriculum they use to teach the urogenital examination. A response rate of 100% was achieved, providing information on resources and faculty available to students, as well as the manner in which students were evaluated. Surprisingly, over one-third of the Canadian medical schools surveyed failed to provide a setting in which students perform a urogenital examination on a patient in their pre-clinical years. Additionally, there was no formal evaluation of this skill set reported by almost 50% of Canadian medical schools prior to clinical training years. To ensure medical students are confident and accurate in performing a urogenital examination, it is vital they be provided the proper resources, teaching, and training. As we progress towards a competency-based curriculum, it is essential that increased focus be placed on patient encounters in undergraduate training. Further research to quantify students' exposure to the urogenital examination during clinical years would be of interest. Without this commitment by Canadian medical schools, we are doing a disservice not only to the medical students, but also to our patient population.

The stigma of having psychological problems: relations with engagement, working alliance, and depression in psychotherapy.

PubMed

Kendra, Matthew S; Mohr, Jonathan J; Pollard, Jeffrey W

2014-12-01

The stigma of having psychological problems is a barrier to seeking mental health treatment, but little research has examined whether this stigma influences the experiences of those in treatment. In a sample of 42 psychotherapy clients, we explored links over the first few sessions between 2 facets of stigma (self-stigma and perceived public stigma) and 3 variables germane to the therapeutic process (depression, working alliance, and engagement). Initial self-stigma (SS) level was positively associated with initial depression, negatively associated with initial working alliance, and unrelated to initial engagement. Initial perceived public stigma (PPS) level was unrelated to initial levels in the 3 outcome variables. Initial SS and PPS levels were both generally unrelated to linear changes in the outcomes over the initial phase of counseling. Relations between stigma and outcome variables often differed within- and between-persons. For example, the association between PPS and engagement was negative at the between-person level but positive at the within-person level. Finally, on average, PPS decreased over the first few sessions but SS remained constant. Such findings may help therapists better understand the role of stigma in their clinical work, and stimulate research examining how to address stigmatization in psychotherapy.

Factors associated with clinical inertia: an integrative review

PubMed Central

Aujoulat, Isabelle; Jacquemin, Patricia; Rietzschel, Ernst; Scheen, André; Tréfois, Patrick; Wens, Johan; Darras, Elisabeth; Hermans, Michel P

2014-01-01

Failure to initiate or intensify therapy according to evidence-based guidelines is increasingly being acknowledged as a phenomenon that contributes to inadequate management of chronic conditions, and is referred to as clinical inertia. However, the number and complexity of factors associated with the clinical reasoning that underlies the decision-making processes in medicine calls for a critical examination of the consistency of the concept. Indeed, in the absence of information on and justification of treatment decisions that were made, clinical inertia may be only apparent, and actually reflect good clinical practice. This integrative review seeks to address the factors generally associated with clinical inaction, in order to better delineate the concept of true clinical inertia. PMID:24868181

Role of radiology in a national initiative to interdict drug smuggling: the Dutch experience.

PubMed

Algra, Paul R; Brogdon, Byron G; Marugg, Roque C

2007-08-01

The purpose of this pictorial essay is to describe the role of radiology in a national initiative to intercept illegal narcotics concealed within the bodies of human transporters. Radiologic examination is increasingly important in identifying intracorporeal drug smuggling as improved wrapping techniques undermine the usefulness of blood and urine testing and clinical observation. Detection rates of high accuracy, sensitivity, and specificity are achieved by experienced radiologists.

Functional outcome from sacroiliac joint prolotherapy in patients with sacroiliac joint instability.

PubMed

Hoffman, Martin D; Agnish, Vikram

2018-04-01

Examine the effectiveness of sacroiliac (SI) joint prolotherapy for SI joint instability, and characterize the patients most likely to benefit from this treatment. Retrospective cohort study. Department of Veterans Affairs outpatient physical medicine clinic. Patients referred for low back pain and diagnosed with SI joint instability received a series of three SI joint prolotherapy injections (15% dextrose in lidocaine) at approximately a one-month interval. The outcome of those completing treatment was retrospectively examined, and characteristics were compared between those with at least a minimum clinically important improvement and those without improvement. Patients completed the Oswestry Disability Index (ODI) before treatment was initiated, immediately preceding each prolotherapy injection, and at 3-4 month follow-up. Of 103 treated patients returning for post-treatment follow-up at a median of 117 days, 24 (23%) showed a minimum clinically important improvement despite a median of 2 years with low back pain and a mean (±SD) pre-intervention ODI of 54 ± 15 points. Much of the improvement was evident after the initial prolotherapy injection, and a 15-point improvement in ODI prior to the second prolotherapy injection had a sensitivity of 92% and specificity of 80% for determining which patients would improve. A satisfactory proportion of patients with symptomatic SI joint instability as an etiology of low back pain can have clinically meaningful functional gains with prolotherapy treatment. The patients who are not likely to improve with prolotherapy are generally evident by lack of improvement following the initial prolotherapy injection. Published by Elsevier Ltd.

[Comparison of reproducibility measurements for calibration of dental caries epidemiological surveys].

PubMed

Assaf, Andréa Videira; Zanin, Luciane; Meneghim, Marcelo de Castro; Pereira, Antonio Carlos; Ambrosano, Gláucia Maria Bovi

2006-09-01

This study compares three measurements (Kappa, general agreement percentage, or GAP, and dice index) used to determine the reproducibility of caries diagnosis in epidemiological surveys under different clinical diagnostic thresholds. Eleven examiners with previous experience in epidemiological surveys were submitted to a theoretical and clinical calibration process. Data analysis used two caries detection thresholds: World Health Organization (WHO) and WHO with the inclusion of initial enamel lesions (WHO + IL). Twenty-three children 6-7 years of age were examined, with and without caries. Mean values for Kappa index, GAP, and Dice were considered high (> 0.90), except for the dice index for the WHO + IL threshold (0.69). Since Kappa is an adjusted agreement index, it can be considered the instrument of choice for calibration of examiners. However, when it is impossible to use, the GAP is recommended together with the dice index in order to orient and improve examiners when examining caries lesions.

The effect of dual accreditation on family medicine residency programs.

PubMed

Mims, Lisa D; Bressler, Lindsey C; Wannamaker, Louise R; Carek, Peter J

2015-04-01

In 1985, the American Osteopathic Association (AOA) Board of Trustees agreed to allow residency programs to become dually accredited by the AOA and Accreditation Council for Graduate Medical Education (ACGME). Despite the increase in such programs, there has been minimal research comparing these programs to exclusively ACGME-accredited residencies. This study examines the association between dual accreditation and suggested markers of quality. Standard characteristics such as regional location, program structure (community or university based), postgraduate year one (PGY-1) positions offered, and salary (PGY-1) were obtained for each residency program. In addition, the faculty to resident ratio in the family medicine clinic and the number of half days residents spent in the clinic each week were recorded. Initial Match rates and pass rates of new graduates on the ABFM examination from 2009 to 2013 were also obtained. Variables were analyzed using chi-square and Student's t test. Logistic regression models were then created to predict a program's 5-year aggregate initial Match rate and Board pass rate in the top tertile as compared to the lowest tertile. Dual accreditation was obtained by 117 (27.0%) of programs. Initial analyses revealed associations between dually accredited programs and mean year of initial ACGME program accreditation, regional location, program structure, tracks, and alternative medicine curriculum. When evaluated in logistic regression, dual accreditation status was not associated with Match rates or ABFM pass rates. By examining suggested markers of program quality for dually accredited programs in comparison to ACGME-only accredited programs, this study successfully established both differences and similarities among the two types.

Incident pregnancy and time to death or AIDS among HIV-positive women receiving antiretroviral therapy.

PubMed

Westreich, Daniel; Maskew, Mhairi; Evans, Denise; Firnhaber, Cindy; Majuba, Pappie; Sanne, Ian

2013-01-01

Little is known about the impact of pregnancy on response to highly active antiretroviral therapy (HAART) in sub-Saharan Africa. We examined the effect of incident pregnancy after HAART initiation on clinical response to HAART. We evaluated a prospective clinical cohort of adult women initiating HAART in Johannesburg, South Africa between 1 April 2004 and 31 March 2011, and followed up until an event, transfer, drop-out, or administrative end of follow-up on 30 September 2011. Women over age 45 and women who were pregnant at HAART initiation were excluded from the study. Main exposure was having experienced pregnancy after HAART initiation; main outcome was death and (separately) death or new AIDS event. We calculated adjusted hazard ratios (HRs) and 95% confidence limits (CL) using marginal structural Cox proportional hazards models. The study included 7,534 women, and 20,813 person-years of follow-up; 918 women had at least one recognized pregnancy during follow-up. For death alone, the weighted (adjusted) HR was 0.84 (95% CL 0.44, 1.60). Sensitivity analyses confirmed main results, and results were similar for analysis of death or new AIDS event. Incident pregnancy was associated with a substantially reduced hazard of drop-out (HR = 0.62, 95% CL 0.51, 0.75). Recognized incident pregnancy after HAART initiation was not associated with increases in hazard of clinical events, but was associated with a decreased hazard of drop-out. High rates of pregnancy after initiation of HAART may point to a need to better integrate family planning services into clinical care for HIV-infected women.

Effects of mother-son incest and positive perceptions of sexual abuse experiences on the psychosocial adjustment of clinic-referred men.

PubMed

Kelly, Robert J; Wood, Jeffrey J; Gonzalez, Lauren S; MacDonald, Virginia; Waterman, Jill

2002-04-01

The primary objective was to examine the long-term impact of mother-son incest and positive initial perceptions of sexual abuse experiences on adult male psychosocial functioning. Sixty-seven clinic-referred men with a history of sexual abuse participated. The participants completed self-report measures regarding their current psychosocial functioning and described the nature of their sexual and physical abuse experiences during childhood. Seventeen men reported mother-son incest, and these men endorsed more trauma symptoms than did other sexually abused men, even after controlling for a history of multiple perpetrators and physical abuse. Mother-son incest was likely to be subtle, involving behaviors that may be difficult to distinguish from normal caregiving (e.g., genital touching), despite the potentially serious long-term consequences. Twenty-seven men recalled positive or mixed initial perceptions of the abuse, including about half of the men who had been abused by their mothers. These men reported more adjustment problems than did men who recalled purely negative initial perceptions. Mother-son incest and positive initial perceptions of sexual abuse experiences both appear to be risk factors for more severe psychosocial adjustment problems among clinic-referred men.

Implementation of Cognitive-Behavioral Substance Abuse Treatment in Sub-Saharan Africa: Treatment Engagement and Abstinence at Treatment Exit.

PubMed

Gouse, Hetta; Magidson, Jessica F; Burnhams, Warren; Remmert, Jocelyn E; Myers, Bronwyn; Joska, John A; Carrico, Adam W

2016-01-01

This study documented the treatment cascade for engagement in care and abstinence at treatment exit as well as examined correlates of these outcomes for the first certified Matrix Model® substance abuse treatment site in Sub-Saharan Africa. This retrospective chart review conducted at a resource-limited community clinic in Cape Town, South Africa, assessed treatment readiness and substance use severity at treatment entry as correlates of the number of sessions attended and biologically confirmed abstinence at treatment exit among 986 clients who initiated treatment from 2009-2014. Sociodemographic and clinical correlates of treatment outcomes were examined using logistic regression, modeling treatment completion and abstinence at treatment exit separately. Of the 2,233 clients who completed screening, approximately 44% (n = 986) initiated treatment. Among those who initiated treatment, 45% completed at least four group sessions, 30% completed early recovery skills training (i.e., at least eight group sessions), and 13% completed the full 16-week program. Approximately half (54%) of clients who provided a urine sample had negative urine toxicology results for any substance at treatment exit. Higher motivation at treatment entry was independently associated with greater odds of treatment completion and negative urine toxicology results at treatment exit. Findings provide initial support for the successful implementation the Matrix Model in a resource-limited setting. Motivational enhancement interventions could support treatment initiation, promote sustained engagement in treatment, and achieve better treatment outcomes.

Periodontist-Dental Hygienist Collaboration in Periodontal Care for Chronic Periodontitis: An 11-year Case Report.

PubMed

Tomita, Sachiyo; Uekusa, Tomomi; Hosono, Meiko; Kigure, Takashi; Sugito, Hiroki; Saito, Atsushi

2016-01-01

We report a case of severe chronic periodontitis treated and longitudinally maintained by a periodontist and dental hygienists. The patient was a 45-year-old woman who presented with the chief complaint of gingival bleeding and tooth mobility. An initial examination revealed generalized gingival inflammation and subgingival calculus in the premolar and molar regions. Premature contact was observed in #14 and 45. Clinical examination revealed 42% of sites with a probing depth (PD) of ≥4 mm and 44% of sites with bleeding on probing. Radiographic examination revealed vertical bone resorption in #35, 36, and 45, and horizontal bone resorption in other regions. Based on a clinical diagnosis of severe chronic periodontitis, initial periodontal therapy consisting of plaque control, scaling and root planing, and removal of an ill-fitting prosthesis was performed. Following suppression of inflammation, occlusal adjustment of premature contact sites was performed. Open flap debridement was performed for teeth with a PD of ≥5 mm. After confirming the stability of the periodontal tissue, final prostheses were placed on #16, 35-37, and 46. Following re-evaluation, the patient was placed on supportive periodontal therapy. It has been 11 years since the patient's first visit, and the periodontal conditions have remained stable. Meticulous periodontal care maintained over a number of years by a periodontist and dental hygienist have yielded a clinically favorable outcome.

Anxiety Adversely Impacts Response to Cognitive Behavioral Therapy in Children with Chronic Pain.

PubMed

Cunningham, Natoshia Raishevich; Jagpal, Anjana; Tran, Susan T; Kashikar-Zuck, Susmita; Goldschneider, Kenneth R; Coghill, Robert C; Lynch-Jordan, Anne M

2016-04-01

To evaluate whether clinical anxiety in children presenting to a pediatric pain management center is associated with a poorer treatment response for those who completed pain-focused cognitive behavioral therapy (CBT). The total sample consisted of 175 children, 40 of whom completed CBT for chronic pain. The Screen for Child Anxiety Related Emotional Disorders was completed at initial evaluation and outcome measures (average pain intensity and the Functional Disability Inventory) were collected during the initial evaluation and at the end of CBT. Group differences in outcomes were examined following CBT. The role of anxiety in CBT initiation and completion was also explored. Presence of clinical anxiety was associated with greater initiation and/or completion of pain-focused CBT but also a poorer treatment response. Specifically, the group with subclinical anxiety exhibited a substantial reduction in pain intensity, and the group with clinical anxiety exhibited a more limited response to treatment (F [1, 36] = 13.68 P < .01). A similar effect was observed for Functional Disability Inventory, such that the group with clinical anxiety had a significantly smaller response to treatment (F [1, 38] = 4.33 P < .05). The difference in pain and disability between groups following CBT suggest moderate effects (Cohen d = 0.77 and 0.78, respectively). Although youths with clinical anxiety are more likely to start and/or complete pain-focused CBT, anxiety has an adverse impact on CBT treatment response in children with chronic pain. Identification of patients with anxiety and use of tailored behavioral interventions may improve clinical outcomes. Copyright © 2016 Elsevier Inc. All rights reserved.

A Review of Clinical Data for Currently Approved Hysteroscopic Sterilization Procedures

PubMed Central

Basinski, Cindy M

2010-01-01

Two hysteroscopic permanent sterilization procedures are approved for use in the United States: Essure® Permanent Birth Control System (Conceptus Incorporated, Mountain View, CA) and Adiana® Permanent Contraception (Hologic, Inc., Bedford, MA). This review compares the clinical trial data for these procedures. A notable difference is the resultant clinical pregnancy risk. The clinical trials for the Essure procedure have reported no pregnancies in 643 relying women in the 9 years since initiation of the studies. The clinical trial for the Adiana procedure has reported 12 pregnancies in 570 relying women in nearly 5 years of collected data. Other clinical outcome parameters concerning Essure and Adiana are examined in this review. PMID:21364861

Cutaneous progressive angiomatosis on the muzzle of a dog, treated by laser photocoagulation therapy.

PubMed

Olivieri, Lara; Nardini, Giordano; Pengo, Graziano; Abramo, Francesca

2010-10-01

A 10-year old, female, cocker spaniel was presented with a bleeding lesion on the muzzle and nasal planum observed initially as a small raised nodule at 1 year of age. This became clinically more pronounced at 5 years of age, progressively enlarged thereafter and was diagnosed initially as a vascular tumour. On clinical examination, multiple confluent nodules of variable diameter (0.5-1.5 cm) deformed the outline of the nose. Histological examination revealed a progressive angiomatosis with multifocal infiltrative growth of increased dermal vascularization with different sized and type of anastomosing vessels lined by a monolayer of reactive endothelium, often arranged as papillary projections into the lumina. Partial nosectomy, the first therapeutic approach, was unsuccessful and the lesion relapsed within 6 months. However, subsequent laser photocoagulation therapy provided a good cosmetic outcome, no relapse 1 year later, and appeared to provide an effective alternative to ablation surgery. © 2010 The Authors. Journal compilation © 2010 ESVD and ACVD.

Evolution of Functional Family Therapy as an Evidence-Based Practice for Adolescents with Disruptive Behavior Problems.

PubMed

Robbins, Michael S; Alexander, James F; Turner, Charles W; Hollimon, Amy

2016-09-01

This article summarizes the evolution of functional family therapy (FFT) based upon four decades of clinical practice and scientific scrutiny through research evidence. FFT research has evolved from an initial focus upon clinical process research, which examined sequential exchanges between therapists and family members. A key element of this research has been an examination of the way in which clinicians acquire, consolidate, and maintain the skills needed to implement FFT effectively with youth and families. Many randomized efficacy and effectiveness studies have evaluated the impact of FFT across diverse clinical populations. Subsequent research investigated factors that influence the effectiveness of implementation across more than 300 clinical settings in which more than 2,500 trained clinicians have provided service to nearly 400,000 families. Another important set of investigations concerned the cost-effectiveness of the interventions. © 2016 Family Process Institute.

Epidemiological study of dogs with otitis externa in Cape Breton, Nova Scotia

PubMed Central

Perry, Laura R.; MacLennan, Bernard; Korven, Rebecca; Rawlings, Timothy A.

2017-01-01

From May 2008 to December 2013, 320 cases of otitis externa were diagnosed among 2012 dogs undergoing routine physical examinations at Celtic Creatures Veterinary Clinic, Sydney River, Nova Scotia for a diagnosis frequency of 15.9% [95% confidence interval (CI): 14.3% to 17.6%]. Twenty-four percent of these dogs exhibited 1 or multiple recurrences despite initial treatment with topical antimicrobial/anti-inflammatory solutions. The frequency of diagnosis was significantly higher in breeds with pendulous ears, but was not affected by ear hairiness. There were no seasonal patterns in the frequency of diagnosis. In clinical examination of 60 dogs with otitis externa, bacteria were evident in 47% of infections. Of 10 genera cultured, Staphylococcus spp. and diptheroids were most common. In this study, analysis of clinical records provided insights into the local prevalence of otitis externa and the efficacy of treatment in routine clinical situations. PMID:28216686

Clinical clearance of the cervical spine in patients with distracting injuries: It is time to dispel the myth.

PubMed

Rose, Melanie K; Rosal, Lindy M; Gonzalez, Richard P; Rostas, Jack W; Baker, Jeremy A; Simmons, Jon D; Frotan, Mohammed A; Brevard, Sydney B

2012-08-01

The purpose of this study was to prospectively assess the sensitivity and efficacy of clinical examination for screening of cervical spine (c-spine) injury in awake and alert blunt trauma patients with concomitant "distracting injuries." During the 24-month period from December 2009 to December 2011, all blunt trauma patients older than 13 years were prospectively evaluated with a standard cervical spine examination protocol by the trauma surgery team at a Level 1 trauma center. Awake and alert patients with a Glasgow Coma Score (GCS) ≥14 underwent clinical examination of the cervical spine. Clinical examination was performed regardless of "distracting injuries." Patients without complaints of pain or tenderness on physical exam had their cervical collar removed, and the c-spine was considered clinically cleared of injury. All awake and alert patients with "distracting injuries," including those clinically cleared and those with complaints of c-spine pain or tenderness underwent computerized tomographic (CT) scanning of the entire c-spine. "Distracting injuries" were categorized into three anatomic regions: head injuries, torso injuries and long bone fractures. Patients with minor distracting injuries were not considered to have a "distracting injury." During the 24-month study period, 761 blunt trauma patients with GCS ≥14 and at least one "distracting injury" had been entered into the study protocol. Two-hundred ninety-six (39%) of the patients with "distracting injuries" had a positive c-spine clinical examination, 85 (29%) of whom were diagnosed with c-spine injury. Four hundred sixty-four (61%) of the patients with "distracting injuries"’ were initially clinically cleared, with one patient (0.2%) diagnosed with a c-spine injury. This yielded an overall sensitivity of 99% (85/86) and negative predictive value greater than 99% (463/464) for cervical spine clinical examination in awake and alert blunt trauma patients with "distracting injuries." In the awake and alert blunt trauma patient with "distracting injuries," clinical examination is a sensitive screening method for cervical spine injury. Radiological assessment is unnecessary for safe clearance of the asymptomatic cervical spine in awake and alert blunt trauma patients with "distracting injuries." These findings suggest the concept of "distracting injury" in the context of cervical spine clinical examination is invalid. Expanding the utility of cervical spine clinical examination to patients with "distracting injuries" allows for significant reduction of both healthcare cost and radiation exposure.

Comparison of neonatal MRI examinations with and without an MR-compatible incubator: advantages in examination feasibility and clinical decision-making.

PubMed

Rona, Z; Klebermass, K; Cardona, F; Czaba, C D; Brugger, P C; Weninger, M; Pollak, A; Prayer, D

2010-09-01

To assess the utility of an MRI-compatible incubator (INC) by comparing. In a retrospective study, the clinical and radiological aspects of 129 neonatal MRI examinations during a 3 year period were analyzed. Routine protocols including fast spin-echo T2-weighted (w) sequences, axial T1w, Gradient-echo, diffusion sequences, and 3D T1 gradient-echo sequences were performed routinely, angiography and spectroscopy were added in some cases. Diffusion-tensor imaging was done in 50% of the babies examined in the INC and 26% without INC. Sequences, adapted from fetal MR-protocols were done in infants younger than 32 gestational weeks. Benefit from MR-information with respect to further management was evaluated. The number of the examinations increased (30-99), while the mean age (43-38, 8 weeks of gestational age) and weight (3308-2766 g) decreased significantly with the use of the MR-compatible incubator. The mean imaging time (34, 43-30, 29 min) decreased, with a mean of one additionally performed sequence in the INC group. All infants received sedatives according to our anaesthetic protocol preceding imaging, but a repeated dose was never necessary (10% without INC) using the INC. Regarding all cases, MR-based changes in clinical management were initiated in 58%, while in 57% of cases the initial ultrasound diagnosis was changed or further specified. The use of the INC enables the MR access of unstable infants with suspect CNS problems to the management, of whom is improved by MR information to significantly higher percentage, than without INC. Copyright (c) 2010 European Paediatric Neurology Society. Published by Elsevier Ltd. All rights reserved.

Attendance at specialist hepatitis clinics and initiation of antiviral treatment among persons chronically infected with hepatitis C: examining the early impact of Scotland's Hepatitis C Action Plan.

PubMed

McDonald, S A; Hutchinson, S J; Innes, H A; Allen, S; Bramley, P; Bhattacharyya, D; Carman, W; Dillon, J F; Fox, R; Fraser, A; Goldberg, D J; Kennedy, N; Mills, P R; Morris, J; Stanley, A J; Wilks, D; Hayes, P C

2014-05-01

Primary goals of the Hepatitis C Action Plan for Scotland Phase II (May 2008-March 2011) were to increase, among persons chronically infected with the hepatitis C (HCV) virus, attendance at specialist outpatient clinics and initiation on antiviral therapy. We evaluated progress towards these goals by comparing the odds, across time, of (a) first clinic attendance within 12 months of HCV diagnosis (n = 9747) and (b) initiation on antiviral treatment within 12 months of first attendance (n = 5736). Record linkage between the national HCV diagnosis (1996-2009) and HCV clinical (1996-2010) databases and logistic regression analyses were conducted for both outcomes. For outcome (a), 32% and 45% in the respective pre-Phase II (before 1 May 2008) and Phase II periods attended a specialist clinic within 12 months of diagnosis; the odds of attendance within 12 months increased over time (OR = 1.05 per year, 95% CI: 1.04-1.07), but was not significantly greater for persons diagnosed with HCV in the Phase II era, compared with the pre-Phase II era (OR = 1.1, 95% CI: 0.9-1.3), after adjustment for temporal trend. For outcome (b), 13% and 28% were initiated on treatment within 12 months of their first clinic attendance in the pre-Phase II and Phase II periods, respectively. Higher odds of treatment initiation were associated with first clinic attendance in the Phase II (OR = 1.9, 95% CI: 1.5-2.4), compared with the pre-Phase II era. Results were consistent with a positive impact of the Hepatitis C Action Plan on the treatment of chronically infected individuals, but further monitoring is required to confirm a sustained effect. © 2013 John Wiley & Sons Ltd.

Prognosis of adult-onset idiopathic bile acid malabsorption.

PubMed

Rössel, P; Sortsøe Jensen, H; Qvist, P; Arveschoug, A

1999-06-01

From 1986 to 1993, 150 patients were investigated with the 75Se-homocholic acid taurine (SeHCAT) test as a late step in the investigation of chronic diarrhoea. On basis of low SeHCAT values and response to cholestyramine treatment, 33 patients were initially classified as having idiopathic bile acid malabsorption (IBAM). The aim was to describe the long-term clinical course of the disease and to assess the reliability of the SeHCAT test in diagnosing IBAM. The methods included 1) clinical follow-up with patient interview combined with information from medical records and 2) repeated SeHCAT test. The diagnosis of IBAM had to be revised in three cases (inflammatory bowel disease in two patients, Clostridium difficile infection in one). Six patients were lost to follow-up and a further four patients were excluded from re-examination either because of old age (>80 years) or bowel resection, leaving 20 patients for re-examination, of which 16 completed both clinical follow-up and a new SeHCAT test. The median duration of symptoms before initial SeHCAT test was 2.5 (1-30) years. In 13 of 16 patients symptoms persisted, and SeHCAT values remained low and almost identical to the initial value after a median observation time of 88 (51-113) months. Despite initial response to treatment with cholestyramine, six patients had to discontinue treatment because of adverse effects or other compliance problems. In three patients the SeHCAT value showed a considerable increase, and bowel function had correspondingly normalized in these cases. The study confirms the reliability of the SeHCAT test in diagnosing IBAM. Despite adult onset of symptoms, only a few patients improve after several years' observation. Treatment with cholestyramine is generally effective but not always tolerated.

Physical Activity Level and Symptom Duration Are Not Associated After Concussion.

PubMed

Howell, David R; Mannix, Rebekah C; Quinn, Bridget; Taylor, J Andrew; Tan, Can Ozan; Meehan, William P

2016-04-01

Physical rest after a concussion has been described as a key component in the management of the injury. Evidence supporting this recommendation, however, is limited. To examine the association between physical activity and symptom duration in a cohort of patients after a concussion. Cohort study; Level of evidence, 2. This study included 364 patients who were diagnosed with a concussion, were seen by a physician within 3 weeks of injury, and completed a questionnaire at the initial clinic visit. The questionnaire assessed the postconcussion symptom scale (PCSS) score, previous number of concussions, presence of the loss of consciousness or amnesia at the time of injury, and prior treatment for headaches. During each follow-up clinic visit, physical activity level was self-reported. A Cox proportional hazard model was constructed to determine the association between symptom duration, initial clinic visit responses, and self-reported physical activity level after the injury. Study participants ranged in age from 8 to 27 years (mean age, 15.0 years) and had sustained a mean of 0.8 prior concussions; 222 patients (61%) were male. On initial examination, the mean PCSS score was 34.7. The mean symptom duration was 48.9 days after the injury. Among the variables included in the model, initial PCSS score and female sex were independently associated with symptom duration, while physical activity level after the injury was not. For participants aged between 13 and 18 years, however, higher levels of physical activity after the injury were associated with a shorter symptom duration. Results from this study indicate that physical activity after the injury may not be universally detrimental to the recovery of concussion symptoms. © 2016 The Author(s).

Do Patients and Oncologists Discuss the Cost of Cancer Treatment? An Observational Study of Clinical Interactions Between African American Patients and Their Oncologists.

PubMed

Hamel, Lauren M; Penner, Louis A; Eggly, Susan; Chapman, Robert; Klamerus, Justin F; Simon, Michael S; Stanton, Sarah C E; Albrecht, Terrance L

2017-03-01

Financial toxicity negatively affects patients with cancer, especially racial/ethnic minorities. Patient-oncologist discussions about treatment-related costs may reduce financial toxicity by factoring costs into treatment decisions. This study investigated the frequency and nature of cost discussions during clinical interactions between African American patients and oncologists and examined whether cost discussions were affected by patient sociodemographic characteristics and social support, a known buffer to perceived financial stress. Methods Video recorded patient-oncologist clinical interactions (n = 103) from outpatient clinics of two urban cancer hospitals (including a National Cancer Institute-designated comprehensive cancer center) were analyzed. Coders studied the videos for the presence and duration of cost discussions and then determined the initiator, topic, oncologist response to the patient's concerns, and the patient's reaction to the oncologist's response. Cost discussions occurred in 45% of clinical interactions. Patients initiated 63% of discussions; oncologists initiated 36%. The most frequent topics were concern about time off from work for treatment (initiated by patients) and insurance (initiated by oncologists). Younger patients and patients with more perceived social support satisfaction were more likely to discuss cost. Patient age interacted with amount of social support to affect frequency of cost discussions within interactions. Younger patients with more social support had more cost discussions; older patients with more social support had fewer cost discussions. Cost discussions occurred in fewer than one half of the interactions and most commonly focused on the impact of the diagnosis on patients' opportunity costs rather than treatment costs. Implications for ASCO's Value Framework and design of interventions to improve cost discussions are discussed.

Advances in Retinal Prosthetic Research: A Systematic Review of Engineering and Clinical Characteristics of Current Prosthetic Initiatives.

PubMed

Cheng, Derrick L; Greenberg, Paul B; Borton, David A

2017-03-01

To date, reviews of retinal prostheses have focused primarily on devices undergoing human trials in the Western Hemisphere and fail to capture significant advances in materials and engineering research in countries such as Japan and Korea, as well as projects in early stages of development. To address these gaps, this systematic review examines worldwide advances in retinal prosthetic research, evaluates engineering characteristics and clinical progress of contemporary device initiatives, and identifies potential directions for future research in the field of retinal prosthetics. A literature search using PubMed, Google Scholar, and IEEExplore was conducted following the PRISMA Guidelines for Systematic Review. Inclusion criteria were peer-reviewed papers demonstrating progress in human or animal trials and papers discussing the prosthetic engineering design. For each initiative, a description of the device, its engineering considerations, and recent clinical results were provided. Ten prosthetic initiatives met our inclusion criteria and were organized by stimulation location. Of these initiatives, four have recently completed human trials, three are undergoing multi- or single-center human trials, and three are undergoing preclinical animal testing. Only the Argus II (FDA 2013, CE 2011) has obtained FDA approval for use in the United States; the Alpha-IMS (CE 2013) has achieved the highest visual acuity using a Landolt-C test to date and is the only device presently undergoing a multicenter clinical trial. Several distinct approaches to retinal stimulation have been successful in eliciting visual precepts in animals and/or humans. However, many clinical needs are still not met and engineering challenges must be addressed before a retinal prosthesis with the capability to fully and safely restore functional vision can be realized.

Changing organizational culture: using the CEO cancer gold standard policy initiatives to promote health and wellness at a school of public health.

PubMed

Towne, Samuel D; Anderson, Kelsey E; Smith, Matthew Lee; Dahlke, Deborah Vollmer; Kellstedt, Debra; Purcell, Ninfa Pena; Ory, Marcia G

2015-09-03

Worksite wellness initiatives for health promotion and health education have demonstrated effectiveness in improving employee health and wellness. We examined the effects of a multifaceted health promotion campaign on organizational capacity to meet requirements to become CEO Cancer Gold Standard Accredited. We conducted an online survey to assess perceived organizational values and support for the five CEO Cancer Gold Standard Pillars for cancer prevention: tobacco cessation; physical activity; nutrition; cancer screening and early detection; and accessing information on cancer clinical trials. Baseline and follow-up surveys were sent 6-months apart to faculty, staff, and students at a school of public health to test the impact of a multifaceted health promotion campaign on perceived organizational change. Descriptive analyses were used to characterize percent improvement. Multivariate logistic regression analyses were used to control for participants' university status. The current organizational culture highly supported tobacco cessation at both time points. Significant improvements (p < .05) from baseline to follow-up were observed for questions measuring organizational values for 'prevention, screening, and early detection of cancer' and 'accessing cancer treatment and clinical trials'. Health promotion and education efforts using multiple approaches were effective to improve perceived organizational values and support for cancer prevention and early detection, and increase access to information about cancer clinical trials. Future studies are needed to examine broader impacts of implementing worksite health promotion initiatives.

Factors influencing utilization of postpartum CD4 count testing by HIV-positive women not yet eligible for antiretroviral treatment.

PubMed

Gilles, Kate P; Zimba, Chifundo; Mofolo, Innocent; Bobrow, Emily; Hamela, Gloria; Martinson, Francis; Hoffman, Irving; Hosseinipour, Mina

2011-03-01

Delayed antiretroviral initiation is associated with increased mortality, but individuals frequently delay seeking treatment. To increase early antiretroviral therapy (ART) enrollment of HIV-positive women, antenatal clinics are implementing regular, postpartum CD4 count testing. We examined factors influencing women's utilization of extended CD4 count testing. About 53 in-depth interviews were conducted with nurses, patients, social support persons, and government health officials at three antenatal clinics in Lilongwe, Malawi. Counseling and positive interactions with staff emerged as facilitating factors. Women wanted to know their CD4 count, but didn't understand the importance of early ART initiation. Support from husbands facilitated women's return to the clinic. Reminders were perceived as helpful but ineffectively employed. Staff identified lack of communication, difficulty in tracking, and referring women as barriers. Counseling messages should emphasize the importance of starting ART early. Clinics should focus on male partner involvement, case management, staff communication, and appointment reminders. Follow-up should be offered at multiple service points.

Primary Care Practices' Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement.

PubMed

Cohen, Deborah J; Dorr, David A; Knierim, Kyle; DuBard, C Annette; Hemler, Jennifer R; Hall, Jennifer D; Marino, Miguel; Solberg, Leif I; McConnell, K John; Nichols, Len M; Nease, Donald E; Edwards, Samuel T; Wu, Winfred Y; Pham-Singer, Hang; Kho, Abel N; Phillips, Robert L; Rasmussen, Luke V; Duffy, F Daniel; Balasubramanian, Bijal A

2018-04-01

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports-but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures.

Primary Care Practices’ Abilities And Challenges In Using Electronic Health Record Data For Quality Improvement

PubMed Central

Cohen, Deborah J.; Dorr, David A.; Knierim, Kyle; DuBard, C. Annette; Hemler, Jennifer R.; Hall, Jennifer D.; Marino, Miguel; Solberg, Leif I.; McConnell, K. John; Nichols, Len M.; Nease, Donald E.; Edwards, Samuel T.; Wu, Winfred Y.; Pham-Singer, Hang; Kho, Abel N.; Phillips, Robert L.; Rasmussen, Luke V.; Duffy, F. Daniel; Balasubramanian, Bijal A.

2018-01-01

Federal value-based payment programs require primary care practices to conduct quality improvement activities, informed by the electronic reports on clinical quality measures that their electronic health records (EHRs) generate. To determine whether EHRs produce reports adequate to the task, we examined survey responses from 1,492 practices across twelve states, supplemented with qualitative data. Meaningful-use participation, which requires the use of a federally certified EHR, was associated with the ability to generate reports—but the reports did not necessarily support quality improvement initiatives. Practices reported numerous challenges in generating adequate reports, such as difficulty manipulating and aligning measurement time frames with quality improvement needs, lack of functionality for generating reports on electronic clinical quality measures at different levels, discordance between clinical guidelines and measures available in reports, questionable data quality, and vendors that were unreceptive to changing EHR configuration beyond federal requirements. The current state of EHR measurement functionality may be insufficient to support federal initiatives that tie payment to clinical quality measures. PMID:29608365

Salvage microbiology: opportunities and challenges in the detection of bacterial pathogens following initiation of antimicrobial treatment

PubMed Central

Farrell, John J.; Hujer, Andrea M.; Sampath, Rangarajan; Bonomo, Robert A.

2015-01-01

Broad-range 16S ribosomal RNA gene PCR coupled with Sanger sequencing was originally employed by soil scientists and was subsequently adapted for clinical applications. PCR coupled with electrospray ionization mass spectrometry has also progressed from initial applications in the detection of organisms from environmental samples into the clinical realm and has demonstrated promise in detection of pathogens in clinical specimens obtained from patients with suspected infection but negative cultures. We review studies of multiplex PCR, 16S ribosomal RNA gene PCR and sequencing and PCR coupled with electrospray ionization mass spectrometry for detection of bacteria in specimens that were obtained from patients during or after administration of antibiotic treatment, and examine the role of each for assisting in antimicrobial treatment and stewardship efforts. Following an exploration of the available data in this field we discuss the opportunities that the preliminary investigations reveal, as well as the challenges faced with implementation of these strategies in clinical practice. PMID:25523281

Integrating Research Into Clinical Internship Training Bridging the Science/Practice Gap in Pediatric Psychology

PubMed Central

Spirito, Anthony

2012-01-01

Existing literature highlights a critical gap between science and practice in clinical psychology. The internship year is a “capstone experience”; training in methods of scientific evaluation should be integrated with the development of advanced clinical competencies. We provide a rationale for continued exposure to research during the clinical internship year, including, (a) critical examination and integration of the literature regarding evidence-based treatment and assessment, (b) participation in faculty-based and independent research, and (c) orientation to the science and strategy of grantsmanship. Participation in research provides exposure to new empirical models and can foster the development of applied research questions. Orientation to grantsmanship can yield an initial sense of the “business of science.” Internship provides an important opportunity to examine the challenges to integrating the clinical evidence base into professional practice; for that reason, providing research exposure on internship is an important strategy in training the next generation of pediatric psychologists. PMID:22286345

Safety Profile during Initiation of Propranolol for Treatment of Infantile Hemangiomas in an Ambulatory Day-Care Hospitalization Setting.

PubMed

Fogel, Itay; Ollech, Ayelet; Zvulunov, Alex; Valdman-Greenshpon, Yulia; Atar-Sagie, Vered; Friedland, Rivka; Lapidoth, Moshe; Ben-Amitai, Dan

2018-03-24

Propranolol is the mainstay of treatment for infantile hemangioma. Despite its good safety profile, it is not risk-free. Guidelines for propranolol initiation and monitoring have been suggested, but protocols vary among practitioners. This study sought to assess the prevalence of adverse events and clinically significant fluctuations in hemodynamic parameters in children with infantile hemangioma during initiation of treatment with propranolol in a day-hospitalization setting. Children with infantile hemangioma treated with propranolol in a day-hospitalization department of a tertiary pediatric medical center in 2008-2014 were identified retrospectively. The pretreatment evaluation included clinical examination by a pediatric dermatologist and electrocardiography, echocardiography, and clinical examination by a pediatric cardiologist. The propranolol dosage was escalated from 0.5mg/kg/day to 2mg/kg/day, divided into 3 doses/day, over 3 days. Heart rate, blood pressure, and blood glucose level were measured before treatment onset and 60 min after the first two doses each day. The third dose was given at home. The cohort included 220 children aged 1 month to 5 years. No severe treatment-related adverse events were documented; 27 patients had minor side effects. There was a significant decrease in heart rate each day after the first two doses (p<0.001), and in systolic blood pressure, on day 2 (1mg/kg/day) after the first dose (p=0.01). Blood glucose level remained stable. The hemodynamic changes were clinically asymptomatic and did not require intervention. Propranolol treatment (2mg/kg/day in three doses) for infantile hemangioma is well tolerated and safe and may be administered and monitored in an ambulatory setting. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Clinical and histopathological evaluation of 16 dogs with T-zone lymphoma

PubMed Central

MIZUTANI, Noriyuki; GOTO-KOSHINO, Yuko; TAKAHASHI, Masashi; UCHIDA, Kazuyuki; TSUJIMOTO, Hajime

2016-01-01

Clinical and histopathological characteristics of 16 dogs with nodal paracortical (T-zone) lymphoma (TZL) were evaluated. At initial examination, generalized lymphadenopathy was found in all dogs, and peripheral lymphocytosis was found in 10 of the 16 dogs. At initial diagnosis or during the disease course, 8 dogs (50%) were affected with demodicosis. Immunohistochemical analysis for CD3, CD20 and CD25 was performed for 6 dogs with TZL; the tumor cells were positive for CD3 and CD25 and negative for CD20. Median overall survival time was 938 days. A watchful waiting approach was adopted for 6 cases (38%), and 5 of the 6 dogs were still alive at the end of follow-up. The clinical course of TZL in dogs is generally indolent; however, many cases develop a variety of infectious and other neoplastic diseases after the diagnosis of TZL. PMID:27098109

Using systems thinking to support clinical system transformation.

PubMed

Best, Allan; Berland, Alex; Herbert, Carol; Bitz, Jennifer; van Dijk, Marlies W; Krause, Christina; Cochrane, Douglas; Noel, Kevin; Marsden, Julian; McKeown, Shari; Millar, John

2016-05-16

Purpose - The British Columbia Ministry of Health's Clinical Care Management initiative was used as a case study to better understand large-scale change (LSC) within BC's health system. Using a complex system framework, the purpose of this paper is to examine mechanisms that enable and constrain the implementation of clinical guidelines across various clinical settings. Design/methodology/approach - Researchers applied a general model of complex adaptive systems plus two specific conceptual frameworks (realist evaluation and system dynamics mapping) to define and study enablers and constraints. Focus group sessions and interviews with clinicians, executives, managers and board members were validated through an online survey. Findings - The functional themes for managing large-scale clinical change included: creating a context to prepare clinicians for health system transformation initiatives; promoting shared clinical leadership; strengthening knowledge management, strategic communications and opportunities for networking; and clearing pathways through the complexity of a multilevel, dynamic system. Research limitations/implications - The action research methodology was designed to guide continuing improvement of implementation. A sample of initiatives was selected; it was not intended to compare and contrast facilitators and barriers across all initiatives and regions. Similarly, evaluating the results or process of guideline implementation was outside the scope; the methods were designed to enable conversations at multiple levels - policy, management and practice - about how to improve implementation. The study is best seen as a case study of LSC, offering a possible model for replication by others and a tool to shape further dialogue. Practical implications - Recommended action-oriented strategies included engaging local champions; supporting local adaptation for implementation of clinical guidelines; strengthening local teams to guide implementation; reducing change fatigue; ensuring adequate resources; providing consistent communication especially for front-line care providers; and supporting local teams to demonstrate the clinical value of the guidelines to their colleagues. Originality/value - Bringing a complex systems perspective to clinical guideline implementation resulted in a clear understanding of the challenges involved in LSC.

[Pathogenetic relationship between pterygium and dry eye syndrome (clinical and cytological study)].

PubMed

Petraevskiĭ, A V; Trishkin, K S

2014-01-01

To study the prevalence of dry eye syndrome in patients with initial primary pterygium for determination of a possible pathogenetic role of dry eye syndrome in the development of pterygium. 30 patients with initial primary pterygium; besides conventional ophthalmic assessment, cytological examination of bulbar conjunctiva was performed in all cases. Signs of dry eye syndrome, of similar severity in both eyes, were found in 100% of patients. Dry eye can be one of the precipitating factors of primary pterygium.

Vertical integration of teaching in Australian general practice--a survey of regional training providers.

PubMed

Stocks, Nigel P; Frank, Oliver; Linn, Andrew M; Anderson, Katrina; Meertens, Sarah

2011-06-06

To examine vertical integration of teaching and clinical training in general practice and describe practical examples being undertaken by Australian general practice regional training providers (RTPs). A qualitative study of all RTPs in Australia, mid 2010. All 17 RTPs in Australia responded. Eleven had developed some vertical integration initiatives. Several encouraged registrars to teach junior doctors and medical students, others encouraged general practitioner supervisors to run multilevel educational sessions, a few coordinated placements, linkages and support across their region. Three RTPs provided case studies of vertical integration. Many RTPs in Australia use vertical integration of teaching in their training programs. RTPs with close associations with universities and rural clinical schools seem to be leading these initiatives.

Delayed Enhancement of Ascites After IV Contrast Material Administration at CT: Time Course and Clinical Correlation

PubMed Central

Benedetti, Nancy; Aslam, Rizwan; Wang, Zhen J.; Joe, Bonnie N.; Fu, Yanjun; Yee, Judy; Yeh, Benjamin M.

2010-01-01

OBJECTIVE The objective of our study was to determine the prevalence and clinical predictors of delayed contrast enhancement of ascites. MATERIALS AND METHODS In this retrospective study, 132 consecutive patients with ascites who underwent repeated abdominopelvic CT examinations performed within 7 days of each other were identified. These patients included 112 patients who received and 20 who did not receive IV contrast material at the initial CT examination. For each examination, we recorded the CT attenuation of the ascites. For the follow-up scan, the presence of delayed enhancement of ascites was defined as an increase in CT attenuation > 10 HU over baseline. The Fisher’s exact test, unpaired Student’s t test, and logistic regression were used to determine predictors of delayed enhancement of ascites. RESULTS A threshold increase in the attenuation of ascites by > 10 HU or more between the initial and follow-up CT examinations occurred only when IV contrast material was given with the initial examination. The increased attenuation was due to delayed contrast enhancement of ascites and occurred in 15 of the 112 patients (13%). Of the 16 patients scanned less than 1 day apart, 10 (63%) showed delayed enhancement of ascites. Delayed enhancement was not observed 3 or more days after IV contrast material administration. For each 1 mg/dL increase in serum creatinine level, the likelihood of delayed enhancement of ascites increased (odds ratio, 2.02; 95% CI, 1.11–3.69). Multivariate logistic regression showed that a short time interval between examinations (p < 0.001), increased serum creatinine level (p < 0.001), and presence of loculated ascites (p = < 0.01) were independent predictors of the magnitude of delayed enhancement of ascites. CONCLUSION Delayed contrast enhancement of ascites occurs commonly after recent prior IV contrast material administration and should not be mistaken for hemoperitoneum or proteinaceous fluid such as pus. PMID:19696286

Relations of Alcohol Consumption with Smoking Cessation Milestones and Tobacco Dependence

ERIC Educational Resources Information Center

Cook, Jessica W.; Fucito, Lisa M.; Piasecki, Thomas M.; Piper, Megan E.; Schlam, Tanya R.; Berg, Kristin M.; Baker, Timothy B.

2012-01-01

Objective: Alcohol consumption is associated with smoking cessation failure in both community and clinical research. However, little is known about the relation between alcohol consumption and smoking cessation milestones (i.e., achieving initial abstinence, avoiding lapses and relapse). Our objective in this research was to examine the relations…

Factors That Influence Clinical Placements for Teacher Candidates

ERIC Educational Resources Information Center

James, Kristi M.

2014-01-01

In 2010, President Barack Obama's administration committed to reevaluate funding streams for No Child Left Behind (NCLB). This effort supported state and local initiatives designed to strengthen teacher quality. While a number of studies have examined preparation programs, candidate efficacy, and even candidate induction and attrition; few studies…

Job Tenure among Persons with Severe Mental Illness.

ERIC Educational Resources Information Center

Xie, Haiyi; Dain, Bradley J.; Becker, Deborah R.; Drake, Robert E.

1997-01-01

Examined job tenure among 85 individuals with psychiatric disabilities. Surveyed clients' demographic, clinical, and vocational histories, their initial reactions to specific jobs, and aspects of the work environment. The average job lasted 70 days. Longer tenure was predicted by previous work history, early satisfaction with the job, lower…

Size of clinical trials and Introductory prices of prophylactic vaccine series

PubMed Central

Weinberg, Steven H.; Butchart, Amy T.; Davis, Matthew M.

2012-01-01

Costs of completing the recommended immunization schedule have increased over the last decade. Access to prophylactic vaccines may become limited due to financing obstacles within current delivery systems. Vaccine prices reflect research and development expenses incurred by vaccine manufacturers, including costs associated with evaluating candidate vaccines in human subjects. If the number of subjects in clinical trials is increasing over time and associated with vaccine price, this may help explain increases in prices of vaccine series. We examined whether: (A) the initial public- and private-sector prices for recommended prophylactic vaccine series licensed and recommended in the US increased from 2000–2011, (B) the number of human subjects per licensed vaccine increased during the time period, and (C) the number of human subjects was associated with the initial public–and private–sector prices of the vaccine series. In regression analyses of 13 vaccines, approval year was not significantly associated with the number of human subjects, initial public-sector prices, or initial private-sector prices. While the number of phase II subjects was not significantly associated with prices, the numbers of phase III and combined late phase (phases II + III) subjects were significantly associated with initial public- and private-sector series prices (p < 0.05). The association between number of subjects and initial prices demonstrated diminishing marginal increases in price with increasing numbers of subjects. These findings may help guide the number of subjects required by the FDA in clinical trials, in order to reduce expenses for manufacturers and thereby help mitigate increases in initial vaccine series prices. PMID:22854668

Size of clinical trials and Introductory prices of prophylactic vaccine series.

PubMed

Weinberg, Steven H; Butchart, Amy T; Davis, Matthew M

2012-08-01

Costs of completing the recommended immunization schedule have increased over the last decade. Access to prophylactic vaccines may become limited due to financing obstacles within current delivery systems. Vaccine prices reflect research and development expenses incurred by vaccine manufacturers, including costs associated with evaluating candidate vaccines in human subjects. If the number of subjects in clinical trials is increasing over time and associated with vaccine price, this may help explain increases in prices of vaccine series. We examined whether: (A) the initial public- and private-sector prices for recommended prophylactic vaccine series licensed and recommended in the US increased from 2000-2011, (B) the number of human subjects per licensed vaccine increased during the time period, and (C) the number of human subjects was associated with the initial public-and private-sector prices of the vaccine series. In regression analyses of 13 vaccines, approval year was not significantly associated with the number of human subjects, initial public-sector prices, or initial private-sector prices. While the number of phase II subjects was not significantly associated with prices, the numbers of phase III and combined late phase (phases II + III) subjects were significantly associated with initial public- and private-sector series prices (p < 0.05). The association between number of subjects and initial prices demonstrated diminishing marginal increases in price with increasing numbers of subjects. These findings may help guide the number of subjects required by the FDA in clinical trials, in order to reduce expenses for manufacturers and thereby help mitigate increases in initial vaccine series prices.

Orthokeratinised odontogenic cyst mimicking periapical cyst

PubMed Central

Rajalakshmi, R; Sreeja, C; Vijayalakshmi, D; Leelarani, V

2013-01-01

Orthokeratinised odontogenic cyst (OOC) denotes the odontogenic cyst that microscopically has an orthokeratinised epithelial lining. OOC is characterised by a less-aggressive behaviour and a low rate of recurrence. This report describes a case of OOC involving posterior part of the mandible that mimicked periapical cyst in a 14-year-old boy. The initial clinical diagnosis was given as periapical cyst based on the clinical and radiographical features. Enucleation of the cyst was performed and the specimen was sent for histopathological examination. A definite diagnosis of OOC was made by histopathological examination of the biopsy specimen. This case emphases on including OOC in the differential diagnosis of radiolucencies occurring in the periapical region of non-vital tooth. PMID:24099763

Orthokeratinised odontogenic cyst mimicking periapical cyst.

PubMed

Rajalakshmi, R; Sreeja, C; Vijayalakshmi, D; Leelarani, V

2013-10-07

Orthokeratinised odontogenic cyst (OOC) denotes the odontogenic cyst that microscopically has an orthokeratinised epithelial lining. OOC is characterised by a less-aggressive behaviour and a low rate of recurrence. This report describes a case of OOC involving posterior part of the mandible that mimicked periapical cyst in a 14-year-old boy. The initial clinical diagnosis was given as periapical cyst based on the clinical and radiographical features. Enucleation of the cyst was performed and the specimen was sent for histopathological examination. A definite diagnosis of OOC was made by histopathological examination of the biopsy specimen. This case emphases on including OOC in the differential diagnosis of radiolucencies occurring in the periapical region of non-vital tooth.

Bisphosphonate-Induced Osteonecrosis of the Maxilla Resembling a Persistent Endodontic Lesion.

PubMed

Mosaferi, Hossein; Fazlyab, Mahta; Sharifi, Sanaz; Rahimian, Sepideh

2016-01-01

A 52-year-old Caucasian woman suffering from pain in the anterior maxillary region, presented to the clinic. Examination revealed a draining sinus tract in the buccal vestibule of the maxilla in the left anterior segment and expansion in the middle of palate. On conventional radiographic examination the lesion was initially assumed to be a periapical problem related to the incisors but subsequently it was diagnosed to be a bisphosphonate osteonecrosis. Acquiring a comprehensive medical history from the patients, conducting the clinical vitality tests and most importantly being familiar with the non-odontogenic lesions that can be side effects of specific medications are important requirements for reaching a correct diagnosis.

Bisphosphonate-Induced Osteonecrosis of the Maxilla Resembling a Persistent Endodontic Lesion

PubMed Central

Mosaferi, Hossein; Fazlyab, Mahta; Sharifi, Sanaz; Rahimian, Sepideh

2016-01-01

A 52-year-old Caucasian woman suffering from pain in the anterior maxillary region, presented to the clinic. Examination revealed a draining sinus tract in the buccal vestibule of the maxilla in the left anterior segment and expansion in the middle of palate. On conventional radiographic examination the lesion was initially assumed to be a periapical problem related to the incisors but subsequently it was diagnosed to be a bisphosphonate osteonecrosis. Conclusion: Acquiring a comprehensive medical history from the patients, conducting the clinical vitality tests and most importantly being familiar with the non-odontogenic lesions that can be side effects of specific medications are important requirements for reaching a correct diagnosis. PMID:26843881

Clinical trials recruitment planning: A proposed framework from the Clinical Trials Transformation Initiative.

PubMed

Huang, Grant D; Bull, Jonca; Johnston McKee, Kelly; Mahon, Elizabeth; Harper, Beth; Roberts, Jamie N

2018-03-01

Patient recruitment is widely recognized as a key determinant of success for clinical trials. Yet a substantial number of trials fail to reach recruitment goals-a situation that has important scientific, financial, ethical, and policy implications. Further, there are important effects on stakeholders who directly contribute to the trial including investigators, sponsors, and study participants. Despite efforts over multiple decades to identify and address barriers, recruitment challenges persist. To advance a more comprehensive approach to trial recruitment, the Clinical Trials Transformation Initiative (CTTI) convened a project team to examine the challenges and to issue actionable, evidence-based recommendations for improving recruitment planning that extend beyond common study-specific strategies. We describe our multi-stakeholder effort to develop a framework that delineates three areas essential to strategic recruitment planning efforts: (1) trial design and protocol development, (2) trial feasibility and site selection, and (3) communication. Our recommendations propose an upstream approach to recruitment planning that has the potential to produce greater impact and reduce downstream barriers. Additionally, we offer tools to help facilitate adoption of the recommendations. We hope that our framework and recommendations will serve as a guide for initial efforts in clinical trial recruitment planning irrespective of disease or intervention focus, provide a common basis for discussions in this area and generate targets for further analysis and continual improvement. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Obstetrics and gynecology clerkship for males and females: similar curriculum, different outcomes?

PubMed Central

Craig, LaTasha B.; Smith, Chad; Crow, Sheila M.; Driver, Whitney; Wallace, Michelle; Thompson, Britta M.

2013-01-01

Objective To determine if performance differences exist between male and female students on a 6-week obstetrics and gynecology (Ob/Gyn) clerkship and to evaluate potential variables that might underlie any observed variations. Study Design Final clerkship grades and component scores (clinical evaluations, objective structured clinical examination [OSCE], oral examination, and National Board of Medical Examiners [NBME] subject examination) from July 2007 to June 2010 were matched by student and analyzed by gender. Basic science grade point average (GPA) and initial United States Medical Licensing Exam (USMLE) Step 1 scores were used to establish students’ baseline medical knowledge. On a post-clerkship questionnaire, a subset of students reported the numbers of procedures they performed during the clerkship; students also completed online pre- and post-clerkship questionnaires reflecting their self-assessed confidence in women's health clinical skills. Results Scores were analyzed for 136 women and 220 men. Final clerkship grades were significantly higher for females than for males (89.05 vs. 87.34, p=0.0004, η 2=0.08). Specifically, females outscored males on the OSCE, oral, and NBME subject examination portions of the clerkship but not clinical evaluations. Males reported completing fewer breast examinations (p=0.001, η 2=0.14). Pre-clerkship, males were significantly less confident than females in women's health clinical skills (p<0.01) but reached similar levels upon completion of the clerkship. No gender differences were detected for basic science GPA and USMLE Step 1 scores. Conclusion Student gender is associated with final grades on an Ob/Gyn clerkship. Further research regarding these differences should be explored. PMID:24300748

Effectiveness of physical therapy for patients with neck pain: an individualized approach using a clinical decision-making algorithm.

PubMed

Wang, Wendy T J; Olson, Sharon L; Campbell, Anne H; Hanten, William P; Gleeson, Peggy B

2003-03-01

The purpose of this study was to determine the effectiveness of an individualized physical therapy intervention in treating neck pain based on a clinical reasoning algorithm. Treatment effectiveness was examined by assessing changes in impairment, physical performance, and disability in response to intervention. One treatment group of 30 patients with neck pain completed physical therapy treatment. The control group of convenience was formed by a cohort group of 27 subjects who also had neck pain but did not receive treatment for various reasons. There were no significant differences between groups in demographic data and the initial test scores of the outcome measures. A quasi-experimental, nonequivalent, pretest-posttest control group design was used. A physical therapist rendered an eclectic intervention to the treatment group based on a clinical decision-making algorithm. Treatment outcome measures included the following five dependent variables: cervical range of motion, numeric pain rating, timed weighted overhead endurance, the supine capital flexion endurance test, and the Patient Specific Functional Scale. Both the treatment and control groups completed the initial and follow-up examinations, with an average duration of 4 wk between tests. Five mixed analyses of variance with follow-up tests showed a significant difference for all outcome measures in the treatment group compared with the control group. After an average 4 wk of physical therapy intervention, patients in the treatment group demonstrated statistically significant increases of cervical range of motion, decrease of pain, increases of physical performance measures, and decreases in the level of disability. The control group showed no differences in all five outcome variables between the initial and follow-up test scores. This study delineated algorithm-based clinical reasoning strategies for evaluating and treating patients with cervical pain. The algorithm can help clinicians classify patients with cervical pain into clinical patterns and provides pattern-specific guidelines for physical therapy interventions. An organized and specific physical therapy program was effective in improving the status of patients with neck pain.

Rib fractures induced by coughing: an unusual cause of acute chest pain.

PubMed

De Maeseneer, M; De Mey, J; Debaere, C; Meysman, M; Osteaux, M

2000-03-01

We report three patients with stress fractures of the ribs induced by coughing. Standard radiographs of the chest and ribs did not reveal evidence of rib fractures in any of the patients. Bone scintigraphy, performed 1 to 2 weeks after initial onset of symptoms, showed a focal area of increased uptake along the chest wall in all cases. Thin section angulated helical CT directly visualized the subtle rib fractures. Initial diagnosis of a cough-induced fracture of the rib may be difficult because of the associated underlying disorder, and unnecessary examinations are commonly performed. Identification of a cough-induced fracture of the rib using helical CT may be clinically important to avoid unnecessary concern and additional examinations.

Improving stressful working lives: complementary therapies, counselling and clinical supervision for staff.

PubMed

Mackereth, Peter A; White, Keven; Cawthorn, Anne; Lynch, Barbara

2005-06-01

The aim of this paper is to briefly examine the contemporary phenomenon of "burnout" within oncology and palliative care. In discussing the suitable interventions to manage stress and avoid burnout, reference will be made to counselling and clinical supervision, but more substantially the paper will report on an innovative subsidised complementary therapy service for staff. The Government's Improving Working Lives Standard will be referred as an initiative that supports the development of supportive services for NHS staff.

Papillon-Lefèvre syndrome: a successful outcome.

PubMed

Ahuja, Vanita; Shin, Richard Hochul; Mudgil, Adarsh; Nanda, Veena; Schoor, Robert

2005-11-01

Papillon-Lefèvre syndrome (PLS) is a rare autosomal recessive condition manifested clinically by hyperkeratosis of the palms and soles and rapidly progressive periodontitis resulting in loss of deciduous and permanent teeth. This case report describes the clinical periodontal findings and treatment of a 10-year-old male patient with PLS. The patient provided informed consent, and the study was conducted in accordance with the Helsinki Declaration of 1975, as revised in 2000. Upon initial presentation, a full periodontal examination was completed. Conventional probing depths, clinical attachment levels (CAL), gingival index (GI), and plaque index (PI) were measured prior to initial therapy, which involved oral hygiene instruction and scaling and root planing. At reevaluation, initial treatment proved unsuccessful, and a surgical approach with concomitant systemic antibiotic therapy was implemented. In addition, the patient's dermatologist treated his palmoplantar keratoderma with systemic retinoids. Subsequently, the patient was placed on a strict 3-month maintenance protocol and was evaluated over a period of 1 year. Initial treatment with mechanical therapy, oral hygiene instruction, frequent recalls, and systemic antibiotics did not yield efficacious results. However, with the addition of surgical treatment, a favorable clinical outcome was obtained. Numerous treatment regimens for the periodontal disease seen in PLS can be found in the literature. We demonstrate successful treatment of the periodontal disease seen in this condition using mechanical therapy, systemic antibiotics, and surgical modalities; over a period of 1 year, we were able to achieve significant reductions in gingival inflammation and erythema.

Intraoperative imaging during Mohs surgery with reflectance confocal microscopy: initial clinical experience

NASA Astrophysics Data System (ADS)

Flores, Eileen S.; Cordova, Miguel; Kose, Kivanc; Phillips, William; Rossi, Anthony; Nehal, Kishwer; Rajadhyaksha, Milind

2015-06-01

Mohs surgery for the removal of nonmelanoma skin cancers (NMSCs) is performed in stages, while being guided by the examination for residual tumor with frozen pathology. However, preparation of frozen pathology at each stage is time consuming and labor intensive. Real-time intraoperative reflectance confocal microscopy (RCM), combined with video mosaicking, may enable rapid detection of residual tumor directly in the surgical wounds on patients. We report our initial experience on 25 patients, using aluminum chloride for nuclear contrast. Imaging was performed in quadrants in the wound to simulate the Mohs surgeon's examination of pathology. Images and videos of the epidermal and dermal margins were found to be of clinically acceptable quality. Bright nuclear morphology was identified at the epidermal margin and detectable in residual NMSC tumors. The presence of residual tumor and normal skin features could be detected in the peripheral and deep dermal margins. Intraoperative RCM imaging may enable detection of residual tumor directly on patients during Mohs surgery, and may serve as an adjunct for frozen pathology. Ultimately, for routine clinical utility, a stronger tumor-to-dermis contrast may be necessary, and also a smaller microscope with an automated approach for imaging in the entire wound in a rapid and controlled manner.

MRI assessment of local acute radiation syndrome.

PubMed

Weber-Donat, G; Amabile, J-C; Lahutte-Auboin, M; Potet, J; Baccialone, J; Bey, E; Teriitehau, C; Laroche, P

2012-12-01

To describe local acute radiation syndrome and its radiological imaging characteristics. We performed a retrospective study of patients who had suffered skin and deeper radiation damage who were investigated by magnetic resonance imaging (MRI). We compared the clinical findings, C-reactive protein (CRP) levels and MRI results. A total of 22 MRI examinations were performed between 2005 and 2010 in 7 patients; 6 patients had increased CRP levels and MRI abnormalities. They were treated by surgery and local cellular therapy. One patient had no CRP or MRI abnormalities, and had a spontaneous good outcome. Eighteen abnormal MR examinations demonstrated high STIR signal and/or abnormal enhancement in the dermis and muscle tissues. Three MRI examinations demonstrated skeletal abnormalities, consistent with radionecrosis. The four normal MRI examinations were associated only with minor clinical manifestations such as pain and pigmentation disorders. MRI seems to be a useful and promising imaging investigation in radiation burns management i.e. initial lesion evaluation, treatment evaluation and complication diagnosis. MRI findings correlated perfectly with clinical stage and no false negative examinations were obtained. In particular, the association between normal MRI and low CRP level seems to be related to good outcome without specific treatment. Local acute radiation syndrome (radioepidermitis) mainly affects the skin and superficial tissues. MRI findings correspond with clinical stage (with a strong negative predictive value). MRI outperformed X-ray examination for the diagnosis of bone radionecrosis. Diffusion-weighted imaging shows low ADC in bone and soft tissue necrosis. Perfusion sequence allows assessment of tissue microcirculation impairment.

Misalignments of Purpose and Power in an Early Canadian Interprofessional Education Initiative

ERIC Educational Resources Information Center

Whyte, Sarah; Paradis, Elise; Cartmill, Carrie; Kuper, Ayelet; Boon, Heather; Hart, Corinne; Razack, Saleem; Pipher, Mandy; Whitehead, Cynthia R.

2017-01-01

Interprofessional education (IPE) has been widely incorporated into health professional curricula and accreditation standards despite an arguably thin base of evidence regarding its clinical effects, theoretical underpinnings, and social implications. To better understand how and why IPE first took root, but failed to grow, this study examines one…

Parent-Child Interaction Therapy and High Functioning Autism: A Conceptual Overview

ERIC Educational Resources Information Center

Masse, Joshua J.; McNeil, Cheryl B.; Wagner, Stephanie M.; Chorney, Daniel B.

2007-01-01

Externalizing behaviors are a common component of the clinical presentation of Autism Spectrum Disorders and are typically the initial focus of treatment for children within this population. This article examines the appropriateness of Parent-Child Interaction Therapy (PCIT) as a first-line, gateway treatment for preschoolers with High Functioning…

Parent Depression and Child Anxiety: An Overview of the Literature with Clinical Implications

ERIC Educational Resources Information Center

Colletti, Christina J. M.; Forehand, Rex; Garai, Emily; Rakow, Aaron; McKee, Laura; Fear, Jessica M.; Compas, Bruce E.

2009-01-01

The association of parental depression with child anxiety has received relatively little attention in the literature. In this paper we initially present several reasons for examining this relationship. We then summarize the empirical support for a link between these two variables. Finally, we discuss directions for future research and clinical…

Long Sick Leave after Orthopaedic Inpatient Rehabilitation: Treatment Failure or Relapse?

ERIC Educational Resources Information Center

Mangels, Marija; Schwarz, Susanne; Worringen, Ulrike; Holme, Martin; Rief, Winfried

2011-01-01

We investigated whether short-term versus long-term sick leave after orthopaedic inpatient rehabilitation can be predicted by initial assessment information, the clinical status at discharge, or whether the follow-up interval is crucial for later sick leave. We examined 214 patients from an orthopaedic rehabilitation hospital at admission,…

Experience of treatment of patients with granulomatous lobular mastitis.

PubMed

Hur, Sung Mo; Cho, Dong Hui; Lee, Se Kyung; Choi, Min-Young; Bae, Soo Youn; Koo, Min Young; Kim, Sangmin; Choe, Jun-Ho; Kim, Jung-Han; Kim, Jee Soo; Nam, Seok-Jin; Yang, Jung-Hyun; Lee, Jeong Eon

2013-07-01

To present the author's experience with various treatment methods of granulomatous lobular mastitis (GLM) and to determine effective treatment methods of GLM. Fifty patients who were diagnosed with GLM were classified into five groups based on the initial treatment methods they underwent, which included observation (n = 8), antibiotics (n = 3), steroid (n = 13), drainage (n = 14), and surgical excision (n = 12). The treatment processes in each group were examined and their clinical characteristics, treatment processes, and results were analyzed respectively. Success rates with each initial treatment were observation, 87.5%; antibiotics, 33.3%; steroids, 30.8%; drainage, 28.6%; and surgical excision, 91.7%. In most cases of observation, the lesions were small and the symptoms were mild. A total of 23 patients underwent surgical excision during treatment. Surgical excision showed particularly fast recovery, high success rate (90.3%) and low recurrence rate (8.7%). The clinical course of GLM is complex and the outcome of each treatment type are variable. Surgery may play an important role when a lesion is determined to be mass-forming or appears localized as an abscess pocket during breast examination or imaging study.

Examining the effects of comorbidities on disease-modifying therapy use in multiple sclerosis

PubMed Central

Zhang, Tingting; Tremlett, Helen; Leung, Stella; Zhu, Feng; Kingwell, Elaine; Fisk, John D.; Bhan, Virender; Campbell, Trudy L.; Stadnyk, Karen; Yu, B. Nancy

2016-01-01

Objective: Comorbidities are common in multiple sclerosis (MS) and adversely affect health outcomes. However, the effect of comorbidity on treatment decisions in MS remains unknown. We aimed to examine the effects of comorbidity on initiation of injectable disease-modifying therapies (DMTs) and on the choice of the initial DMT in MS. Methods: We conducted a retrospective observational analysis using population-based health administrative and linked clinical databases in 3 Canadian provinces. MS cases were defined as any individual with ≥3 diagnostic codes for MS. Cohort entry (index date) was the first recorded demyelinating disease-related claim. The outcomes included choice of initial first-line DMTs and time to initiating a DMT. Logistic and Cox regression models were used to examine the association between comorbidity status and study outcomes, adjusting for sex, age, year of index date, and socioeconomic status. Meta-analysis was used to estimate overall effects across the 3 provinces. Results: We identified 10,698 persons with incident MS, half of whom had ≥1 comorbidities. As the total number of comorbidities increased, the likelihood of initiating a DMT decreased. Comorbid anxiety and ischemic heart disease were associated with reduced initiation of a DMT. However, patients with depression were 13% more likely to initiate a DMT compared to those without depression at the index date (adjusted hazard ratio 1.13; 95% confidence interval 1.00–1.27). Conclusions: Comorbidities are associated with treatment decisions regarding DMTs in MS. A better understanding of the effects of comorbidity on effectiveness and safety of DMTs is needed. PMID:26944268

Bone scintigraphy in hypervitaminosis A

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

Miller, J.H.; Hayon, I.I.

1985-04-01

The diagnosis of vitamin A intoxification may be difficult at the time of initial presentation. The radionuclide bone scan in cases of vitamin A toxicity may serve as a more sensitive indicator of the presence of this disease than radiographs in the initial evaluation and follow-up of patients with skeletal involvement. This is achieved at a lower radiation dose to the patient. The authors present a case in which bone scintigraphy played a crucial role in the early identification of this disorder. The radionuclide examination was the first method that indicated the presence of this disorder, significantly before changes demonstrablemore » on conventional radiography. The clinical and scintigraphic appearance of this process should be recognized to allow identification of hypervitaminosis A before the clinical symptoms become severe or permanent skeletal deformities result.« less

Improving information technology adoption and implementation through the identification of appropriate benefits: creating IMPROVE-IT.

PubMed

Leonard, Kevin J; Sittig, Dean F

2007-05-04

This paper describes the objectives of a collaborative initiative that attempts to provide the evidence that increased information technology (IT) capabilities, availability, and use lead directly to improved clinical quality, safety, and effectiveness within the inpatient hospital setting. This collaborative network has defined specific measurement indicators in an attempt to examine the existence, timing, and level of improvements in health outcomes that can be derived from IT investment. These indicators are in three areas: (1) IT costs (which includes both initial and ongoing investment), (2) IT infusion (ie, system availability, adoption, and deployment), and (3) health performance (eg, clinical efficacy, efficiency, quality, and effectiveness). Herein, we outline the theoretical framework, the methodology employed to create the metrics, and the benefits that can be obtained.

Novel challenges of multi-society investigator-initiated studies: a paradigm shift for technique and technology evaluation.

PubMed

Schwaitzberg, Steven D; Hawes, Robert H; Rattner, David W; Kochman, Michael L

2013-08-01

The introduction of innovative techniques and novel technologies into clinical practice is a challenge that confronts all aspects of healthcare delivery. Upheaval from shrinking research funding and declining healthcare reimbursements now forces patients, doctors, hospitals, payers, regulators, and even health systems into conflict as new therapies struggle to find a place in the therapeutic armamentarium. The escalating costs of healthcare force all parties to consider both the medical risks/benefits as well as the economic efficiency of proposed tools and therapies. We highlight these challenges by examining the process of initiating and conducting a "society-as-investigator" clinical trial to assess the safety of the natural orifice translumenal endoscopic surgery (NOTES) approach to cholecystectomy in the context of the issues that confront technology diffusion today.

The clinical outcome of childhood masturbation.

PubMed

Unal, F

2000-01-01

This study was performed to investigate the clinical outcome of childhood masturbation. For this purpose 50 children (mean age = 48.7 +/- 24.5 months, 34 girls females and 16 boys males) with masturbation symptoms were examined at first visit to the Department of Child Psychiatry and two years thereafter with psychiatric interviews. The mean masturbation frequency at the initial interview was significantly decreased after two years. It was noted that 39 children (78%) were completely recovered and 11 children (22%) continued to masturbate after two years. Children who did not recover were significantly younger, began to masturbate earlier and masturbated more frequently than others at the time of initial evaluation. It was concluded that the findings about the beneficial effect of sedative drugs in combination with parental guidance, education and means for behavior modification were promising.

Longitudinal Assessment of Health-Related Quality of Life following Adolescent Sports-Related Concussion.

PubMed

Russell, Kelly; Selci, Erin; Chu, Stephanie; Fineblit, Samuel; Ritchie, Lesley; Ellis, Michael J

2017-07-01

To examine initial and longitudinal health-related quality of life (HRQOL) in adolescent sports-related concussion (SRC) patients, a prospective observational case-series study was conducted among adolescent SRC patients who were evaluated at a multi-disciplinary pediatric concussion program. Health-related quality of life was measured using the child self-report Pediatric Quality of Life Inventory (PedsQL) generic score scale (age 13-18 version) and the PedsQL Cognitive Functioning scale. Initial and longitudinal HRQOL outcomes were compared between patients who did and did not develop post-concussion syndrome (PCS). A total of 63 patients met the inclusion criteria during the study period. The mean age of the cohort was 14.57 years (standard deviation, 1.17) and 61.9% were male. The median time from injury to initial consultation was 6.5 days (interquartile range, 5, 11). At initial consultation, impairments in physical and cognitive HRQOL but not social or emotional HRQOL were observed. Initial symptom burden and length of recovery were associated with greater impairment in physical and cognitive HRQOL. Patients who went on to develop PCS had significantly worse physical and cognitive HRQOL at initial consultation and demonstrated a slower rate of recovery in these domains, compared with those who recovered in less than 30 days. Adolescent SRC was associated with HRQOL impairments that correlated with clinical outcomes. No persistent impairments in HRQOL were detected among patients who achieved physician-documented clinical recovery. Future studies are needed to evaluate the clinical utility of HRQOL measurement in the longitudinal management of adolescent SRC and PCS patients.

Differential diagnosis and management of an older runner with an atypical neurodynamic presentation: a case for clinical reasoning.

PubMed

Sylvain, Jonathan; Reiman, Michael P

2015-04-01

Case Report. The purpose of this case report is to describe the clinical reasoning process involved with the differential diagnosis and management of a 69 year-old male runner reporting a six month history of insidious onset of left sided low back and buttock pain of low to medium degree of irritability. The case presented describes the utilization of clinical reasoning by a clinician in fellowship training when a patient with atypical adverse neurodynamic dysfunction related to running was encountered. The patient's physical examination was relatively unremarkable. Assessment of the patient's subjective history, self-report measures [Oswestry Disability Index (ODI), global rating of change scale (GROC)], objective findings, and tests and measures led to a working diagnosis of atypical adverse peripheral neurodynamic dysfunction. The lumbar spine, sacroiliac joint, hip joint and lower extremity were ruled out by a comprehensive subjective and objective examination. The diagnosis of adverse neurodynamic dysfunction became a diagnosis of exclusion. Returning two and a half weeks after initial evaluation the patient reported no pain with running. Twelve weeks after the initiation of physical therapy, the patient was contacted via email. He was sent, and asked to fill out an ODI. The patient demonstrated an improvement in ODI from 10% to 2%. He also reported that he continued to run after treatment without pain. Determining the source of a patient complaint can occasionally be an arduous undertaking. Pathological sources of a patient's symptoms may not be easily determined. Development of differential diagnosis and clinical reasoning skills is imperative. Improving clinical reasoning skills requires deliberate practice through reflective thinking before, during, and after patient interactions. Refinement of these skills leads to the primary goal of identifying the patient's clinical presentation, thus matching it with the most effective treatment approach. Level 4.

The impact of extended longitudinal observation on the assessment of personality disorders.

PubMed

Pedersen, G; Karterud, S; Hummelen, B; Wilberg, T

2013-11-01

Multiple sources of information are necessary for a valid assessment of personality disorders (PDs). This study investigates the impact of longitudinal observation. The sample comprised 1217 patients from 15 different treatment units. PDs were assessed at admission to treatment using the Structured Clinical Interview for DSM-IV Axis II Personality Disorders (SCID-II) and additional clinical information (best estimate diagnosis). After approximately 18 weeks of treatment, the SCID-II protocols were re-examined at clinical conferences and the diagnostic status reassessed on the basis of longitudinal observations in multiple group situations (longitudinal, expert, all data principle). Using this procedure, 78% of the patients' diagnostic criteria sets were changed, and 32% of patients' diagnostic statuses were changed. Many (32%) patients who were evaluated initially as not having a PD received a PD diagnosis after re-examination. The information provided by customary clinical assessment has important limitations, and longitudinal observation provides additional information that may change the diagnostic status in approximately one-third of PD cases. Copyright © 2013 John Wiley & Sons, Ltd.

Conjunctival papilloma: features and outcomes based on age at initial examination.

PubMed

Kaliki, Swathi; Arepalli, Sruthi; Shields, Carol L; Klein, Kendra; Sun, Hong; Hysenj, Eralda; Lally, Sara E; Shields, Jerry A

2013-05-01

Conjunctival papilloma is a benign epithelial tumor occurring in both children and adults with varying clinical features and outcomes. In this article, we describe our experience regarding the difference in the clinical features and outcomes of conjunctival papilloma based on age at initial examination. To evaluate the clinical features, treatment, and outcomes in patients with conjunctival papilloma based on age at initial examination. Retrospective study. Ocular Oncology Service, Wills Eye Hospital, Philadelphia, Pennsylvania. Ten children and adolescents (aged ≤20 years) and 63 adults (aged >20 years) with conjunctival papilloma. Excisional biopsy, cryotherapy, oral cimetidine, topical or injection interferon alfa-2b, and photodynamic therapy. Tumor response. A comparison of conjunctival papillomas between age groups revealed significant differences in the mean number of tumors per eye (children and adolescents vs adults, 2 vs 1; P = .05), tumor basal dimension (8 vs 6 mm; P = .05), and associated feeder vessels (20% vs 47%; P = .05). Primary treatment included sole treatment with oral cimetidine (15% vs 5%), topical interferon alfa-2b (0% vs 1%), cryotherapy (0% vs 3%), photodynamic therapy (0% vs 1%), excisional biopsy and cryotherapy (38% vs 65%), excisional biopsy and cryotherapy with adjuvant oral cimetidine (8% vs 9%), and excisional biopsy and cryotherapy with adjuvant topical or injection interferon alfa-2b (38% vs 15%). Significant differences in age groups in treatment outcome during the follow-up period (mean, 24 vs 38 months) included complete regression with single treatment (38% vs 95%; P < .01) and tumor recurrence (15% vs 1%; P = .05). Conjunctival papillomas are larger and more likely to be multiple in children and adolescents than in adults. Excisional biopsy and cryotherapy with or without adjuvant oral cimetidine and/or topical interferon alfa-2b provide satisfactory tumor control. Papilloma recurrence is more common in children and adolescents than in adults.

Performance, emotion work, and transition: challenging experiences of complementary therapy student practitioners commencing clinical practice.

PubMed

Fixsen, Alison; Ridge, Damien

2012-09-01

Few researchers have explored the clinical experiences of complementary and alternative medical practitioners and students, including the emotion work they perform. In this article, using a constant comparison approach and a heuristic framework (a dramaturgical perspective), we analyze semistructured interviews with 9 undergraduate practitioners in training to examine challenges experienced when students first attend to patients. A feature of students' learning about clinical work concerned performance in a public arena and associated demands placed on the inchoate practitioner. Preliminary patient consultations represented a dramatic rite of passage and initiation into a transitional phase in professional identity. Juggling the roles of student and practitioner within an observed consultation led to anticipatory anxiety, impression management strategies, and conflict with other individuals. Of the coping strategies, participants regarded sharing and feedback from peer groups as most effective in examining and resolving the challenges of becoming a practitioner.

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents

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

Burmeister, Jay, E-mail: burmeist@karmanos.org; Chen, Zhe; Chetty, Indrin J.

Purpose: The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. Methods and Materials: The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. Results: The newmore » curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. Conclusions: The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint.« less

The American Society for Radiation Oncology's 2015 Core Physics Curriculum for Radiation Oncology Residents.

PubMed

Burmeister, Jay; Chen, Zhe; Chetty, Indrin J; Dieterich, Sonja; Doemer, Anthony; Dominello, Michael M; Howell, Rebecca M; McDermott, Patrick; Nalichowski, Adrian; Prisciandaro, Joann; Ritter, Tim; Smith, Chadd; Schreiber, Eric; Shafman, Timothy; Sutlief, Steven; Xiao, Ying

2016-07-15

The American Society for Radiation Oncology (ASTRO) Physics Core Curriculum Subcommittee (PCCSC) has updated the recommended physics curriculum for radiation oncology resident education to improve consistency in teaching, intensity, and subject matter. The ASTRO PCCSC is composed of physicists and physicians involved in radiation oncology residency education. The PCCSC updated existing sections within the curriculum, created new sections, and attempted to provide additional clinical context to the curricular material through creation of practical clinical experiences. Finally, we reviewed the American Board of Radiology (ABR) blueprint of examination topics for correlation with this curriculum. The new curriculum represents 56 hours of resident physics didactic education, including a 4-hour initial orientation. The committee recommends completion of this curriculum at least twice to assure both timely presentation of material and re-emphasis after clinical experience. In addition, practical clinical physics and treatment planning modules were created as a supplement to the didactic training. Major changes to the curriculum include addition of Fundamental Physics, Stereotactic Radiosurgery/Stereotactic Body Radiation Therapy, and Safety and Incidents sections, and elimination of the Radiopharmaceutical Physics and Dosimetry and Hyperthermia sections. Simulation and Treatment Verification and optional Research and Development in Radiation Oncology sections were also added. A feedback loop was established with the ABR to help assure that the physics component of the ABR radiation oncology initial certification examination remains consistent with this curriculum. The ASTRO physics core curriculum for radiation oncology residents has been updated in an effort to identify the most important physics topics for preparing residents for careers in radiation oncology, to reflect changes in technology and practice since the publication of previous recommended curricula, and to provide practical training modules in clinical radiation oncology physics and treatment planning. The PCCSC is committed to keeping the curriculum current and consistent with the ABR examination blueprint. Copyright © 2016 The Authors. Published by Elsevier Inc. All rights reserved.

Odontogenic keratocyst: The role of the orthodontist in the diagnosis of initial lesions.

PubMed

Leandro Santos, Raphaela Silva; Ramos-Perez, Flávia Maria de Moraes; Silva, Gleyson Kleber do Amaral; Rocha, André Caroli; Prado, José Divaldo; Perez, Danyel Elias da Cruz

2017-10-01

Odontogenic keratocysts (OKCs) are locally infiltrative odontogenic cysts that are usually diagnosed during routine radiographic examinations. Therefore, it is critical that dental practitioners, in particular orthodontists, recognize and diagnose OKCs to recommend appropriate treatment. This report describes a patient whose OKC was not initially identified during orthodontic pretreatment. In addition, this report discusses the clinical and radiographic features of OKCs, as well as the differential diagnoses of these lesions. Copyright © 2017 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.

Adult-onset Still's disease initially thought to be an odontogenic infection: A case report.

PubMed

Hino, Shunsuke; Nakamura, Satoshi; Kaneko, Takahiro; Horie, Norio; Shimoyama, Tetsuo

2018-06-01

To present a case of Adult-onset Still's disease (AOSD) initially suspected to be odontogenic inflammation. Adult-onset Still's disease is a rare, complex autoinflammatory disease and a known cause of fever of unknown origin. The patient had both a fever and dental pain. Following meticulous examination, the patient was diagnosed with AOSD. Clinicians should keep in mind that a patient such as AOSD may visit their clinics. © 2018 John Wiley & Sons A/S and The Gerodontology Association. Published by John Wiley & Sons Ltd.

Tinea capitis caused by Trichophyton tonsurans presenting as an obscure patchy hair loss due to daily antifungal shampoo use.

PubMed

Sombatmaithai, Alita; Pattanaprichakul, Penvadee; Tuchinda, Papapit; Surawan, Theetat; Muanprasart, Chanai; Matthapan, Lalita; Bunyaratavej, Sumanas

2015-04-01

Tinea capitis is unusual and often misdiagnosed in healthy adults. We report a case of a healthy woman with a several-year history of asymptomatic, bizarre-shaped, non-scarring alopecia. She had used over-the-counter ketoconazole shampoo regularly for a long time. An initial potassium hydroxide preparation showed negative result for fungal organism. The scalp biopsy revealed endothrix infection, and dermoscopic examination demonstrated the comma hair and corkscrew hair signs. The fungal culture showed Trichophyton tonsurans. The daily use of antifungal shampoo could be the important factor to conceal clinical and laboratory findings for diagnosis of T. tonsurans tinea capitis in our case, which required high clinical suspicion and histopathology and dermoscopic examinations.

Tinea capitis caused by Trichophyton tonsurans presenting as an obscure patchy hair loss due to daily antifungal shampoo use

PubMed Central

Sombatmaithai, Alita; Pattanaprichakul, Penvadee; Tuchinda, Papapit; Surawan, Theetat; Muanprasart, Chanai; Matthapan, Lalita; Bunyaratavej, Sumanas

2015-01-01

Tinea capitis is unusual and often misdiagnosed in healthy adults. We report a case of a healthy woman with a several-year history of asymptomatic, bizarre-shaped, non-scarring alopecia. She had used over-the-counter ketoconazole shampoo regularly for a long time. An initial potassium hydroxide preparation showed negative result for fungal organism. The scalp biopsy revealed endothrix infection, and dermoscopic examination demonstrated the comma hair and corkscrew hair signs. The fungal culture showed Trichophyton tonsurans. The daily use of antifungal shampoo could be the important factor to conceal clinical and laboratory findings for diagnosis of T. tonsurans tinea capitis in our case, which required high clinical suspicion and histopathology and dermoscopic examinations. PMID:26114071

[Differential diagnosis of abdominal pain].

PubMed

Frei, Pascal

2015-09-02

Despite the frequency of functional abdominal pain, potentially dangerous causes of abdominal pain need to be excluded. Medical history and clinical examination must focus on red flags and signs for imflammatory or malignant diseases. See the patient twice in the case of severe and acute abdominal pain if lab parameters or radiological examinations are normal. Avoid repeated and useless X-ray exposure whenever possible. In the case of subacute or chronic abdominal pain, lab tests such as fecal calprotectin, helicobacter stool antigen and serological tests for celiac disease are very useful. Elderly patients may show atypical or missing clinical signs. Take care of red herrings and be skeptical whether your initial diagnosis is really correct. Abdominal pain can frequently be an abdominal wall pain.

Clinical features and radiological evaluation of otic capsule sparing temporal bone fractures.

PubMed

Song, S W; Jun, B C; Kim, H

2017-03-01

To evaluate the clinical and radiological aspects of otic capsule sparing temporal bone fractures. Using medical records, 188 temporal bones of 173 patients with otic capsule sparing temporal bone fractures were evaluated. Otoscopic findings and symptoms, facial paralysis, and hearing loss were assessed. Using regional analysis, 7 fractures were classified as type I, 85 as type II, 169 as type III and 114 as type IV. Fourteen of the 17 facial paralysis cases improved to House-Brackmann grade II or lower at an average of 57.6 days after the initial evaluation. Thirty-one patients underwent initial and follow-up pure tone audiometry examinations. The air-bone gap closed significantly from 27.2 dB at an average of 21.8 days post-trauma to 19.6 dB at an average of 79.9 days post-trauma, without the need for surgical intervention. Initial conservative treatment for facial paralysis or conductive hearing loss is possible in otic capsule sparing fracture cases after careful evaluation of the patient.

Lupus pneumonitis as the initial presentation of systemic lupus erythematosus: case series from a single institution.

PubMed

Wan, S A; Teh, C L; Jobli, A T

2016-11-01

Objective The aim of this study was to examine the clinical features, treatment and outcome of systemic lupus erythematosus (SLE) patients in our centre who presented with lupus pneumonitis as the initial manifestation. Methods We performed a retrospective review of all patients who presented with lupus pneumonitis during the initial SLE manifestation from March 2006 to March 2015. Results There were a total of five patients in our study who presented with fever and cough as the main clinical features. All patients had pulmonary infiltrates on chest radiographs. High-resolution computed tomography, which was performed in two patients, showed ground glass opacities with patchy consolidations bilaterally. All patients received high-dose steroids, 80% received intravenous cyclophosphamide and 60% received intravenous immunoglobulin. Two patients died from severe lupus pneumonitis within 2 weeks of admission despite treatment with ventilation, steroids, cyclophosphamide and intravenous immunoglobulin. Conclusions Acute lupus pneumonitis is an uncommon presentation of SLE. Mortality in this case series is 40%.

DIAGNOSIS AND SUCCESSFUL TREATMENT OF A POTENTIALLY ZOONOTIC DERMATOPHYTOSIS CAUSED BY MICROSPORUM GYPSEUM IN A ZOO-HOUSED NORTH AMERICAN PORCUPINE (ERETHIZON DORSATUM).

PubMed

Hackworth, Christine E; Eshar, David; Nau, Melissa; Bagladi-Swanson, Mary; Andrews, Gordon A; Carpenter, James W

2017-06-01

A female North American porcupine ( Erethizon dorsatum ) was evaluated for a unilateral pedal crusting and alopecic dermatopathy. Fungal culture and histopathology testing revealed Microsporum gypseum dermatophytosis. Treatment with topical miconazole was initiated and then discontinued after 9 days and changed to oral terbinafine. Twenty-eight days after initial examination, clinical signs were improving, and fungal cultures of the front foot, muzzle, and noninfected area along the dorsum were negative for M. gypseum. Visual exams were conducted on a regular basis. Eighty-three days after initial evaluation, clinical signs had completely resolved and repeat fungal cultures were negative. One of the animal's keepers was suspected to have acquired a dermal fungal infection 3 days after contact with this porcupine, and lesions had resolved after treatment with topical ketoconazole. To the authors' knowledge, this is the first report of M. gypseum diagnosed and treated in a captive North American porcupine. Veterinary staff and zookeepers should be aware of this potentially zoonotic infection.

Acromegaly and gigantism in the medical literature. Case descriptions in the era before and the early years after the initial publication of Pierre Marie (1886).

PubMed

de Herder, Wouter W

2009-01-01

In 1886 Pierre Marie used the term "acromegaly" for the first time and gave a full description of the characteristic clinical picture. However several others had already given clear clinical descriptions before him and sometimes had given the disease other names. After 1886, it gradually became clear that pituitary enlargement (caused by a pituitary adenoma) was the cause and not the consequence of acromegaly, as initially thought. Pituitary adenomas could be found in the great majority of cases. It also became clear that acromegaly and gigantism were the same disease but occurring at different stages of life and not different diseases as initially thought. At the end of the 19th and beginning of the 20th century most information was derived from case descriptions and post-mortem examinations of patients with acromegaly or (famous) patients with gigantism. The stage was set for further research into the pathogenesis, diagnosis and therapy of acromegaly and gigantism.

Impaired systolic blood pressure recovery directly after standing predicts mortality in older falls clinic patients.

PubMed

Lagro, Joep; Schoon, Yvonne; Heerts, Inger; Meel-van den Abeelen, Aisha S S; Schalk, Bianca; Wieling, Wouter; Olde Rikkert, Marcel G M; Claassen, Jurgen A H R

2014-04-01

Normally, standing up causes a blood pressure (BP) drop within 15 seconds, followed by recovery to baseline driven by BP control mechanisms. The prognostic value of this initial BP drop, but also of the recovery hereafter, is unknown. The aim of this study was to examine the prognostic value of these BP characteristics in response to standing. In a retrospective cohort study of 238 consecutive patients visiting our falls outpatient clinic, we examined the relation between all-cause mortality and BP decline and recovery directly after active standing up with Cox proportional hazards analyses. Of 238 patients (mean age 78.4 ± 7.8 years), during a median follow-up of 21.0 months, 36 (15%) patients died. Neither absolute nor relative (%) initial BP drop after standing predicted mortality. In contrast, the magnitude of BP recovery 40-60 seconds after standing was associated with mortality, even after adjustment for age, comorbidity, and other baseline characteristics. When systolic BP had recovered to less than 80% of prestanding baseline after 60 seconds of standing, this was a powerful independent predictor of mortality (hazard ratio: 3.00; 95% confidence interval 1.17-7.68). Failure to recover from BP decline in the first minute after active standing up is associated with excess mortality in falls clinic patients. A recovery of systolic BP to less than 80% of baseline after 60 seconds may be used as an easily available cardiovascular marker for increased mortality risk in older falls clinic patients.

Performance of FDG PET/CT in the clinical management of breast cancer.

PubMed

Groheux, David; Espié, Marc; Giacchetti, Sylvie; Hindié, Elif

2013-02-01

In this analysis, the role of metabolic imaging with fluorine 18 fluorodeoxyglucose (FDG) in breast cancer is reviewed. The analysis was limited to recent works by using state-of-the-art positron emission tomography (PET)/computed tomography (CT) technology. The strengths and limitations of FDG PET/CT are examined in various clinical settings, and the following questions are answered: Is FDG PET/CT useful to differentiate malignant from benign breast lesions? Can FDG PET/CT replace sentinel node biopsy for axillary staging? What is the role of FDG PET/CT in initial staging of inflammatory or locally advanced breast cancer? What is the role of FDG PET/CT in initial staging of clinical stage IIA and IIB and primary operable stage IIIA breast cancer? How does FDG PET/CT compare with conventional techniques in the restaging of cancer in patients who are suspected of having disease recurrence? What is the role of FDG PET/CT in the assessment of early response to neoadjuvant therapy and of response to therapy for metastatic disease? Some recommendations for clinical practice are given.

Loss to Follow-Up in a Community Clinic in South Africa – Roles of Gender, Pregnancy and CD4 count

PubMed Central

Wang, Bingxia; Losina, Elena; Stark, Ruth; Munro, Alison; Walensky, Rochelle P.; Wilke, Marisa; Martin, Des; Lu, Zhigang; Freedberg, Kenneth A.; Wood, Robin

2013-01-01

Background Faith-based organizations have expanded access to antiretroviral therapy (ART) in community clinics across South Africa. Loss to follow-up (LTFU), however, limits both the potential individual and population treatment benefits and is an obstacle to optimal care. Objective To identify patient characteristics associated with LTFU six months after starting ART in patients in a large South African community clinic. Methods Patients initiating ART between April 2004 and October 2006 in one Catholic Relief Services HIV treatment clinic who had at least one follow-up visit were included in the analysis. Standardized instruments were used for data collection. Routine monitoring was performed every 6 months following ART initiation. Rates of LTFU over time were estimated by the Kaplan-Meier method. The log-rank test was used to examine the impact of age, baseline CD4 count, HIV RNA, gender and pregnancy status for women on LTFU. Cox proportional hazard regression was performed to analyze hazard ratios for LTFU. Results Data from 925 patients (age > 14 years), median age 36 years, 70% female (16% pregnant) were included in the analysis. Fifty one patients (6%) were lost to follow-up six months after ART initiation. When stratified by baseline CD4 count, gender and pregnancy status, pregnant women with lower baseline CD4 count (≤200 /μl) had 6.06 times (95% CI: 2.20 – 16.71) the hazard of LTFU compared to men. Conclusions HIV-infected pregnant women initiating ART are significantly more likely to be lost to follow-up in a community clinic in South Africa. Interventions to successfully retain pregnant women in care are urgently needed. PMID:21786730

Giant fibroadenoma presenting like fungating breast cancer in a Nigerian teenager.

PubMed

Arowolo, O A; Akinkuolie, A A; Adisa, A O; Obonna, G C; Olasode, B J

2013-03-01

Giant fibroadenoma of the breast is a rare benign breast tumour which seldom grows to a giant size, it is even rarer for this benign tumour to grow rapidly, ulcerate spontaneously and present like a fungating breast tumour in a way mimicking breast cancer. This is a presentation of a 14 year old premenarchal girl with a massive ulcerating and fungating left breast mass that was initially thought to be a fungating locally advanced breast carcinoma on clinical examination. Further examination of the morphology of the resected surgical specimen and histological examination confirmed it to be giant fibroadenoma of the breast. It was successfully managed by partial mastectomy and breast reconstruction with an excellent result and a high degree of patient satisfaction was achieved. Though a rare clinical entity benign breast tumour can present like a fungating breast cancer and this must be bore in mind especially in young adolescent patients presenting with ulcerating breast tumour.

Managed care and critical pathway development: the joint replacement experience.

PubMed

Benham, A J

1999-01-01

This article examines the economic, social, ethical, and political issues affecting total joint replacement patients in a managed care environment. Using general systems theory as a framework, it examines the interrelated historical events that have shaped the development of both joint replacement procedures and managed care, and discusses the extent to which these two phenomena have been mutually influential. Specifically, the article examines the initial development, implementation, and continuing evolution of clinical pathways as an easily identified and relatively discrete manifestation of managed care for the joint replacement population. While the overall impact of managed care is beyond the scope of this presentation, it is hoped that a focus on the practical application of clinical pathways to joint replacement will allow some general principles to emerge that may be useful for both patients and practitioners operating in other aspects of the managed care environment.

Pediatric Return Appointment Adherence for Child Welfare-Involved Children in Los Angeles California.

PubMed

Schneiderman, Janet U; Smith, Caitlin; Arnold-Clark, Janet S; Fuentes, Jorge; Kennedy, Andrea K

2016-02-01

This study of primarily Latino caregivers and Latino child welfare-involved children had the following aims: (1) explore the return appointment adherence patterns at a pediatric medical clinic; and (2) determine the relationship of adherence to return appointments and caregiver, child, and clinic variables. The sample consisted of caregivers of child welfare-involved children who were asked to make a pediatric outpatient clinic return appointment (N = 87). Predictors included caregiver demographics, child medical diagnoses and age, and clinic/convenience factors including distance from the clinic to caregiver's home, days until the return appointment, reminder telephone call, Latino provider, and additional specialty appointment. Predictors were examined using χ(2) and t tests of significance. Thirty-nine percent of all caregivers were nonadherent in returning for pediatric appointments. When return appointments were scheduled longer after the initial appointment, caregivers were less likely to bring children back for medical care. The 39 % missed return appointment rate in this study is higher than other similar pediatric populations. Better coordination between pediatricians and caregivers in partnership with child welfare case workers is needed to ensure consistent follow-up regarding health problems, especially when appointments are not scheduled soon after the initial appointment.

The FAMULATUR PLUS as an innovative approach for teaching physical examination skills.

PubMed

Jerg, Achim; Öchsner, Wolfgang; Wander, Henriette; Traue, Harald C; Jerg-Bretzke, Lucia

2016-01-01

The FAMULATUR PLUS is an innovative approach to teaching physical examination skills. The concept is aimed at medical students during the clinical part of their studies and includes a clinical traineeship (English for "Famulatur") extended to include various courses ("PLUS"). The courses are divided into clinical examination courses and problembased-learning (PBL) seminars. The concept's special feature is the full integration of these courses into a 30-day hospital traineeship. The aim is to facilitate the transfer of knowledge from the courses into daily practice. Each week of the FAMULATUR PLUS is structured in line with the courses and focuses on a particular part of the body (e.g., abdomen). A physical examination course under the supervision of a physician is offered at the beginning of the week. Here, medical students learn the relevant examination techniques by practicing on each other (partner exercises). Subsequently, the techniques taught are applied independently during everyday work on the ward, corrected by the supervisor, if necessary, and thereby reinforced. The final POL seminar takes place towards the end of the week. Possible differential diagnoses are developed based on a clinical case study. The goal is to check these by taking a fictitious medical history and performing a physical examination, as well as to make a preliminary diagnosis. Finally, during the PBL seminar, medical students will be shown how physical examination techniques can be efficiently applied in the diagnosis of common cardinal symptoms (e.g., abdominal pain). The initial implementation of the FAMULATUR PLUS proved the practical feasibility of the concept. In addition, the accompanying evaluation showed that the participants of the pilot project improved with regard to their practical physical examination skills.

The FAMULATUR PLUS as an innovative approach for teaching physical examination skills

PubMed Central

Jerg, Achim; Öchsner, Wolfgang; Wander, Henriette; Traue, Harald C.; Jerg-Bretzke, Lucia

2016-01-01

The FAMULATUR PLUS is an innovative approach to teaching physical examination skills. The concept is aimed at medical students during the clinical part of their studies and includes a clinical traineeship (English for “Famulatur”) extended to include various courses (“PLUS”). The courses are divided into clinical examination courses and problembased-learning (PBL) seminars. The concept’s special feature is the full integration of these courses into a 30-day hospital traineeship. The aim is to facilitate the transfer of knowledge from the courses into daily practice. Each week of the FAMULATUR PLUS is structured in line with the courses and focuses on a particular part of the body (e.g., abdomen). A physical examination course under the supervision of a physician is offered at the beginning of the week. Here, medical students learn the relevant examination techniques by practicing on each other (partner exercises). Subsequently, the techniques taught are applied independently during everyday work on the ward, corrected by the supervisor, if necessary, and thereby reinforced. The final POL seminar takes place towards the end of the week. Possible differential diagnoses are developed based on a clinical case study. The goal is to check these by taking a fictitious medical history and performing a physical examination, as well as to make a preliminary diagnosis. Finally, during the PBL seminar, medical students will be shown how physical examination techniques can be efficiently applied in the diagnosis of common cardinal symptoms (e.g., abdominal pain). The initial implementation of the FAMULATUR PLUS proved the practical feasibility of the concept. In addition, the accompanying evaluation showed that the participants of the pilot project improved with regard to their practical physical examination skills. PMID:26958652

Joint Healthcare Manpower Standards (JHMS)

DTIC Science & Technology

1989-11-01

I ’I I I I I I I I6 I 0 9 I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I I Ilhticl Sport 1 2 3 1 21 21 21 21 3 31 I I I I I I...TREATMENT. Performs minor surgical treatment or biopsy in the clinic, to include cryotherapy for warts and colposcopy examinations on obstetrical patients...Supports Community/ Sports Activities. (4) Clinic Initiated Research. (5) Performs Data Collection in PT Clinic in Support S of Research Sponsored by

From Free to Free Market: Cost Recovery in Federally Funded Clinical Research

PubMed Central

McCammon, Margaret G.; Fogg, Thomas T.; Jacobsen, Lynda; Roache, John; Sampson, Royce; Bower, Cynthia L.

2012-01-01

In a climate of increased expectation for the translation of research, academic clinical research units are looking at new ways to streamline their operation and maintain effective translational support services. Clinical research, although undeniably expensive, is an essential step in the translation of any medical breakthrough, and as a result, many academic clinical research units are actively looking to expand their clinical services despite financial pressures. We examine some of the hybrid academic-business models in 19 clinical research centers within the Clinical and Translational Science Award consortium that are emerging to address the issue of cost recovery of clinical research that is supported by the United States federal government. We identify initiatives that have succeeded or failed, essential supporting and regulatory components, and lessons learned from experience to design an optimal cost recovery model and a timeline for its implementation. PMID:22764204

[Inflammatory myofibroblastic tumor of the lymph node with paraneoplastic thrombosis and eosinophilia].

PubMed

Behzad, Ali; Müller, Andrea; Rösler, Wolf; Amann, Kerstin; Linke, Rainer; Mackensen, Andreas

2010-04-01

A 52-year-old female patient was admitted to hospital because of progressive thrombosis despite therapeutic anticoagulation as well as leukocytosis with eosinophilia and thrombocytopenia. On examination, the patient presented with dyspnea and swelling oft her left leg and arm. The laboratory findings revealed leukocytosis (31,000/microl) with eosinophilia (54%), thrombocytopenia (58,000/microl), together with an increased C-reactive protein of 247 mg/dl (reference range < 5 mg/dl). Initial computed tomography scans showed pulmonary embolism and a slightly enlarged left inguinal lymph node. Histological examination of the lymph node biopsy revealed in part an epitheloid and spindle cell-like tumorous lesion with slightly increased tissue eosinophilia consistent with an inflammatory myofibroblastic tumor (IMT). Resection of the left inguinal lymph node resulted in an immediate regression of the paraneoplastic eosinophilia and thrombocytopenia. Anti-inflammatory medication with ibuprofen was subsequently initiated. Imaging and clinical examination at 3 months after discharge revealed no relapse and no signs of a paraneoplastic syndrome. The IMT is a rare soft-tissue tumor of intermediate dignity with a low tendency to metastasize. It is consistently accompanied by paraneoplastic syndromes. Therapy of choice is complete resection of the tumor. In nonresectable cases, corticosteroids and nonsteroidal antirheumatics have been shown to be effective. Because of the variable clinical course ranging from spontaneous regression to metastasis, IMTs might be separated into different entities (autoimmune, inflammatory, neoplastic subtype) which thus far cannot be classified on a histopathologic basis. A clinical assessment of the dignity is therefore important until further subclassifications of this rare disease become available.

Magnetic resonance imaging in Alzheimer's Disease Neuroimaging Initiative 2.

PubMed

Jack, Clifford R; Barnes, Josephine; Bernstein, Matt A; Borowski, Bret J; Brewer, James; Clegg, Shona; Dale, Anders M; Carmichael, Owen; Ching, Christopher; DeCarli, Charles; Desikan, Rahul S; Fennema-Notestine, Christine; Fjell, Anders M; Fletcher, Evan; Fox, Nick C; Gunter, Jeff; Gutman, Boris A; Holland, Dominic; Hua, Xue; Insel, Philip; Kantarci, Kejal; Killiany, Ron J; Krueger, Gunnar; Leung, Kelvin K; Mackin, Scott; Maillard, Pauline; Malone, Ian B; Mattsson, Niklas; McEvoy, Linda; Modat, Marc; Mueller, Susanne; Nosheny, Rachel; Ourselin, Sebastien; Schuff, Norbert; Senjem, Matthew L; Simonson, Alix; Thompson, Paul M; Rettmann, Dan; Vemuri, Prashanthi; Walhovd, Kristine; Zhao, Yansong; Zuk, Samantha; Weiner, Michael

2015-07-01

Alzheimer's Disease Neuroimaging Initiative (ADNI) is now in its 10th year. The primary objective of the magnetic resonance imaging (MRI) core of ADNI has been to improve methods for clinical trials in Alzheimer's disease (AD) and related disorders. We review the contributions of the MRI core from present and past cycles of ADNI (ADNI-1, -Grand Opportunity and -2). We also review plans for the future-ADNI-3. Contributions of the MRI core include creating standardized acquisition protocols and quality control methods; examining the effect of technical features of image acquisition and analysis on outcome metrics; deriving sample size estimates for future trials based on those outcomes; and piloting the potential utility of MR perfusion, diffusion, and functional connectivity measures in multicenter clinical trials. Over the past decade the MRI core of ADNI has fulfilled its mandate of improving methods for clinical trials in AD and will continue to do so in the future. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

Behavioral Characteristics of Agitated Nursing Home Residents with Dementia at the End of Life

ERIC Educational Resources Information Center

Allen, Rebecca S.; Burgio, Louis D.; Fisher, Susan E.; Hardin, J. Michael; Shuster, John L., Jr.

2005-01-01

Purpose: The purpose of this study was to examine group differences in verbal agitation, verbal interaction, bed restraint, pain, analgesic and neuroleptic medication use, and medical comorbidity among agitated nursing home residents who died during a 6-month clinical trial compared with residents of the same gender and similar initial cognitive…

Prevalence of and interventions for sarcopenia in ageing adults - a systematic review report of the international sarcopenia initiative (EWGSOP and IWGS)

USDA-ARS?s Scientific Manuscript database

Objective: to examine the clinical evidence reporting the prevalence of sarcopenia and the effect of nutrition and exercise interventions from studies using the consensus definition of sarcopenia proposed by the European Working Group on Sarcopenia in Older People (EWGSOP). Methods: PubMed and Dial...

The Prediction of Disruptive Behaviour Disorders in an Urban Community Sample: The Contribution of Person-Centred Analyses

ERIC Educational Resources Information Center

Burt, Keith B.; Hay, Dale F.; Pawlby, Susan; Harold, Gordon; Sharp, Deborah

2004-01-01

Background: Variable- and person-centred analyses were used to examine prediction of middle childhood behaviour problems from earlier child and family measures. Method: A community sample of 164 families, initially recruited at antenatal clinics at two South London practices, was assessed for children's behaviour problems and cognitive ability,…

Directionality of Change in Youth Anxiety Treatment Involving Parents: An Initial Examination

ERIC Educational Resources Information Center

Silverman, Wendy K.; Kurtines, William M.; Jaccard, James; Pina, Armando A.

2009-01-01

This randomized clinical trial compared cognitive behavioral therapy (CBT) with minimal parent involvement to CBT with active parent involvement in a sample of 119 youths (7-16 years old; 33.6% Caucasian, 61.3% Latino) with anxiety disorders. The dynamics of change between youth anxiety and parent variables (positive-negative behaviors toward the…

Neurological disruption produced in hens by two organophosphate esters

PubMed Central

Baron, R. L.; Johnson, H.

1964-01-01

A histological and enzymatic examination was made of the neurological disruption produced in hens by two organophosphate esters. Intraperitoneal administration of DEF (tributyl phosphorotrithiolate) and Merphos (tributyl phosphorotrithioite) produced central and perpheral nervous system lesions accompanied by clinical signs of ataxia similar to those seen following administration of tri-o-cresyl phosphate. Histological examination (utilizing the Marchi stain) showed the occurence of spinal cord disruption before the onset of clinical ataxia. Oral administration of DEF and Merphos did not induce signs of peripheral weakness. However, severe lesions in the spinal cord and sciatic nerve were prominent. A discussion of the occurrence of central and peripheral nerve disruption either in the presence or absence of clinical ataxia is presented. Enzymatic examination of the effect of DEF on spinal cord and brain esterases at various intervals following administration showed a pattern of esterase inhibition similar to that found after tri-o-cresyl phosphate, dyflos and other organophosphates. Some prolonged inhibition is believed due to the extent of initial involvement rather than to selective prolonged inhibition. ImagesFig. 1Fig. 2 PMID:14228131

Clinical examination of subjects with halitosis.

PubMed

Donaldson, A C; Riggio, M P; Rolph, H J; Bagg, J; Hodge, P J

2007-01-01

To develop and apply a detailed clinical protocol for screening and assessing subjects with a complaint of halitosis. Cross-sectional. Several methods were used to recruit subjects with a complaint of halitosis, including a newspaper advertisement. A definition of halitosis arising from within the oral cavity, which is not related to generalized chronic gingivitis, chronic periodontitis or pathology of the oral mucosa was used. An extensive list of exclusion criteria was applied at the initial visit. Eligible subjects were asked to follow strict instructions and complete a questionnaire prior to their second visit for data collection. The clinical examination consisted of an organoleptic assessment, Halimeter reading and periodontal examination. The best method of recruiting subjects was advertising. Of 66 individuals recruited, four failed to attend the screening visit and 25 were excluded. The main reasons for exclusion were poor oral hygiene and existing periodontal disease. Thirty-seven completed the full protocol, resulting in identification of 18 with halitosis and 19 controls. Application of the exclusion criteria resulted in significant attrition of eligible participants. Our results suggest that organoleptic assessment should be regarded as a useful standard for defining subjects with halitosis.

Initiation of reflective frames in counseling for Huntingtons Disease predictive testing.

PubMed

Sarangi, Srikant; Bennert, Kristina; Howell, Lucy; Clarke, Angus; Harper, Peter; Gray, Jonathon

2004-04-01

Genetic professionals and clients are likely to assign different meanings to the extended format of the counseling protocols for predictive testing. In order to facilitate informed, client-centered decisions about the possibility of predictive testing, counselors routinely use the question format to initiate what we call "reflective frames" that invite clients to discuss their feelings and encourage them to adopt introspective and self-reflective stances toward their own experience--spanning the past, the present, and the hypothetical future. We suggest that such initiations of reflective frames constitute a key element of counselors' nondirective stance, although the exact nature of their formulations can be complex and varied. Examining 24 Huntington's Disease (HD) clinic sessions involving 12 families in South Wales with the tools of discourse analysis, our focus in this paper is twofold: (i) to propose a classification of six types of reflective questions (e.g. nonspecific invites, awareness and anxiety, decision about testing, impact of result, dissemination, and other) and to examine their distribution across the various clinic appointments, and (ii) to investigate the scope of these questions in terms of temporal and social axes. We link our analysis to the current debate within the genetic counseling profession about the merits of reflection- versus information-focused counseling styles and the need to abide by professionally warranted and institutionally embedded counseling protocols.

Alzheimer disease-like clinical phenotype in a family with FTDP-17 caused by a MAPT R406W mutation.

PubMed

Lindquist, S G; Holm, I E; Schwartz, M; Law, I; Stokholm, J; Batbayli, M; Waldemar, G; Nielsen, J E

2008-04-01

We report clinical, molecular, neuroimaging and neuropathological features of a Danish family with autosomal dominant inherited dementia, a clinical phenotype resembling Alzheimer's disease and a pathogenic mutation (R406W) in the microtubule associated protein tau (MAPT) gene. Pre-symptomatic and affected family members underwent multidisciplinary (clinical, molecular, neuroimaging and neuropathological) examinations. Treatment with memantine in a family member with early symptoms, based on the clinical phenotype and the lack of specific treatment, appears to stabilize the disease course and increase the glucose metabolism in cortical and subcortical areas, as determined by serial [F(18)]FDG-PET scanning before and after initiation of treatment. Neuropathological examination of a second affected and mutation-positive family member showed moderate atrophy of the temporal lobes including the hippocampi. Microscopy revealed abundant numbers of tau-positive neurofibrillary tangles in all cortical areas and in some brainstem nuclei corresponding to a diagnosis of frontotemporal lobe degeneration on the basis of a MAPT mutation. The clinical and genetic heterogeneity of autosomal dominant inherited dementia must be taken into account in the genetic counselling and genetic testing of families with autosomal dominantly inherited dementia in general.

Initial Clinical Trial of Robot of Endovascular Treatment with Force Feedback and Cooperating of Catheter and Guidewire.

PubMed

Jiang, Yuhua; Liu, Keyun; Li, Youxiang

2018-01-01

To evaluate the feasibility and safety of the robot of endovascular treatment (RobEnt) in clinical practice, we carried out a cerebral angiography using this robot system. We evaluated the performance of application of the robot system to clinical practice through using this robotic system to perform the digital subtraction angiography for a patient who was suspected of suffering intracranial aneurysm. At the same time, through comparing the postoperative head nuclear magnetic and blood routine with the preoperative examination, we evaluated the safety of application of the robot system to clinical practice. We performed the robot system to complete the bilateral carotid artery and bilateral vertebral arteriography. The results indicate that there was no obvious abnormality in the patient's cerebral artery. No obvious abnormality was observed in the examination of patients' check-up, head nuclear magnetism, and blood routine after the digital subtraction angiography. From this clinical trial, it can be observed that the robot system can perform the operation of cerebral angiography. The robot system can basically complete the related observation indexes, and its accuracy, effectiveness, stability, and safety basically meet the requirements of clinical application in neurointerventional surgery.

Costs of Multidisciplinary Parenteral Nutrition Care Provided at a Distance via Mobile Tablets

PubMed Central

Kim, Heejung; Spaulding, Ryan; Werkowitch, Marilyn; Yadrich, Donna; Piamjariyakul, Ubolrat; Gilroy, Richard; Smith, Carol E.

2014-01-01

Background Determining the costs of healthcare delivery is a key step for providing efficient nutrition-based care. This analysis tabulates the costs of delivering home parenteral nutrition (HPN) interventions and clinical assessments through encrypted mobile technologies to increase patients’ access to healthcare providers, reduce their travel expenses, and allow early detection of infection and other complications. Methods A traditional cost-accounting method was used to tabulate all expenses related to mobile distance HPN clinic appointments, including (1) personnel time of multidisciplinary healthcare professionals, (2) supply of HPN intervention materials, and (3) equipment, connection, and delivery expenses. Results A total of 20 mobile distance clinic appointments were conducted for an average of 56 minutes each with 45 patients who required HPN infusion care. The initial setup costs included mobile tablet devices, 4G data plans, and personnel's time as well as intervention materials. The initial costs were on average $916.64 per patient, while the follow-up clinic appointments required $361.63 a month, with these costs continuing to decline as the equipment was used by multiple patients more frequently over time. Patients reported high levels of satisfaction with cost savings in travel expenses and rated the quality of care comparable to traditional in-person examinations. Conclusion This study provides important aspects of the initial cost tabulation for visual assessment for HPN appointments. These findings will be used to generate a decision algorithm for scheduling mobile distance clinic appointments intermittent with in-person visits to determine how to lower costs of nutrition assessments. To maximize the cost benefits, clinical trials must continue to collect clinical outcomes. PMID:25245253

Length of Recovery From Sports-Related Concussions in Pediatric Patients Treated at Concussion Clinics.

PubMed

Thomas, Donald J; Coxe, Kathryn; Li, Hongmei; Pommering, Thomas L; Young, Julie A; Smith, Gary A; Yang, Jingzhen

2018-01-01

We quantified the length of recovery time by week in a cohort of pediatric sports-related concussion patients treated at concussion clinics, and examined patient and injury characteristics associated with prolonged recovery. A retrospective, cohort design. Seven concussion clinics at a Midwest children's hospital. Patients aged 10 to 17 years with a diagnosed sports-related concussion presenting to the clinic within 30 days of injury. Length of recovery by week. Unadjusted and adjusted multinomial logistic regression analyses were used to model the effect of patient and injury characteristics on length of recovery by week. Median length of recovery was 17 days. Only 16.3% (299/1840) of patients recovered within one week, whereas 26.4% took longer than four weeks to recover. By 2 months postinjury, 6.7% of patients were still experiencing symptoms. Higher symptom scores at injury and initial visit were significantly associated with prolonged symptoms by week. Patients who presented to the clinic more than 2 weeks postinjury or who had 2 or more previous concussions showed increased risk for prolonged recovery. Females were at greater risk for prolonged recovery than males (odds ratio = 2.08, 95% confidence interval = 1.49-2.89). Age was not significantly associated with recovery length. High symptom scores at injury and initial visit, time to initial clinical presentation, presence of 2 or more previous concussions, and female sex are associated with prolonged concussion recovery. Further research should aim to establish objective measures of recovery, accounting for treatment received during the recovery. The median length of recovery is 17 days among pediatric sports-related concussion patients treated at concussion clinics. Only 16.3% of patients recovered within one week, whereas 26.4% took longer than 4 weeks to recover.

Interim methadone and patient navigation in jail: Rationale and design of a randomized clinical trial.

PubMed

Schwartz, Robert P; Kelly, Sharon M; Mitchell, Shannon G; Dunlap, Laura; Zarkin, Gary A; Sharma, Anjalee; O'Grady, Kevin E; Jaffe, Jerome H

2016-07-01

Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs. This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions. We describe the background and rationale for the study, its aims, hypotheses, and study design. Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. ClinicalTrials.gov: NCT02334215. Copyright © 2016 Elsevier Inc. All rights reserved.

Cost-effectiveness of competing strategies for management of recurrent Clostridium difficile infection: a decision analysis.

PubMed

Konijeti, Gauree G; Sauk, Jenny; Shrime, Mark G; Gupta, Meera; Ananthakrishnan, Ashwin N

2014-06-01

Clostridium difficile infection (CDI) is an important cause of morbidity and healthcare costs, and is characterized by high rates of disease recurrence. The cost-effectiveness of newer treatments for recurrent CDI has not been examined, yet would be important to inform clinical practice. The aim of this study was to analyze the cost effectiveness of competing strategies for recurrent CDI. We constructed a decision-analytic model comparing 4 treatment strategies for first-line treatment of recurrent CDI in a population with a median age of 65 years: metronidazole, vancomycin, fidaxomicin, and fecal microbiota transplant (FMT). We modeled up to 2 additional recurrences following the initial recurrence. We assumed FMT delivery via colonoscopy as our base case, but conducted sensitivity analyses based on different modes of delivery. Willingness-to-pay threshold was set at $50 000 per quality-adjusted life-year. At our base case estimates, initial treatment of recurrent CDI using FMT colonoscopy was the most cost-effective strategy, with an incremental cost-effectiveness ratio of $17 016 relative to oral vancomycin. Fidaxomicin and metronidazole were both dominated by FMT colonoscopy. On sensitivity analysis, FMT colonoscopy remained the most cost-effective strategy at cure rates >88.4% and CDI recurrence rates <14.9%. Fidaxomicin required a cost <$1359 to meet our cost-effectiveness threshold. In clinical settings where FMT is not available or applicable, the preferred strategy appears to be initial treatment with oral vancomycin. In this decision analysis examining treatment strategies for recurrent CDI, we demonstrate that FMT colonoscopy is the most cost-effective initial strategy for management of recurrent CDI.

Evaluation of American Board of Orthodontics certification protocols in postgraduate orthodontic programs in the United States and Canada.

PubMed

Park, Jae Hyun; Putrus, Raphael R; Pruzansky, Dawn P; Grubb, John

2017-03-01

The objective of this study was to identify the board certification protocols that hospital and university-based postgraduate orthodontic programs have in place to prepare residents for the American Board of Orthodontics (ABO) certification examination. An electronic survey was sent to the program directors of each of the 72 postgraduate orthodontic programs in the United States and Canada. The survey consisted of 49 questions about demographics, resident case assignment protocols, and ABO examination preparation methods. The response rate was 81%. Most programs were 30 to 36 months in length (72.7%). Many residents had a case load of 51 to 75 during their first year (50.9%), with an average maximum case load of 70 to 109. There was a positive correlation with both the number of cases that first-year residents start and the length of the program (Spearman correlation coefficient = 0.379; P <0.01) when compared with maximum case load. Approximately 72% of the programs do not offer a written mock board examination; however, 72% reported offering a clinical mock board examination. ABO cases are identified within the first 6 months of most programs. About 88% of respondents believe that residents take advantage of the banking system, and that over the past 5 years ABO Initial Certification Examination applications have increased. Most program directors (89.1%) believe that their program length is sufficient for board preparation. Subjects tested in the written examination are integrated into the didactic curriculum and strengthened with ongoing literature reviews, with a passing rate over 90%. Clinical examination preparation varies, with most programs requiring a mock board examination for graduation. Total participation in both the Initial Certification Examination and banking has increased since 2010; better follow-up protocols are needed to track residents after graduation. Copyright © 2017 American Association of Orthodontists. Published by Elsevier Inc. All rights reserved.

Understanding External Cervical Resorption in Vital Teeth.

PubMed

Mavridou, Athina M; Hauben, Esther; Wevers, Martine; Schepers, Evert; Bergmans, Lars; Lambrechts, Paul

2016-12-01

The aim of this study was to investigate the 3-dimensional (3D) structure and the cellular and tissue characteristics of external cervical resorption (ECR) in vital teeth and to understand the phenomenon of ECR by combining histomorphological and radiographic findings. Twenty-seven cases of vital permanent teeth displaying ECR were investigated. ECR diagnosis was based on clinical and radiographic examination with cone-beam computed tomographic imaging. The extracted teeth were further analyzed by using nanofocus computed tomographic imaging, hard tissue histology, and scanning electron microscopy. All examined teeth showed some common characteristics. Based on the clinical and experimental findings, a 3-stage mechanism of ECR was proposed. At the first stage (ie, the initiation stage), ECR was initiated at the cementum below the gingival epithelial attachment. At the second stage (ie, the resorption stage), the resorption invaded the tooth structure 3-dimensionally toward the pulp space. However, it did not penetrate the pulp space because of the presence of a pericanalar resorption-resistant sheet. This layer was observed to consist of predentin, dentin, and occasionally reparative mineralized (bonelike) tissue, having a fluctuating thickness averaging 210 μm. At the last advanced stage (ie, the repair stage), repair took place by an ingrowth and apposition of bonelike tissue into the resorption cavity. During the reparative stage, repair and remodeling phenomena evolve simultaneously, whereas both resorption and reparative stages progress in parallel at different areas of the tooth. ECR is a dynamic and complex condition that involves periodontal and endodontic tissues. Using clinical, histologic, radiographic, and scanning microscopic analysis, a better understanding of the evolution of ECR is possible. Based on the experimental findings, a 3-stage mechanism for the initiation and growth of ECR is proposed. Copyright © 2016 American Association of Endodontists. Published by Elsevier Inc. All rights reserved.

Spine deviations and orthodontic treatment of asymmetric malocclusions in children

PubMed Central

2012-01-01

Background The aim of this randomized clinical trial was to assess the effect of early orthodontic treatment for unilateral posterior cross bite in the late deciduous and early mixed dentition using orthopedic parameters. Methods Early orthodontic treatment was performed by initial maxillary expansion and subsequent activator therapy (Münster treatment concept). The patient sample was initially comprised of 80 patients with unilateral posterior cross bite (mean age 7.3 years, SD 2.1 years). After randomization, 77 children attended the initial examination appointment (therapy = 37, control = 40); 31 children in the therapy group and 35 children in the control group were monitored at the follow-up examination (T2). The mean interval between T1 and T2 was 1.1 years (SD 0.2 years). Rasterstereography was used for back shape analysis at T1 and T2. Using the profile, the kyphotic and lordotic angle, the surface rotation, the lateral deviation, pelvic tilt and pelvic torsion, statistical differences at T1 and T2 between the therapy and control groups were calculated (t-test). Our working hypothesis was, that early orthodontic treatment can induce negative therapeutic changes in body posture through thoracic and lumbar position changes in preadolescents with uniltaral cross bite. Results No clinically relevant differences between the control and the therapy groups at T1 and T2 were found for the parameters of kyphotic and lordotic angle, the surface rotation, lateral deviation, pelvic tilt, and pelvic torsion. Conclusions Our working hypothesis was tested to be not correct (within the limitations of this study). This randomized clinical trial demonstrates that in a juvenile population with unilateral posterior cross bite the selected early orthodontic treatment protocol does not affect negatively the postural parameters. Trial registration DRKS00003497 on DRKS PMID:22906114

Brief Report: Stigma and HIV Care Continuum Outcomes Among Ethiopian Adults Initiating ART.

PubMed

Hoffman, Susie; Tymejczyk, Olga; Kulkarni, Sarah; Lahuerta, Maria; Gadisa, Tsigereda; Remien, Robert H; Melaku, Zenebe; Nash, Denis; Elul, Batya

2017-12-01

Stigma harms the mental health of HIV-positive individuals and reduces adherence to antiretroviral therapy (ART), but less is known about stigma and other outcomes across the HIV care continuum. Among 1180 Ethiopian adults initiating ART at 6 urban HIV clinics, we examined the relationship of internalized, anticipated, and enacted stigma to HIV care-related outcomes ascertained by interview (repeat HIV-positive testing, provider vs. self-referred testing, missed clinic visit before ART initiation, eagerness to begin ART), and by abstraction of routinely collected clinical data (late ART initiation, 3-month gap in care following ART initiation). Logistic regression was used to assess the association of each type of stigma with each outcome, adjusting for potential confounders. Scoring higher on each stigma domain was associated with 50%-90% higher odds of repeat HIV-positive testing. High internalized stigma was associated with higher odds of provider vs. self-referred test [adjusted odds ratio (aOR)high vs. low: 1.7; 95% confidence interval (CI): 1.3 to 2.2]. Higher anticipated stigma was associated with lower eagerness to begin ART (aORhigh vs. low: 0.55; 0.35-0.87; aORmedium vs. low: 0.45; 95% CI: 0.30 to 0.69). Any enacted stigma was associated with higher odds of a missed visit (aORany vs. none 1.8; 1.2-2.8). Stigma was not associated with late ART-initiation or with a subsequent gap in care. These findings provide further evidence of the importance of measuring and addressing stigma across the entire care continuum. Future work should test hypotheses about specific stigma domains and outcomes in prospective intervention or observational studies.

Can clinical CT data improve forensic reconstruction?

PubMed

Schuh, P; Scheurer, E; Fritz, K; Pavlic, M; Hassler, E; Rienmüller, R; Yen, K

2013-05-01

In accidents resulting in severe injuries, a clinical forensic examination is generally abandoned in the initial phase due to high-priority clinical needs. However, in many cases, data from clinical computed tomography (CT) examinations are available. The goals of this prospective study were (a) to evaluate clinical CT data as a basis for forensic reconstruction of the sequence of events, (b) to assess if forensic radiological follow-up reading improves the forensic diagnostic benefit compared to the written clinical radiological reports, and (c) to evaluate if full data storage including additional reconstructed 0.6-mm slices enhances forensic analysis. Clinical CT data of 15 living individuals with imaging of at least the head, thorax, and abdomen following polytrauma were examined regarding the forensic evaluation of the sequence of events. Additionally, 0.6-mm slices and 3D images were reconstructed for forensic purposes and used for the evaluation. At the forensic radiological readings, additional traumatic findings were observed in ten of the 15 patients. The main weakness of the clinical reports was that they were not detailed enough, particularly regarding the localization of injuries and description of wound morphology. In seven cases, however, forensic conclusions were possible on the basis of the written clinical reports, whereas in five cases forensic reconstruction required specific follow-up reading. The additional 0.6-mm slices were easily available and with improved 3D image quality and forensic diagnostics. In conclusion, the use of clinical CT data can considerably support forensic expertise regarding reconstruction issues. Forensic follow-up reading as well as the use of additional thin slices for 3D analysis can further improve its benefit for forensic reconstruction purposes.

Prehospital blood product transfusion by U.S. army MEDEVAC during combat operations in Afghanistan: a process improvement initiative.

PubMed

Malsby, Robert F; Quesada, Jose; Powell-Dunford, Nicole; Kinoshita, Ren; Kurtz, John; Gehlen, William; Adams, Colleen; Martin, Dustin; Shackelford, Stacy

2013-07-01

U.S. Army flight medics performed a process improvement initiative of 15 blood product transfusions on select Category A (Urgent) helicopter evacuation casualties meeting approved clinical indications for transfusion. These transfusions were initiated from point of injury locations aboard MEDEVAC aircraft originating from one of two locations in southern Afghanistan. All flight medics executing the transfusions were qualified through a standardized and approved program of instruction, which included day and night skills validation, and a 90% or higher written examination score. There was no adverse reaction or out-of-standard blood product temperature despite hazardous conditions and elevated cabin temperatures. All casualties within a 10-minute flight time who met clinical indications were transfused. Utilization of a standard operating procedure with strict handling and administration parameters, a rigorous training and qualification program, an elaborate cold chain system, and redundant documentation of blood product units ensured that flight medic initiated transfusions were safe and effective. Research study is needed to refine the indications for prehospital blood transfusion and to determine the effect on outcomes in severely injured trauma patients. Reprint & Copyright © 2013 Association of Military Surgeons of the U.S.

Clinical predictors of cardiac magnetic resonance late gadolinium enhancement in patients with atrial fibrillation.

PubMed

Chrispin, Jonathan; Ipek, Esra Gucuk; Habibi, Mohammadali; Yang, Eunice; Spragg, David; Marine, Joseph E; Ashikaga, Hiroshi; Rickard, John; Berger, Ronald D; Zimmerman, Stefan L; Calkins, Hugh; Nazarian, Saman

2017-03-01

This study aims to examine the association of clinical co-morbidities with the presence of left atrial (LA) late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR). Previous studies have established the severity of LA LGE to be associated with atrial fibrillation (AF) recurrence following AF ablation. We sought to determine whether baseline clinical characteristics were associated with LGE extent among patients presenting for an initial AF ablation. The cohort consisted of 179 consecutive patients with no prior cardiac ablation procedures who underwent pre-procedure LGE-CMR. The extent of LA LGE for each patient was calculated using the image intensity ratio, normalized to the mean blood pool intensity, corresponding to a bipolar voltage ≤0.3 mV. The association of LGE extent with baseline clinical characteristics was examined using non-parametric and multivariable models. The mean age of the cohort was 60.9 ± 9.6 years and 128 (72%) were male. In total, 56 (31%) patients had persistent AF. The mean LA volume was 118.4 ± 41.6 mL, and the mean LA LGE extent was 14.1 ± 10.4%. There was no association with any clinical variables with LGE extent by quartiles in the multivariable model. Extent of LGE as a continuous variable was positively, but weakly associated with LA volume in a multivariable model adjusting for age, body mass index, AF persistence, and left ventricular ejection fraction (1.5% scar/mL, P = 0.038). In a cohort of patients presenting for initial AF ablation, the presence of pre-ablation LA LGE extent was weakly, but positively associated with increasing LA volume. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

The disparity of frontline clinical staff and managers' perceptions of a quality and patient safety initiative.

PubMed

Parand, Anam; Burnett, Susan; Benn, Jonathan; Pinto, Anna; Iskander, Sandra; Vincent, Charles

2011-12-01

Arguably, a shared perspective between managers and their clinical staff on an improvement initiative would allow for most effective implementation and increase programme success. However, it has been reported that research has failed to differentiate between managers and line employees on quality management implementation and examine their differences in perceptions of quality and safety initiatives. The aim of this study was to compare clinical frontline staff and senior managers' perceptions on the importance of an organization-wide quality and safety collaborative: the Safer Patients Initiative (SPI). A quantitative study obtained 635 surveys at 20 trusts participating in SPI. Participants included the teams and frontline staff involved within the programme at each organization. Independent T-tests were carried out between frontline staff and senior managers' perceptions of SPI programme elements, success factors and impact & sustainability. Statistically significant differences were found between the perceptions of frontline staff and senior managers on a wide number of issues, including the frontline perceiving a significantly larger improvement on the timeliness of care delivery (t = 2.943, P = 0.004), while managers perceived larger improvement on the culture within the organization for safe, effective and reliable care (t = -2.454, P = 0.014). This study has identified statistically significant disparities in perceptions of an organization-wide improvement initiative between frontline staff and senior managers. This holds valuable implications for the importance of getting both frontline and management perspectives when designing such interventions, in monitoring their performance, and in evaluating their impact. © 2010 Blackwell Publishing Ltd.

Development of clinical process measures for pediatric burn care: Understanding variation in practice patterns.

PubMed

Kazis, Lewis E; Sheridan, Robert L; Shapiro, Gabriel D; Lee, Austin F; Liang, Matthew H; Ryan, Colleen M; Schneider, Jeffrey C; Lydon, Martha; Soley-Bori, Marina; Sonis, Lily A; Dore, Emily C; Palmieri, Tina; Herndon, David; Meyer, Walter; Warner, Petra; Kagan, Richard; Stoddard, Frederick J; Murphy, Michael; Tompkins, Ronald G

2018-04-01

There has been little systematic examination of variation in pediatric burn care clinical practices and its effect on outcomes. As a first step, current clinical care processes need to be operationally defined. The highly specialized burn care units of the Shriners Hospitals for Children system present an opportunity to describe the processes of care. The aim of this study was to develop a set of process-based measures for pediatric burn care and examine adherence to them by providers in a cohort of pediatric burn patients. We conducted a systematic literature review to compile a set of process-based indicators. These measures were refined by an expert panel of burn care providers, yielding 36 process-based indicators in four clinical areas: initial evaluation and resuscitation, acute excisional surgery and critical care, psychosocial and pain control, and reconstruction and aftercare. We assessed variability in adherence to the indicators in a cohort of 1,076 children with burns at four regional pediatric burn programs in the Shriners Hospital system. The percentages of the cohort at each of the four sites were as follows: Boston, 20.8%; Cincinnati, 21.1%; Galveston, 36.0%; and Sacramento, 22.1%. The cohort included children who received care between 2006 and 2010. Adherence to the process indicators varied both across sites and by clinical area. Adherence was lowest for the clinical areas of acute excisional surgery and critical care, with a range of 35% to 48% across sites, followed by initial evaluation and resuscitation (range, 34%-60%). In contrast, the clinical areas of psychosocial and pain control and reconstruction and aftercare had relatively high adherence across sites, with ranges of 62% to 93% and 71% to 87%, respectively. Of the 36 process indicators, 89% differed significantly in adherence between clinical sites (p < 0.05). Acute excisional surgery and critical care exhibited the most variability. The development of this set of process-based measures represents an important step in the assessment of clinical practice in pediatric burn care. Substantial variation was observed in practices of pediatric burn care. However, further research is needed to link these process-based measures to clinical outcomes. Therapeutic/care management, level IV.

Metastatic carcinoma presenting as hind-limb lameness: diagnosis by synovial fluid cytology.

PubMed

Meinkoth, J H; Rochat, M C; Cowell, R L

1997-01-01

A dog presented for evaluation of left hind-limb lameness and pain associated with manipulation of the tail. Synovial metastasis of a carcinoma was diagnosed by joint fluid examination. A primary bronchiolar-alveolar carcinoma with widespread (including synovial and skeletal) metastases was diagnosed on postmortem examination. Metastasis to synovial surfaces is uncommon, but when it occurs, the metastasis-induced arthritis may be the initial presenting complaint for which medical attention is sought. Although rarely reported, cytological examination of synovial fluid may be diagnostic. This paper presents an interesting clinical case and reviews the literature concerning metastatic disease of the synovium.

Disorders of the neonatal nasal cavity: Fundamentals for practice.

PubMed

Sohal, Maheep; Schoem, Scott R

2016-08-01

Neonatal nasal obstruction is a well-known clinical entity. Fortunately, it is rarely life-threatening and usually resolves with conservative management. As with most conditions, a systematic history and thorough physical examination are crucial for correct diagnosis and management. The initial diagnosis may be elusive and require either serial or more in-depth evaluations. Occasionally, examination may reveal structural abnormalities necessitating surgical intervention. Fortunately most of these abnormalities are amenable to surgery; however, a select few are notoriously difficult to treat. Copyright © 2016. Published by Elsevier Ltd.

State-Sponsored Public Reporting Programs of Hospital Quality in the United States

PubMed Central

Ross, Joseph S.; Sheth, Sameer D.; Krumholz, Harlan M.

2011-01-01

The prevalence of state public reporting initiatives focused on hospital quality is not known. We systematically reviewed state-sponsored publicly reporting programs focused on clinical aspects of hospital quality and performance for adults, surveying the 50 U.S. states and the District of Columbia. We found that while identifying information about programs was frequently a challenge, programs were present in 25 states (49%) and provided hospital quality information that varied considerably from state to state both by condition and by process and outcome measures reported. We examine the implications of these findings for future state initiatives. PMID:21134936

Progressive Posterior Lenticonus in a Patient with Alport Syndrome

PubMed Central

Al-Mahmood, Ammar M.; Al-Swailem, Samar A.; Al-Khalaf, Abdulrahman; Al-Binali, Ghada Y.

2010-01-01

We report a rare case of Alport syndrome with progressive posterior lenticonus. A 24-year-old male presented to our tertiary eye care center with history of poor vision. At initial presentation, the patient had bilateral anterior lenticonus, posterior subcapsular cataract, and renal failure. The patient was diagnosed with Alport syndrome based on a positive family history of the disease and clinical findings. Further examination revealed progressive posterior lenticonus that was not present initially. The presence of such finding is important because it influences the surgical approach to avoid complications during cataract surgery. PMID:21180444

Implementing the objective structured clinical examination in a geriatrics fellowship program-a 3-year experience.

PubMed

Avelino-Silva, Thiago J; Gil, Luiz A; Suemoto, Claudia K; Kikuchi, Elina L; Lin, Sumika M; Farias, Luciana L; Jacob-Filho, Wilson

2012-07-01

The Objective Structured Clinical Examination (OSCE) appears to be an effective alternative for assessing not only medical knowledge, but also clinical skills, including effective communication and physical examination skills. The purpose of the current study was to implement an OSCE model in a geriatrics fellowship program and to compare the instrument with traditional essay examination. Seventy first- and second-year geriatric fellows were initially submitted to a traditional essay examination and scored from 0 to 10 by a faculty member. The same fellows subsequently underwent an OSCE with eight 10-minute stations covering a wide range of essential aspects of geriatric knowledge. Each OSCE station had an examiner responsible for its evaluation according to a predefined checklist. Checklist items were classified for analysis purposes as clinical knowledge items (CKI) and communication skills items (CSI); fellow responses were scored from 0 to 10.Although essay examinations took from 30 to 45 minutes to complete, 180-200 minutes were required to evaluate fellows using the proposed OSCE method. Fellows scored an average of 6.2 ± 1.2 on the traditional essay examination and 6.6 ± 1.0 on the OSCE (P < .001). Subanalyses of OSCE scores indicated that average performance on CKI was lower than the average on CSI (6.4 ± 1.1 vs. 8.4 ± 1.1; P < .001). Fellow performance on the essay examination was similar to their performance on CKI (P = .13). Second-year fellows performed better than first-year fellows on the essay examination (P < .001) and CKI (P = .05), but not on CSI (P = .25).The OSCE was successfully implemented as an educational strategy during a geriatrics fellowship program. Combining different testing modalities may provide the best assessment of competence for various domains of knowledge, skills, and behavior. © 2012, Copyright the Authors Journal compilation © 2012, The American Geriatrics Society.

Dispositional Optimism and Terminal Decline in Global Quality of Life

ERIC Educational Resources Information Center

Zaslavsky, Oleg; Palgi, Yuval; Rillamas-Sun, Eileen; LaCroix, Andrea Z.; Schnall, Eliezer; Woods, Nancy F.; Cochrane, Barbara B.; Garcia, Lorena; Hingle, Melanie; Post, Stephen; Seguin, Rebecca; Tindle, Hilary; Shrira, Amit

2015-01-01

We examined whether dispositional optimism relates to change in global quality of life (QOL) as a function of either chronological age or years to impending death. We used a sample of 2,096 deceased postmenopausal women from the Women's Health Initiative clinical trials who were enrolled in the 2005-2010 Extension Study and for whom at least 1…

The application of a "6S Lean" initiative to improve workflow for emergency eye examination rooms.

PubMed

Nazarali, Samir; Rayat, Jaspreet; Salmonson, Hilary; Moss, Theodora; Mathura, Pamela; Damji, Karim F

2017-10-01

Ophthalmology residents on call at the Royal Alexandra Hospital identified workplace disorganization and lack of standardization in emergency eye examination rooms as an impediment to efficient patient treatment. The aim of the study was to use the "6S Lean" model to improve workflow in eye examination rooms at the Royal Alexandra Hospital. With the assistance of quality improvement consultants, the "6S Lean" model was applied to the current operation of the emergency eye clinic examination rooms. This model, considering 8 waste categories, was then used to recommend and implement changes to the examination rooms and to workplace protocols to enhance efficiency and safety. Eye examination rooms were improved with regards to setup, organization of supplies, inventory control, and maintenance. All targets were achieved, and the 5S audit checklist score increased by 33 points from 44 to 77. Implementation of the 6S methodology is a simple approach that removes inefficiencies from the workplace. The ophthalmology clinic removed waste from all 8 waste categories, increased audit results, mitigated patient and resident safety risks, and ultimately redirected resident time back to patient care delivery. Copyright © 2017 Canadian Ophthalmological Society. Published by Elsevier Inc. All rights reserved.

Depression Symptom Trajectories and Associated Risk Factors among Adolescents in Chile

PubMed Central

Stapinski, Lexine A.; Montgomery, Alan A.; Heron, Jon; Jerrim, John; Vignoles, Anna; Araya, Ricardo

2013-01-01

Adolescence is a key period for studying the development of depression, with studies in Europe and North America showing a pattern of elevated risk that begins in early adolescence and continues to increase as adolescents age. Few studies have examined the course of adolescent depression and associated risk factors in low and middle-income countries. This longitudinal cohort study examined depression symptom trajectories and risk factors in a sample of socio-economically disadvantaged adolescents in Chile (n = 2,508). Data were collected over an 18-month period as part of a clinical trial for secondary students aged 12 to 18 (median age 14). Clinical levels of depression were prevalent in this sample at baseline (35% for girls and 28% for boys); yet latent growth models of symptom trajectories revealed a pattern of decreasing symptoms over time. There was evidence of an anxiety-depression developmental pathway for girls, with elevated anxiety levels initially predicting poorer depression outcomes later on. Poor problem-solving skills were associated with initial depression levels but did not predict the course of depressive symptoms. Critically, the declining symptom trajectories raise important methodological issues regarding the effects of repeated assessment in longitudinal studies. PMID:24147131

The role of fundus autofluorescence in late-onset retinitis pigmentosa (LORP) diagnosis.

PubMed

Lee, Tamara J; Hwang, John C; Chen, Royce W S; Lima, Luiz H; Wang, Nan-Kai; Tosi, Joaquin; Freund, K Bailey; Yannuzzi, Lawrence A; Tsang, Stephen H

2014-09-01

To demonstrate the utility and characteristics of fundus autofluorescence in late-onset retinitis pigmentosa. Observational case series. Patients diagnosed with late-onset retinitis pigmentosa were identified retrospectively in an institutional setting. Twelve eyes of six patients were identified and medical records were reviewed. All patients presented with slowly progressive peripheral field loss and initial clinical examination revealed only subtle retinal changes. There was a notable lack of intraretinal pigment migration in all patients. Five out of six patients underwent magnetic resonance imaging of the brain to rule out intracranial processes and all were referred from another ophthalmologist for further evaluation. Fundus autofluorescence was ultimately employed in all patients and revealed more extensive retinal pathology than initially appreciated on clinical examination. Fundus autofluorescence directed the workup toward a retinal etiology in all cases and led to the eventual diagnosis of late-onset retinitis pigmentosa through electroretinogram testing. Fundus autofluorescence may be a more sensitive marker for retinal pathology than stereo fundus biomicroscopy alone in late-onset retinitis pigmentosa. Early use of fundus autofluorescence imaging in the evaluation of patients with subtle retinal lesions and complaints of peripheral field loss may be an effective strategy for timely and cost-efficient diagnosis.

Experience of treatment of patients with granulomatous lobular mastitis

PubMed Central

Hur, Sung Mo; Cho, Dong Hui; Lee, Se Kyung; Choi, Min-Young; Bae, Soo Youn; Koo, Min Young; Kim, Sangmin; Choe, Jun-Ho; Kim, Jung-Han; Kim, Jee Soo; Nam, Seok-Jin; Yang, Jung-Hyun

2013-01-01

Purpose To present the author's experience with various treatment methods of granulomatous lobular mastitis (GLM) and to determine effective treatment methods of GLM. Methods Fifty patients who were diagnosed with GLM were classified into five groups based on the initial treatment methods they underwent, which included observation (n = 8), antibiotics (n = 3), steroid (n = 13), drainage (n = 14), and surgical excision (n = 12). The treatment processes in each group were examined and their clinical characteristics, treatment processes, and results were analyzed respectively. Results Success rates with each initial treatment were observation, 87.5%; antibiotics, 33.3%; steroids, 30.8%; drainage, 28.6%; and surgical excision, 91.7%. In most cases of observation, the lesions were small and the symptoms were mild. A total of 23 patients underwent surgical excision during treatment. Surgical excision showed particularly fast recovery, high success rate (90.3%) and low recurrence rate (8.7%). Conclusion The clinical course of GLM is complex and the outcome of each treatment type are variable. Surgery may play an important role when a lesion is determined to be mass-forming or appears localized as an abscess pocket during breast examination or imaging study. PMID:23833753

Depression symptom trajectories and associated risk factors among adolescents in Chile.

PubMed

Stapinski, Lexine A; Montgomery, Alan A; Heron, Jon; Jerrim, John; Vignoles, Anna; Araya, Ricardo

2013-01-01

Adolescence is a key period for studying the development of depression, with studies in Europe and North America showing a pattern of elevated risk that begins in early adolescence and continues to increase as adolescents age. Few studies have examined the course of adolescent depression and associated risk factors in low and middle-income countries. This longitudinal cohort study examined depression symptom trajectories and risk factors in a sample of socio-economically disadvantaged adolescents in Chile (n = 2,508). Data were collected over an 18-month period as part of a clinical trial for secondary students aged 12 to 18 (median age 14). Clinical levels of depression were prevalent in this sample at baseline (35% for girls and 28% for boys); yet latent growth models of symptom trajectories revealed a pattern of decreasing symptoms over time. There was evidence of an anxiety-depression developmental pathway for girls, with elevated anxiety levels initially predicting poorer depression outcomes later on. Poor problem-solving skills were associated with initial depression levels but did not predict the course of depressive symptoms. Critically, the declining symptom trajectories raise important methodological issues regarding the effects of repeated assessment in longitudinal studies.

Disseminated protothecosis associated with diskospondylitis in a dog.

PubMed

Manino, Paul M; Oliveira, Fabiano; Ficken, Martin; Swinford, Amy; Burney, Derek

2014-01-01

A 6 yr old female Labrador retriever was evaluated for an acute onset of difficulty walking and a head tilt. Initial physical examination revealed bilateral retinal detachment, a left-sided head tilt, positional rotary nystagmus, and lumbar hyperpathia. Pertinent preliminary diagnostic findings included systemic hypertension, bony lysis and adjacent sclerosis of the vertebral endplates of the first and second lumbar vertebrae, and positive urine and blood cultures for a yeast identified as Candida spp. Concerned about disseminated candidiasis after subsequent subretinal aspirates confirmed the presence of a yeast-like organism, therapy with voriconazole was initiated. Because of progressive clinical deterioration and the poor prognosis for recovery, the dog was eventually euthanized. Postmortem histological examination of tissues, including the affected vertebral endplates, revealed numerous intralesional algae compatible with Prototheca spp. To the authors' knowledge, this report is the first to document a case of protothecal diskospondylitis with possible concurrent candidiasis in a dog. Although typically associated with signs referable to the gastrointestinal tract, this report underscores the importance of not excluding protothecosis as a differential diagnosis when such signs are absent. Lastly, the use of voriconazole appears ineffective for reversing the clinical course of late-stage disseminated protothecosis.

Applying Social Network Analysis to Identify the Social Support Needs of Adolescent and Young Adult Cancer Patients and Survivors.

PubMed

Koltai, Kolina; Walsh, Casey; Jones, Barbara; Berkelaar, Brenda L

2018-04-01

This article examines how theoretical and clinical applications of social network analysis (SNA) can inform opportunities for innovation and advancement of social support programming for adolescent and young adult (AYA) cancer patients and survivors. SNA can help address potential barriers and challenges to initiating and sustaining AYA peer support by helping to identify the diverse psychosocial needs among individuals in the AYA age range; find strategic ways to support and connect AYAs at different phases of the cancer trajectory with resources and services; and increase awareness of psychosocial resources and referrals from healthcare providers. Network perspectives on homophily, proximity, and evolution provide a foundational basis to explore the utility of SNA in AYA clinical care and research initiatives. The uniqueness of the AYA oncology community can also provide insight into extending and developing current SNA theories. Using SNA in AYA psychosocial cancer research has the potential to create new ideas and pathways for supporting AYAs across the continuum of care, while also extending theories of SNA. SNA may also prove to be a useful tool for examining social support resources for AYAs with various chronic health conditions and other like groups.

Case of recurrent paracoccidioidomycosis in female. 10 years after initial treatment.

PubMed

De Azevedo Izidoro, Ana Claudia Santos; Da Silva, Paulo Cesar; De Oliveira Ribas, Marina; De Azevedo, Luciana Reis; Machado, Maria Angela Naval; De Lima, Antonio Adilson Soares

2007-05-01

This report describes a case of recurrence of chronic paracoccidioidomycosis 10 years following the initial diagnosis. A 56-year-old female was admitted to the Dental Clinic of the Pontifical Catholic University of Paraná complaining of oral soreness. Mulberry-like ulcerations were observed on the gingiva, right labial comissura, and vermillion of the lip. The patient reported persistent chronic cough, weight loss, appetite loss and fever. The anamnesis revealed that the patient had developed and been treated for paracoccidioidomycosis 10 years earlier. A biopsy was performed and microscopic examination revealed microabscesses, collections of macrophages organized into granulomas, multinucleated giant cells and Paracoccidioides brasiliensis. The patient was treated with Itraconazole and, the oral lesions disappeared within 3 months. Persistent follow-up examination in patients with a history of paracoccidioidomycosis is essential in the management of this disease.

An initial investigation of abnormal bodily phenomena in subjects at ultra high risk for psychosis: Their prevalence and clinical implications.

PubMed

Madeira, Luis; Bonoldi, Ilaria; Rocchetti, Matteo; Samson, Carly; Azis, Matilda; Queen, Beverly; Bossong, Matthijs; Perez, Jesus; Stone, James; Allen, Paul; Howes, Oliver D; McGuire, Philip; Raballo, Andrea; Fusar-Poli, Paolo; Ballerini, Massimo; Stanghellini, Giovanni

2016-04-01

Contemporary phenomenological research has considered abnormal bodily phenomena (ABP) to be a phenotypic trait of subjects with schizophrenia in their first psychotic episode. Yet the prevalence of ABP and their clinical significance in subjects at Ultra High Risk (UHR) of psychosis remain unidentified. This study is an exploratory investigation of ABP in UHR subjects and matched healthy controls (HCs) examining their relation to clinical features and basic self-disturbances. A sample of 26 UHR and 14 HC subjects from three prodromal and early intervention clinics in South London, West London and Cambridge was assessed with the Abnormal Bodily Phenomena questionnaire (ABPq), Comprehensive Assessment of At-Risk Mental States (CAARMS), the Positive and Negative Syndrome Scale (PANSS), the Social and Occupational Functioning Assessment Scale (SOFAS) and the Examination of Anomalous Self Experiences (EASE) checklist. In our sample ABP occurred in 73.1% of UHR subjects and prominent ABP (proABP) were referred in 53.8% of them. No HC subject reported ABP. The UHR group with proABP had lower CAARMS total score (t=-9.265, p=0.006). There were no differences in PANSS total score (t=-1.235, p=0.277), SOFAS score (H(2) 22.27, p=0.666) and EASE total scores (z=8.565, adjusted p=0.185) in the UHR subjects with prominent ABP versus those that did not. This initial investigation suggests that ABP could be a prevalent phenotypic feature of UHR subjects. Copyright © 2015 Elsevier Inc. All rights reserved.

Validation of a model to evaluate the role of radiographs in the diagnosis and treatment planning of periodontal diseases.

PubMed

Tugnait, A; Hirschmann, P N; Clerehugh, V

2006-08-01

The purposes of this study were (i) to see if an indirect method of design (paper patients) could be developed for study of change affected by radiographs on diagnostic outcome and planned treatment of periodontal patients and (ii) to investigate the effect of the nature of clinical examination on the value of radiographs in reaching a periodontal diagnosis. Paper cases could allow the design of examiner blind studies where repeatability could be assessed. 201 patients were assigned to one of four groups and clinically assessed according to group specifications. Radiographs were taken. Periodontal diagnoses and treatment plans were drawn up for each patient with and without radiographic information (real patient). Simulated paper transcriptions were made for each subject and diagnoses and treatment plans were again drawn up (paper patient). For many diagnoses and treatment options assessments were similar for real and paper patients. There was substantial agreement between periodontal diagnoses reached from real and paper assessments (kappa=0.68). Greater differences were seen for extractions and periodontal surgery. Paper assessments better replicated real assessments when more thorough clinical examinations were undertaken. The relatively time efficient Group 2 clinical assessment appeared to perform similarly to the extensive Group 4 clinical assessment. The model described may be useful for simulating real patients for studies of this nature. The Group 2 assessment appeared to give sufficient clinical information for patient management and may be an appropriate choice for initial diagnosis and treatment planning of periodontal patients.

Drug-induced sleep endoscopy changes snoring management plan very significantly compared to standard clinical evaluation.

PubMed

Pilaete, Karen; De Medts, Joris; Delsupehe, Kathelijne Godelieve

2014-05-01

Drug-induced sleep endoscopy (DISE) is a new tool in the work-up of patients with sleep-disordered breathing (SDB). We assessed the impact of DISE on the treatment plan of snoring patients. This is a single institution prospective longitudinal clinical trial. The setting is a private teaching hospital. A consecutive series of 100 snoring patients prospectively underwent a standardised questionnaire, clinical examination, rhinomanometry, allergy skin prick testing, DISE and polysomnography. Management plan before and after DISE evaluation was compared. In 61 patients (excluding 16 patients sent for continuous positive airway pressure, three patients refused sleep endoscopy and 20 were lost to follow-up), we compared the treatment plans. DISE showed single level airway collapse in 13 and multilevel collapse in 48 patients. The site of flutter did not add additional information as compared to the pattern and the location of the collapse. After DISE, the initial management plan changed in 41% of patients irrespective of the type of initial management plan. The only somewhat accurate initial treatment plan was uvulopalatopharyngoplasty (unchanged in 11/13 patients). Excluding moderate to severe obstructive sleep apnea patients DISE is an indispensable tool in treatment decision in all SDB patients. We suggest to simplify the protocol for DISE reporting.

Breast-feeding and Vitamin D Supplementation Rates in the Ochsner Health System

PubMed Central

Ponnapakkam, Tulasi; Ravichandran, Anisha; Bradford, Elease; Tobin, Gregory; Gensure, Robert

2008-01-01

Breast-feeding imparts many benefits to both mothers and infants. Because of these numerous recognized benefits, there has been an effort to increase breast-feeding rates nationwide; increasing breast-feeding rates was one of the goals of the U.S. Department of Health and Human Services' Healthy People 2010 initiative. This study examined the breast-feeding rate at the Ochsner Clinic Foundation by conducting a retrospective chart review of patients aged 0–12 months who visited any branch of the Ochsner hospital system. Our results indicate that the rate of initiation of breast-feeding for children followed at the Ochsner Clinic Foundation is 66.3%. However, as breast-feeding rates rise, there is concern that there may be a resurgence of rickets, a disease caused by the deficiency of vitamin D. Currently the American Academy of Pediatrics recommends that exclusively breast-fed infants receive vitamin D supplementation starting within the first 2 months of life. We have therefore initiated a clinical trial to determine whether vitamin D supplementation is required to prevent rickets in breast-fed children. In the course of conducting this study, we have gathered additional data regarding the patterns of breast-feeding and of vitamin D supplementation for babies born at Ochsner. PMID:21603467

Breast-feeding and Vitamin D Supplementation Rates in the Ochsner Health System.

PubMed

Ponnapakkam, Tulasi; Ravichandran, Anisha; Bradford, Elease; Tobin, Gregory; Gensure, Robert

2008-01-01

Breast-feeding imparts many benefits to both mothers and infants. Because of these numerous recognized benefits, there has been an effort to increase breast-feeding rates nationwide; increasing breast-feeding rates was one of the goals of the U.S. Department of Health and Human Services' Healthy People 2010 initiative. This study examined the breast-feeding rate at the Ochsner Clinic Foundation by conducting a retrospective chart review of patients aged 0-12 months who visited any branch of the Ochsner hospital system. Our results indicate that the rate of initiation of breast-feeding for children followed at the Ochsner Clinic Foundation is 66.3%. However, as breast-feeding rates rise, there is concern that there may be a resurgence of rickets, a disease caused by the deficiency of vitamin D. Currently the American Academy of Pediatrics recommends that exclusively breast-fed infants receive vitamin D supplementation starting within the first 2 months of life. We have therefore initiated a clinical trial to determine whether vitamin D supplementation is required to prevent rickets in breast-fed children. In the course of conducting this study, we have gathered additional data regarding the patterns of breast-feeding and of vitamin D supplementation for babies born at Ochsner.

Fractographic features of glass-ceramic and zirconia-based dental restorations fractured during clinical function.

PubMed

Oilo, Marit; Hardang, Anne D; Ulsund, Amanda H; Gjerdet, Nils R

2014-06-01

Fractures during clinical function have been reported as the major concern associated with all-ceramic dental restorations. The aim of this study was to analyze the fracture features of glass-ceramic and zirconia-based restorations fractured during clinical use. Twenty-seven crowns and onlays were supplied by dentists and dental technicians with information about type of cement and time in function, if available. Fourteen lithium disilicate glass-ceramic restorations and 13 zirconia-based restorations were retrieved and analyzed. Fractographic features were examined using optical microscopy to determine crack initiation and crack propagation of the restorations. The material comprised fractured restorations from one canine, 10 incisors, four premolars, and 11 molars. One crown was not categorized because of difficulty in orientation of the fragments. The results revealed that all core and veneer fractures initiated in the cervical margin and usually from the approximal area close to the most coronally placed curvature of the margin. Three cases of occlusal chipping were found. The margin of dental all-ceramic single-tooth restorations was the area of fracture origin. The fracture features were similar for zirconia, glass-ceramic, and alumina single-tooth restorations. Design features seem to be of great importance for fracture initiation. © 2014 Eur J Oral Sci.

Completed | Office of Cancer Clinical Proteomics Research

Cancer.gov

Prior to the current Clinical Proteomic Tumor Analysis Consortium (CPTAC), previously funded initiatives associated with clinical proteomics research included: Clinical Proteomic Tumor Analysis Consortium (CPTAC 2.0) Clinical Proteomic Technologies for Cancer Initiative (CPTC) Mouse Proteomic Technologies Initiative

Determinants of successful clinical networks: the conceptual framework and study protocol.

PubMed

Haines, Mary; Brown, Bernadette; Craig, Jonathan; D'Este, Catherine; Elliott, Elizabeth; Klineberg, Emily; McInnes, Elizabeth; Middleton, Sandy; Paul, Christine; Redman, Sally; Yano, Elizabeth M

2012-03-13

Clinical networks are increasingly being viewed as an important strategy for increasing evidence-based practice and improving models of care, but success is variable and characteristics of networks with high impact are uncertain. This study takes advantage of the variability in the functioning and outcomes of networks supported by the Australian New South Wales (NSW) Agency for Clinical Innovation's non-mandatory model of clinical networks to investigate the factors that contribute to the success of clinical networks. The objective of this retrospective study is to examine the association between external support, organisational and program factors, and indicators of success among 19 clinical networks over a three-year period (2006-2008). The outcomes (health impact, system impact, programs implemented, engagement, user perception, and financial leverage) and explanatory factors will be collected using a web-based survey, interviews, and record review. An independent expert panel will provide judgements about the impact or extent of each network's initiatives on health and system impacts. The ratings of the expert panel will be the outcome used in multivariable analyses. Following the rating of network success, a qualitative study will be conducted to provide a more in-depth examination of the most successful networks. This is the first study to combine quantitative and qualitative methods to examine the factors that contribute to the success of clinical networks and, more generally, is the largest study of clinical networks undertaken. The adaptation of expert panel methods to rate the impacts of networks is the methodological innovation of this study. The proposed project will identify the conditions that should be established or encouraged by agencies developing clinical networks and will be of immediate use in forming strategies and programs to maximise the effectiveness of such networks.

Psychological distress, health and treatment-related factors among individuals initiating ART in Oromia, Ethiopia.

PubMed

Parcesepe, Angela M; Tymejczyk, Olga; Remien, Robert; Gadisa, Tsigereda; Kulkarni, Sarah Gorrell; Hoffman, Susie; Melaku, Zenebe; Elul, Batya; Nash, Denis

2018-03-01

HIV diagnosis may be a source of psychological distress. Late initiation of antiretroviral therapy (ART) and treatment-related beliefs may intensify psychological distress among those recently diagnosed. This analysis describes the prevalence of psychological distress among people living with HIV (PLWH) and examines the association of recent HIV diagnosis, late ART initiation and treatment-related beliefs with psychological distress. The sample includes 1175 PLWH aged 18 or older initiating ART at six HIV clinics in Ethiopia. Psychological distress was assessed with Kessler Psychological Distress Scale. Scores ≥ 29 were categorized as severe psychological distress. Individuals who received their first HIV diagnosis in the past 90 days were categorized as recently diagnosed. Multivariable logistic regression modeled the association of recent diagnosis, late ART initiation and treatment-related beliefs on severe psychological distress, controlling for age, sex, education, area of residence, relationship status, and health facility. Among respondents, 29.5% reported severe psychological distress, 46.6% were recently diagnosed and 31.0% initiated ART late. In multivariable models, relative to those who did not initiate ART late and had longer time since diagnosis, odds of severe psychological distress was significantly greater among those with recent diagnosis and late ART initiation (adjusted OR [aOR]: 1.9 [95% CI 1.4, 2.8]). Treatment-related beliefs were not associated with severe psychological distress in multivariable models. Severe psychological distress was highly prevalent, particularly among those who were recently diagnosed and initiated ART late. Greater understanding of the relationship between psychological distress, recent diagnosis, and late ART initiation can inform interventions to reduce psychological distress among this population. Mental health screening and interventions should be incorporated into routine HIV clinical care from diagnosis through treatment.

Physicians' Religious Topic Avoidance during Clinical Interactions.

PubMed

Villagran, Melinda M; MacArthur, Brenda L; Lee, Lauren E; Ledford, Christy J W; Canzona, Mollie R

2017-05-08

Religious and spiritual (R/S) conversations at the end-of-life function to help patients and their families find comfort in difficult circumstances. Physicians who feel uncertain about how to discuss topics related to religious beliefs may seek to avoid R/S conversations with their patients. This study utilized a two-group objective structured clinical examination with a standardized patient to explore differences in physicians' use of R/S topic avoidance tactics during a clinical interaction. Results indicated that physicians used more topic avoidance tactics in response to patients' R/S inquiries than patients' R/S disclosures; however, the use of topic avoidance tactics did not eliminate the need to engage in patient-initiated R/S interactions.

Third-space fluid shift in elderly patients undergoing gastrointestinal surgery: Part 1: Pathophysiological mechanisms.

PubMed

Redden, Maurine; Wotton, Karen

2002-06-01

Third-space fluid shift, the movement of body fluid to a non-functional space, is a frequently occurring and potentially fatal clinical phenomenon. Little published research exists however in medical or nursing journals concerning its incidence, significance and ramifications in elderly patients undergoing major gastrointestinal surgery. This initial article, part I, explores fluid movement between fluid compartments and uses these principles to discuss the pathophysiology of the two distinct phases of third-space fluid shift. Part II will examine the criteria nurses could use in the clinical assessment of patients in both first and second phases third-space fluid shift and discuss the clinical reliability of these criteria.

Physicians’ Religious Topic Avoidance during Clinical Interactions

PubMed Central

Villagran, Melinda M.; MacArthur, Brenda L.; Lee, Lauren E.; Ledford, Christy J. W.; Canzona, Mollie R.

2017-01-01

Religious and spiritual (R/S) conversations at the end-of-life function to help patients and their families find comfort in difficult circumstances. Physicians who feel uncertain about how to discuss topics related to religious beliefs may seek to avoid R/S conversations with their patients. This study utilized a two-group objective structured clinical examination with a standardized patient to explore differences in physicians’ use of R/S topic avoidance tactics during a clinical interaction. Results indicated that physicians used more topic avoidance tactics in response to patients’ R/S inquiries than patients’ R/S disclosures; however, the use of topic avoidance tactics did not eliminate the need to engage in patient-initiated R/S interactions. PMID:28481290

Introducing universal ultrasound screening for developmental dysplasia of the hip doubled the treatment rate.

PubMed

Olsen, Stine F; Blom, Hans C; Rosendahl, Karen

2018-02-01

There is no evidence on the effect of universal ultrasound screening on developmental dysplasia of the hip. We examined the impact of adding an ultrasound examination to a one examiner clinical screening strategy on treatment, follow-up rates and the number of cases detected late in a low-prevalence population. All eligible babies born at Kongsberg Hospital, Norway, from 1998 to 2006 (n = 4245) underwent both clinical and ultrasound hip examinations within three days of life. Indications for immediate treatment were positive Barlow or Ortolani manoeuvres and, or, sonographic dysplasia. Sonographic immature hips were followed until normalisation. Treatment rates and rates from the 1989 to 1997 prestudy period (n = 3594), including late diagnoses, were collected from hospital records. Treatment was initiated in 90 (2.1%) infants (74 girls), 63 (70%) from birth, compared to 33 (0.9%) during the prestudy period. The follow-up rate did not change (11%). There were two (0.5/1000) and four (1.0/1000) cases detected late, respectively. No one underwent surgery during the first year of life and no avascular necrosis was seen. Adding universal ultrasound to clinical screening performed by the same, experienced paediatrician doubled the treatment rate, without influencing the already low numbers of late cases. ©2017 Foundation Acta Paediatrica. Published by John Wiley & Sons Ltd.

[Continuing importance of the clinical approach. Observations on a regional collaboration between general practitioners, internists and cardiologists].

PubMed

Jaussi, A

1994-11-12

The advent of high-tech diagnostic methods raises concerns nowadays about the value of the clinical approach and bedside diagnosis. This at least is the impression given by modern scientific literature, which rarely even mentions this part of examination of the patient. In order to define the actual role played by auscultation in the management of cardiological patients by the primary care physician, the records of 250 patients consecutively referred to a cardiologist are analyzed. The practitioner's initial clinical diagnosis is compared to the final cardiological diagnosis. Per referred patient, 1.76 specialized consultations were needed. In 64% of the cases only one such consultation took place. Initial diagnosis was correct in 80% of all cases, partly correct in 11% and incorrect in 9% of the cases. Out of the 64 cases of valvular diseases, 33 were initially correctly recognized by the physician. The cardiological investigation was also invasive in 6.5% of all cases, 4.5% of the patients eventually undergoing invasive or surgical treatment. Thus the great majority of the patients (93.5%) were managed by the primary physician with "first-line" cardiologist's support, which was often only occasional (only one specialized consultation in about two thirds of all cases). This highly independent and presumably cost-effective patient management by the primary care physician implies a high level of clinical skill. It stresses the outstanding importance of continuing teaching of the clinical approach and particularly of cardiac auscultation, which is still the best screening method for valvular heart disease.

Changing Provider Behavior in the Context of Chronic Disease Management: Focus on Clinical Inertia.

PubMed

Lavoie, Kim L; Rash, Joshua A; Campbell, Tavis S

2017-01-06

Widespread acceptance of evidence-based medicine has led to the proliferation of clinical practice guidelines as the primary mode of communicating current best practices across a range of chronic diseases. Despite overwhelming evidence supporting the benefits of their use, there is a long history of poor uptake by providers. Nonadherence to clinical practice guidelines is referred to as clinical inertia and represents provider failure to initiate or intensify treatment despite a clear indication to do so. Here we review evidence for the ubiquity of clinical inertia across a variety of chronic health conditions, as well as the organizational and system, patient, and provider factors that serve to maintain it. Limitations are highlighted in the emerging literature examining interventions to reduce clinical inertia. An evidence-based framework to address these limitations is proposed that uses behavior change theory and advocates for shared decision making and enhanced guideline development and dissemination.

The transition of a large-scale quality improvement initiative: a bibliometric analysis of the Productive Ward: Releasing Time to Care programme.

PubMed

White, Mark; Wells, John S G; Butterworth, Tony

2014-09-01

To examine the literature related to a large-scale quality improvement initiative, the 'Productive Ward: Releasing Time to Care', providing a bibliometric profile that tracks the level of interest and scale of roll-out and adoption, discussing the implications for sustainability. Productive Ward: Releasing Time to Care (aka Productive Ward) is probably one of the most ambitious quality improvement efforts engaged by the UK-NHS. Politically and financially supported, its main driver was the NHS Institute for Innovation and Improvement. The NHS institute closed in early 2013 leaving a void of resources, knowledge and expertise. UK roll-out of the initiative is well established and has arguably peaked. International interest in the initiative however continues to develop. A comprehensive literature review was undertaken to identify the literature related to the Productive Ward and its implementation (January 2006-June 2013). A bibliometric analysis examined/reviewed the trends and identified/measured interest, spread and uptake. Overall distribution patterns identify a declining trend of interest, with reduced numbers of grey literature and evaluation publications. However, detailed examination of the data shows no reduction in peer-reviewed outputs. There is some evidence that international uptake of the initiative continues to generate publications and create interest. Sustaining this initiative in the UK will require re-energising, a new focus and financing. The transition period created by the closure of its creator may well contribute to further reduced levels of interest and publication outputs in the UK. However, international implementation, evaluation and associated publications could serve to attract professional/academic interest in this well-established, positively reported, quality improvement initiative. This paper provides nurses and ward teams involved in quality improvement programmes with a detailed, current-state, examination and analysis of the Productive Ward literature, highlighting the bibliometric patterns of this large-scale, international, quality improvement programme. It serves to disseminate updated publication information to those in clinical practice who are involved in Productive Ward or a similar quality improvement initiative. © 2014 John Wiley & Sons Ltd.

Risk factors contributing to a poor prognosis of papillary thyroid carcinoma: validity of UICC/AJCC TNM classification and stage grouping.

PubMed

Ito, Yasuhiro; Miyauchi, Akira; Jikuzono, Tomoo; Higashiyama, Takuya; Takamura, Yuuki; Miya, Akihiro; Kobayashi, Kaoru; Matsuzuka, Fumio; Ichihara, Kiyoshi; Kuma, Kanji

2007-04-01

In 2002, the UICC/AJCC TNM classification for papillary thyroid carcinoma was revised. In this study, we examined the validity of this classification system by investigating the predictors of disease-free survival (DFS) and cause-specific survival (CSS) in patients. We examined various clinicopathological features, including the component of the TNM classification, for 1,740 patients who underwent initial and curative surgery for papillary carcinoma between 1987 and 1995. Clinical and pathological T4a, clinical N1b in the TNM classification, and patient age were recognized as independent predictors of not only DFS, but also CSS of patients. Tumor size, male gender, and central node metastasis independently affected DFS only. There were 1,005 pathological N1b patients, but pathological N1b did not independently affect either DFS or CSS. Regarding the stage grouping, clinical stage IVA including clinical N1b more clearly affected DFS and CSS than pathological stage IVA including pathological N1b. Clinical stage grouping was more useful than pathological stage grouping for predicting the prognosis of papillary carcinoma patients possibly because pathological stage overestimates the biological characteristics of many pathological N1b tumors.

Unilateral Laryngoscopic Findings Associated With Response to Gabapentin in Patients With Chronic Cough.

PubMed

Giliberto, John Paul; Dibildox, Daniel; Merati, Albert

2017-11-01

Chronic cough is a debilitating, often multifactorial problem. Vagal neuropathy has been proposed as a cause for a fraction of these cases. There are certain features that support the clinical diagnosis of vagal neuropathy. It is hypothesized that patients with neurogenic cough who have vocal fold motion asymmetry (VFMA) on laryngoscopy will be more likely to respond to gabapentin. To evaluate the association between the history, physical and videostroboscopic examinations, and clinical response to gabapentin. In a retrospective cohort study, patients with chronic cough visiting an academic tertiary laryngology clinic from January 1, 2013, to September 1, 2015, were identified through International Classification of Diseases, Ninth Revision. Of those who had a chronic cough (>8 weeks), 27 patients who received a prescription for gabapentin were included. Patients without videostroboscopy, who did not complete voice therapy, or those without a follow-up examination more than 1 month from the initial evaluation were excluded. Initial history, physical and videostroboscopic examinations, and follow-up evaluations, were performed in a multidisciplinary laryngology clinic including a speech-language pathologist. Documented VFMA by a multidisciplinary team was decided by consensus after review of videostroboscopy recording at the time of the visit. Response to gabapentin was defined by physician-documented subjective patient report of improvement in cough symptoms. Follow-up data were available on 25 of the 27 patients (15 [60%] women; mean [SD] age, 57 [11.8] years). Therapy was initiated in patients with chronic cough with gabapentin, 100 mg twice daily, which was titrated to response or adverse effects. The maximum daily dose was 1800 mg. Partial or complete response to gabapentin was noted in 16 (64%) patients. Vocal fold motion asymmetry was noted in 20 (80%) patients. Fifteen of 16 (94%) responders had VFMA compared with 5 of 9 (56%) nonresponders. The difference in the frequency of VFMA between responders and nonresponders was 38% (95% CI, 18%-58%). Adverse effects limited the gabapentin dose in 4 of 9 (44%) nonresponders and 4 of 16 (25%) responders (odds ratio, 2.5; 95% CI, 0.42-13.6). In patients with chronic cough suspected to be related to vagal neuropathy, the odds of response to gabapentin are higher with the presence of VFMA noted on videostroboscopy.

Clinical appearances, healing patterns, risk factors, and outcomes of horses with fungal keratitis: 53 cases (1978-1996)

PubMed

Gaarder, J E; Rebhun, W C; Ball, M A; Patten, V; Shin, S; Erb, H

1998-07-01

To compare initial clinical appearances, healing mechanisms, risk factors, and outcomes of horses with fungal keratitis. Retrospective analysis. 52 horses (53 eyes) with fungal keratitis. Medical records and clinical photographs of eyes were reviewed. Keratomycoses were categorized on the basis of clinical appearance at initial examination and pattern of healing. Five distinct forms of mycotic keratitis were recognized. Of 53 affected eyes, 34 (64%) retained sight and had varying degrees of corneal scarring after treatment, 6 (11%) had a cosmetic appearance but were blind, and 13 (25%) were enucleated. Bacterial-like ulcers were the most frequent type and the most difficult for predicting outcome. Eyes affected by superficial fungal keratitis were likely to be chronically infected and to require debridement and extended treatment but usually healed with minimal scarring. Keratomycosis with a surrounding furrow resulted in a grave prognosis. Aspergillus organisms were isolated from 9 of 10 such eyes. Cake-frosting material was a positive prognostic sign. Fungal corneal stromal abscesses tended to be caused by yeast. This information will aid practitioners in recognizing various forms of fungal keratitis and guide them when making therapeutic decisions and prognoses for affected horses.

Wells syndrome and its relationship to Churg-Strauss syndrome.

PubMed

Ratzinger, Gudrun; Zankl, Julia; Zelger, Bernhard

2013-08-01

  Wells syndrome has been described as an inflammatory disorder based on typical clinical appearance combined with the histopathological presence of eosinophilic infiltrates and flame figures in the absence of vasculitis. Churg-Strauss syndrome, on the other hand, is primarily a diffuse, necrotizing vasculitis but is also typically displaying eosinophils and flame figures. Despite several parallels, the present understanding of these two diseases excludes any pathogenetic relationship.   We describe the clinical course and histopathological appearance of three patients who had initially been diagnosed with Wells syndrome that developed into Churg-Strauss syndrome during the course of their disease.   The clinical presentation of all three patients led to the diagnosis of Wells syndrome by independent specialists. Histopathology showed an eosinophilic infiltrate and flame figures next to features of leukocytoclastic vasculitis. Detailed examination revealed asthma bronchiale and additional symptoms indicating Churg-Strauss syndrome. The initial diagnosis of Wells syndrome had to be revised to Churg-Strauss syndrome.   We conclude that Wells syndrome could be the starting point of a pathogenetic process that might reach its maximum in Churg-Strauss syndrome. As a clinical consequence, patients with Wells syndrome should be evaluated and followed for Churg-Strauss syndrome. © 2013 The International Society of Dermatology.

Exome sequencing for the differential diagnosis of ciliary chondrodysplasias: Example of a WDR35 mutation case and review of the literature.

PubMed

Antony, Dinu; Nampoory, Narayanan; Bacchelli, Chiara; Melhem, Motasem; Wu, Kaman; James, Chela T; Beales, Philip L; Hubank, Mike; Thomas, Daisy; Mashankar, Anant; Behbehani, Kazem; Schmidts, Miriam; Alsmadi, Osama

2017-12-01

Exome sequencing is becoming widely popular and affordable, making it one of the most desirable methods for the identification of rare genetic variants for clinical diagnosis. Here, we report the clinical application of whole exome sequencing for the ultimate diagnosis of a ciliary chondrodysplasia case presented with an initial clinical diagnosis of Asphyxiating Thoracic Dystrophy (ATD, Jeune Syndrome). We have identified a novel homozygous missense mutation in WDR35 (c.206G > A), a gene previously associated with Sensenbrenner Syndrome, Ellis-van Creveld syndrome and Short-rib polydactyly syndrome type V. The genetic findings in this family led to the re-evaluation of the initial diagnosis and a differential diagnosis of Sensenbrenner Syndrome was made after cautious re-examination of the patient. Cell culture studies revealed normal subcellular localization of the mutant WDR35 protein in comparison to wildtype protein, pointing towards impaired protein-protein interaction and/or altered cell signaling pathways as a consequence of the mutated allele. This research study highlights the importance of including pathogenic variant identification in the diagnosis pipeline of ciliary chondrodysplasias, especially for clinically not fully defined phenotypes. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Initiating a Human Variome Project Country Node.

PubMed

AlAama, Jumana; Smith, Timothy D; Lo, Alan; Howard, Heather; Kline, Alexandria A; Lange, Matthew; Kaput, Jim; Cotton, Richard G H

2011-05-01

Genetic diseases are a pressing global health problem that requires comprehensive access to basic clinical and genetic data to counter. The creation of regional and international databases that can be easily accessed by clinicians and diagnostic labs will greatly improve our ability to accurately diagnose and treat patients with genetic disorders. The Human Variome Project is currently working in conjunction with human genetics societies to achieve this by establishing systems to collect every mutation reported by a diagnostic laboratory, clinic, or research laboratory in a country and store these within a national repository, or HVP Country Node. Nodes have already been initiated in Australia, Belgium, China, Egypt, Malaysia, and Kuwait. Each is examining how to systematically collect and share genetic, clinical, and biochemical information in a country-specific manner that is sensitive to local ethical and cultural issues. This article gathers cases of genetic data collection within countries and takes recommendations from the global community to develop a procedure for countries wishing to establish their own collection system as part of the Human Variome Project. We hope this may lead to standard practices to facilitate global collection of data and allow efficient use in clinical practice, research and therapy. © 2011 Wiley-Liss, Inc.

Potential nonresponse bias in a clinical examination after initial screening using iron phenotyping and HFE genotyping in the hemochromatosis and iron overload screening study.

PubMed

Speechley, Mark; Barton, James C; Passmore, Leah; Harrison, Helen; Reboussin, David M; Harris, Emily L; Rivers, Charles A; Fadojutimi-Akinsiku, Margaret; Wenzel, Lari; Diaz, Sharmin

2009-12-01

Little is known about the factors affecting participation in clinical assessments after HEmochromatosis and IRon Overload Screening. Initial screening of 101,168 primary care patients in the HEmochromatosis and IRon Overload Screening study was performed using serum iron measures and hemochromatosis gene (HFE) genotyping. Using iron phenotypes and HFE genotypes, we identified 2256 cases and 1232 controls eligible to participate in a clinical examination. To assess the potential for nonresponse bias, we compared the sociodemographic, health status, and attitudinal characteristics of participants and nonparticipants using adjusted odds ratios (ORs) and 95% confidence interval (CI). Overall participation was 74% in cases and 52% in controls; in both groups, participation was highest at a health maintenance organization and lowest among those under 45 years of age (cases: OR = 0.68; 95% CI 0.53, 0.87; controls: OR = 0.59; 95% CI 0.44, 0.78). In controls only, participation was also lower among those over 65 years of age than the reference group aged 46-64 (OR = 0.64; 95% CI 0.47, 0.88). Among cases, participation was higher in HFE C282Y homozygotes (OR = 3.98; 95% CI 2.60, 6.09), H63D homozygotes (OR = 2.79; 95% CI 1.23, 6.32), and C282Y/H63D compound heterozygotes (OR = 1.82; 95% CI 1.03, 3.22) than in other genotypes, and lower among non-Caucasians and those who preferred a non-English language than in Caucasians and those who preferred English (p < 0.0001). Subjects with greatest risk to have iron overload (C282Y homozygotes; cases > or =45 years; Caucasians) were more likely to participate in a postscreening clinical examination than other subjects. We detected no evidence of strong selection bias.

Translating research into practice: the role of provider-based research networks in the diffusion of an evidence-based colon cancer treatment innovation.

PubMed

Carpenter, William R; Meyer, Anne-Marie; Wu, Yang; Qaqish, Bahjat; Sanoff, Hanna K; Goldberg, Richard M; Weiner, Bryan J

2012-08-01

Provider-based research networks (PBRNs)--collaborative research partnerships between academic centers and community-based practitioners--are a promising model for accelerating the translation of research into practice; however, empirical evidence of accelerated translation is limited. Oxaliplatin in adjuvant combination chemotherapy is an innovation with clinical trial-proven survival benefit compared with prior therapies. The goal of this study is to examine the diffusion of oxaliplatin into community practice, and whether affiliation with the National Cancer Institute's (NCI's) Community Clinical Oncology Program (CCOP)--a nationwide cancer-focused PBRN--is associated with accelerated innovation adoption. This retrospective observational study used linked Surveillance, Epidemiology, and End Results-Medicare and NCI CCOP data to examine Medicare participants with stage III colon cancer initiating treatment in 2003 through 2006, the years surrounding oxaliplatin's Food and Drug Administration approval. A fixed-effects analysis examined chemotherapy use among patients treated outside academic centers at CCOP-affiliated practices compared with non-CCOP practices. Two-group modeling controlled for multiple levels of clustering, year of chemotherapy initiation, tumor characteristics, patient age, race, comorbidity, Medicaid dual-eligibility status, and education. Of 4055 community patients, 35% received 5-fluoruracil, 20% received oxaliplatin, 7% received another chemotherapy, and 38% received no chemotherapy. Twenty-five percent of CCOP patients received oxaliplatin, compared with 19% of non-CCOP patients. In multivariable analysis, CCOP exposure was associated with higher odds of receiving guideline-concordant treatment in general, and oxaliplatin specifically. These findings contribute to a growing set of evidence linking PBRNs with a greater probability of receiving treatment innovations and high-quality cancer care, with implications for clinical and research policy.

The initial electrocardiogram during admission for myocardial infarction. Use as a predictor of clinical course and facility utilization.

PubMed

Stark, M E; Vacek, J L

1987-05-01

The first electrocardiogram obtained on presentation for suspected myocardial infarction was examined for its usefulness in predicting clinical course and facility use. We studied 221 patients consecutively admitted to a nonuniversity hospital coronary care unit. High-risk patients were identified if the electrocardiographic diagnoses included myocardial infarction, ischemia, left ventricular hypertrophy, left bundle-branch block, or paced rhythm. These 63 patients (29% of total) had significantly greater incidences of serious events, need for procedures, and death than low-risk patients whose initial electrocardiograms did not carry the above diagnoses. Patients with a low-risk initial electrocardiogram may not require the facilities of a coronary care unit and perhaps could be safely observed in an intermediate care area. However, many hospitals do not have an intermediate care facility available, and in those that do, daily costs may not be markedly different than for treatment in a coronary care unit. Whether these low-risk patients could be safely treated in general medicine beds, where potential cost savings would be much greater, is unknown.

Corticobasal degeneration initially developing motor versus non-motor symptoms: a comparative clinicopathological study.

PubMed

Ikeda, Chikako; Yokota, Osamu; Nagao, Shigeto; Ishizu, Hideki; Morisada, Yumi; Terada, Seishi; Nakashima, Yoshihiko; Akiyama, Haruhiko; Uchitomi, Yosuke

2014-09-01

Clinical presentations of pathologically confirmed corticobasal degeneration (CBD) vary, and the heterogeneity makes its clinical diagnosis difficult, especially when a patient lacks any motor disturbance in the early stage. We compared clinical and pathological features of four pathologically confirmed CBD cases that initially developed non-motor symptoms, including behavioural and psychiatric symptoms but without motor disturbance (CBD-NM), and five CBD cases that initially developed parkinsonism and/or falls (CBD-M). The age range at death for the CBD-NM and CBD-M subjects (58-85 years vs 45-67 years) and the range of disease duration (2-18 years vs 2-6 years) did not significantly differ between the groups. Prominent symptoms in the early stage of CBD-NM cases included self-centred behaviours such as frontotemporal dementia (n = 1), apathy with and without auditory hallucination (n = 2), and aggressive behaviours with delusion and visual hallucination (n = 1). Among the four CBD-NM cases, only one developed asymmetric motor disturbance, and two could walk without support throughout the course. Final clinical diagnoses of the CBD-NM cases were frontotemporal dementia (n = 2), senile psychosis with delirium (n = 1), and schizophrenia (n = 1). Neuronal loss was significantly less severe in the subthalamic nucleus and substantia nigra in the CBD-NM cases than in the CBD-M cases. The severity of tau pathology in all regions examined was comparable in the two groups. CBD cases that initially develop psychiatric and behavioural changes without motor symptoms may have less severe degenerative changes in the subthalamic nucleus and substantia nigra, and some CBD cases can lack motor disturbance not only in the early stage but also in the last stage of the course. © 2014 The Authors. Psychogeriatrics © 2014 Japanese Psychogeriatric Society.

Talking about sex in the gender identity clinic: implications for training and practice.

PubMed

Speer, Susan A

2013-11-01

This article provides the first systematic examination of the ways 'talk about sex' is occasioned and managed by doctors and patients in real-life interactions in a National Health Service Gender Identity Clinic. Drawing on a corpus of 194 recordings of psychiatric assessment sessions, the article examines how parties initiate and develop talk about sex, and which strategies appear to work best for doctor-patient alignment. The analyses revealed that the most aligning methods were for clinicians to make transitions from asking questions about relationships in general to talk about sex, or to build opportunistically on patients' relationship talk. However, talk about sex that lacked specificity or which made inaccurate presumptions about patients' sex lives, generated misalignment between clinician and patient. I suggest that such misalignment is not intrinsically bad. Rather, it provides evidence for the virtues of a more nuanced understanding of patient-centred communication. The article concludes with a discussion of the importance of grounding communication skills training and clinical practice in recordings of actual consultations.

A Business Case for Tele-Intensive Care Units

PubMed Central

Coustasse, Alberto; Deslich, Stacie; Bailey, Deanna; Hairston, Alesia; Paul, David

2014-01-01

Objectives: A tele-intensive care unit (tele-ICU) uses telemedicine in an intensive care unit (ICU) setting, applying technology to provide care to critically ill patients by off-site clinical resources. The purpose of this review was to examine the implementation, adoption, and utilization of tele-ICU systems by hospitals to determine their efficiency and efficacy as identified by cost savings and patient outcomes. Methods: This literature review examined a large number of studies of implementation of tele-ICU systems in hospitals. Results: The evidence supporting cost savings was mixed. Implementation of a tele-ICU system was associated with cost savings, shorter lengths of stay, and decreased mortality. However, two studies suggested increased hospital cost after implementation of tele-ICUs is initially expensive but eventually results in cost savings and better clinical outcomes. Conclusions: Intensivists working these systems are able to more effectively treat ICU patients, providing better clinical outcomes for patients at lower costs compared with hospitals without a tele-ICU. PMID:25662529

Parameters for measurement of oxidative stress in diabetes mellitus: applicability of enzyme-linked immunosorbent assay for clinical evaluation.

PubMed

Noiri, Eisei; Tsukahara, Hirokazu

2005-05-01

Investigations of the mechanisms involved in the onset and progression of diabetes have recently confronted the role of reactive oxygen species (ROS) and oxidative stress. Prolonged exposure to hyperglycemic conditions induces nonenzymatic glycation of protein via the so-called Maillard reaction, resulting in Schiff-base products and Amadori products that engender ROS production. These processes initiate and exacerbate micro- and macrovascular complications in diabetes. Increased oxidative stress is induced by excessive ROS production and inadequate antioxidant defenses. Recently, oxidative stress status markers have been associated directly with the severity and prognosis of diabetes. To examine oxidative stress, reliable and high-throughput methods are needed to examine large numbers of clinical samples. The emerging availability of enzyme-linked immunosorbent assay (ELISA) for oxidative stress status markers allows its application to assessment of various pathophysiologic conditions, including diabetes. This review outlines the recent achievements of ELISA application for clinical studies elucidating oxidative stress. It introduces the potential applicability of ELISA for investigating oxidative stress in diabetes.

DIFFERENTIAL DIAGNOSTIC PROCESS AND CLINICAL DECISION MAKING IN A YOUNG ADULT FEMALE WITH LATERAL HIP PAIN: A CASE REPORT.

PubMed

Livingston, Jennifer I; Deprey, Sara M; Hensley, Craig P

2015-10-01

differential diagnosis and clinical decision making. Young adults with lateral hip pain are often referred to physical therapy (PT). A thorough examination is required to obtain a diagnosis and guide management. The purpose of this case report is to describe the physical therapist's differential diagnostic process and clinical decision making for a subject with the referring diagnosis of trochanteric bursitis. A 29-year-old female presented to PT with limited sitting and running tolerance secondary to right lateral hip pain. Her symptoms began three months prior when she abruptly changed her running intensity and frequency of weight bearing activities, including running and low impact plyometrics for the lower extremity. Physical examination revealed a positive Trendelenburg sign, manual muscle test that was weak and painless of the right hip abductors, and pain elicited when performing a vertical hop on a concrete surface (+single leg hop test), but pain-free when performing the same single leg hop on a foam surface. Examination findings warranted discussion with the referring physician for further diagnostic imaging. Magnetic resonance imaging revealed a focus of edema in the posterior acetabulum, suspicious for an acetabular stress fracture. The subject was subsequently diagnosed with an acetabular stress fracture and restricted from running and plyometrics for four weeks. Thorough examination and appropriate clinical decision making by the physical therapist at the initial examination led to the diagnosis of an acetabular stress fracture in this subject. Clinicians must be aware of symptoms and signs which place the subject at risk for stress fracture for timely referral and management. 4.

A decade of the Clinical Trials Transformation Initiative: What have we accomplished? What have we learned?

PubMed

Tenaerts, P; Madre, L; Landray, M

2018-02-01

The Clinical Trials Transformation Initiative reflects on 10 years of working to improve the quality and efficiency of clinical trials. This article highlights many of the Clinical Trials Transformation Initiative's accomplishments and offers examples of the impact that the Clinical Trials Transformation Initiative has had on the clinical trials enterprise. After conducting more than 25 projects and issuing recommendations for specific strategies to improve the design and execution of clinical trials, some common themes and lessons learned have emerged. Lessons include the importance of engaging many stakeholders, advanced planning to address critical issues, discontinuation of non-value added practices, and new opportunities presented by technology. Through its work, the Clinical Trials Transformation Initiative has also derived some operational best practices for conducting collaborative, multi-stakeholder projects covering project selection, project team dynamics and execution, and multi-stakeholder meetings and team discussions. Through these initiatives, the Clinical Trials Transformation Initiative has helped move the needle toward needed change in the clinical trials enterprise that has directly impacted stakeholders and patients alike.

Effect of the dedicated education unit on nursing student self-efficacy: A quasi-experimental research study.

PubMed

George, Lynn E; Locasto, Lisa W; Pyo, Katrina A; W Cline, Thomas

2017-03-01

Although the Dedicated Education Unit (DEU) has shown initial promise related to satisfaction with the teaching/learning environment, few studies have examined student outcomes related to the use of the DEU as a clinical education model beyond student satisfaction. The purpose of this quantitative, quasi-experimental study was to compare student outcomes from the traditional clinical education (TCE) model with those from the DEU model. Participants were students enrolled in a four-year baccalaureate program in nursing (n = 193) who had clinical education activities in one of three clinical agencies. Participants were assigned to either the DEU or a TCE model. Pre-clinical and post-clinical self-efficacy scores were measured for each group using an adapted Generalized Self-Efficacy Scale (Schwarzer and Jerusalem, 1995). Both groups experienced a significant increase in self-efficacy scores post clinical education. The increase in self-efficacy for the DEU students was significantly greater than the increase in self-efficacy for the traditional students. Self-efficacy is considered an important outcome of nursing education because high self-efficacy has been linked to making an easier transition from student to nursing professional. This study supports the quality of the DEU as a clinical education model by examining student self-efficacy outcomes. Copyright © 2017 Elsevier Ltd. All rights reserved.

Prevalence and predictors of chlamydia co-infection among patients infected with gonorrhoea at a sexual health clinic in Sydney.

PubMed

Templeton, David J; Manokaran, Niveditha; O'Connor, Catherine C

2012-09-01

Anogenital gonorrhoea (Neisseria gonorrhoeae) is commonly diagnosed at sexual health clinics by on-site microscopy. Whether to add anti-chlamydial therapy in such situations is unclear. The medical records of all patients diagnosed with gonorrhoea between May 2005 and April 2010 at RPA Sexual Health were reviewed. Of 165 patients diagnosed with anogenital gonorrhoea, 27 (16.4%, 95% confidence interval (CI) 11.1-22.9%) were co-infected with chlamydia (Chlamydia trachomatis). Compared with those only infected with anogenital gonorrhoea, there was no correlation of anogenital gonorrhoea-chlamydia co-infection with any demographic, behavioural or clinical variables examined. Anti-chlamydial therapy should be considered for all patients with gram stain diagnosed anogenital gonorrhoea at the initial clinic visit.

A Tiered Approach to Retinopathy of Prematurity Screening (TARP) Using a Weight Gain Predictive Model and a Telemedicine System.

PubMed

Gurwin, Jaclyn; Tomlinson, Lauren A; Quinn, Graham E; Ying, Gui-Shuang; Baumritter, Agnieshka; Binenbaum, Gil

2017-01-05

The Telemedicine Approaches to Evaluating Acute-Phase Retinopathy of Prematurity (e-ROP) Study telemedicine system of remote fundus image grading and The Children's Hospital of Philadelphia Retinopathy of Prematurity (CHOP-ROP) postnatal weight gain predictive model are 2 approaches for improving ROP screening efficiency. Current screening has low specificity for severe ROP. To describe a tiered approach to ROP screening (TARP) for identifying children who develop severe ROP using telemedicine and a predictive model synergistically. This investigation was a post hoc analysis of a cohort in the e-ROP Study (a multicenter prospective telemedicine study) and the Postnatal Growth and Retinopathy of Prematurity (G-ROP) Study (a multicenter retrospective cohort study). The setting was neonatal intensive care units at The Children's Hospital of Philadelphia and the Hospital of the University of Pennsylvania. Participants in the e-ROP Study were premature infants with a birth weight less than 1251 g and a known ROP outcome enrolled between May 25, 2011, and October 31, 2013. The G-ROP Study enrolled all infants undergoing ROP examinations with a known ROP outcome who were born between January 1, 2006, and December 31, 2011. The mean outcomes were the sensitivity for type 1 ROP, reductions in infants requiring imaging or examinations, numbers of imaging sessions and examinations, and total clinical encounters (imaging sessions and examinations combined). The following 4 screening approaches were evaluated: ROUTINE (only diagnostic examinations by an ophthalmologist), CHOP-ROP (birth weight and gestational age, with weekly weight gain initiating examinations when the risk cut point is surpassed), e-ROP IMAGING (trained reader grading of type 1 or 2 ROP initiates diagnostic examinations), and TARP (CHOP-ROP alarm initiates imaging, and imaging finding of severe ROP initiates diagnostic examinations). A total of 242 infants were included in the study, with a median birth weight of 858 g (range, 690-1035 g). The median gestational age was 27 weeks (range, 25-29 weeks). Fifty-one percent (124 of 242) were female, and 49% (118 of 242) were male. The race/ethnicity was 27.3% (66 of 242) white, 56.2% (136 of 242) black, 2.1% (5 of 242) Native American, 1.7% (4 of 242) Asian, and 12.8% (31 of 242) other. The sensitivity for detecting type 1 ROP (32 infants) was 100% (95% CI, 89.3%-100%) with each approach. With ROUTINE, 242 infants had 877 examinations; with CHOP-ROP, 184 infants had 730 examinations; with e-ROP IMAGING, 242 infants had 532 imaging sessions, and 94 infants had 345 examinations (877 patient encounters); and with TARP, 182 infants had 412 imaging sessions, and 87 infants had 322 examinations (734 patient encounters). The tiered approach to ROP screening was associated with a reduced number of examinations and imaging sessions compared with the other approaches. Applying a postnatal growth model and telemedicine system in a tiered approach may reduce the number of clinical ROP interventions more than either approach alone.

Landscape of Innovation for Cardiovascular Pharmaceuticals: From Basic Science to New Molecular Entities.

PubMed

Beierlein, Jennifer M; McNamee, Laura M; Walsh, Michael J; Kaitin, Kenneth I; DiMasi, Joseph A; Ledley, Fred D

2017-07-01

This study examines the complete timelines of translational science for new cardiovascular therapeutics from the initiation of basic research leading to identification of new drug targets through clinical development and US Food and Drug Administration (FDA) approval of new molecular entities (NMEs) based on this research. This work extends previous studies by examining the association between the growth of research on drug targets and approval of NMEs associated with these targets. Drawing on research on innovation in other technology sectors, where technological maturity is an important determinant in the success or failure of new product development, an analytical model was used to characterize the growth of research related to the known targets for all 168 approved cardiovascular therapeutics. Categorizing and mapping the technological maturity of cardiovascular therapeutics reveal that (1) there has been a distinct transition from phenotypic to targeted methods for drug discovery, (2) the durations of clinical and regulatory processes were significantly influenced by changes in FDA practice, and (3) the longest phase of the translational process was the time required for technology to advance from initiation of research to a statistically defined established point of technology maturation (mean, 30.8 years). This work reveals a normative association between metrics of research maturation and approval of new cardiovascular therapeutics and suggests strategies for advancing translational science by accelerating basic and applied research and improving the synchrony between the maturation of this research and drug development initiatives. Copyright © 2017 Elsevier HS Journals, Inc. All rights reserved.

Cost-effectiveness of Competing Strategies for Management of Recurrent Clostridium difficile Infection: A Decision Analysis

PubMed Central

Konijeti, Gauree G.; Sauk, Jenny; Shrime, Mark G.; Gupta, Meera; Ananthakrishnan, Ashwin N.

2014-01-01

Background. Clostridium difficile infection (CDI) is an important cause of morbidity and healthcare costs, and is characterized by high rates of disease recurrence. The cost-effectiveness of newer treatments for recurrent CDI has not been examined, yet would be important to inform clinical practice. The aim of this study was to analyze the cost effectiveness of competing strategies for recurrent CDI. Methods. We constructed a decision-analytic model comparing 4 treatment strategies for first-line treatment of recurrent CDI in a population with a median age of 65 years: metronidazole, vancomycin, fidaxomicin, and fecal microbiota transplant (FMT). We modeled up to 2 additional recurrences following the initial recurrence. We assumed FMT delivery via colonoscopy as our base case, but conducted sensitivity analyses based on different modes of delivery. Willingness-to-pay threshold was set at $50 000 per quality-adjusted life-year. Results. At our base case estimates, initial treatment of recurrent CDI using FMT colonoscopy was the most cost-effective strategy, with an incremental cost-effectiveness ratio of $17 016 relative to oral vancomycin. Fidaxomicin and metronidazole were both dominated by FMT colonoscopy. On sensitivity analysis, FMT colonoscopy remained the most cost-effective strategy at cure rates >88.4% and CDI recurrence rates <14.9%. Fidaxomicin required a cost <$1359 to meet our cost-effectiveness threshold. In clinical settings where FMT is not available or applicable, the preferred strategy appears to be initial treatment with oral vancomycin. Conclusions. In this decision analysis examining treatment strategies for recurrent CDI, we demonstrate that FMT colonoscopy is the most cost-effective initial strategy for management of recurrent CDI. PMID:24692533

Situational awareness within objective structured clinical examination stations in undergraduate medical training - a literature search.

PubMed

Fischer, Markus A; Kennedy, Kieran M; Durning, Steven; Schijven, Marlies P; Ker, Jean; O'Connor, Paul; Doherty, Eva; Kropmans, Thomas J B

2017-12-21

Medical students may not be able to identify the essential elements of situational awareness (SA) necessary for clinical reasoning. Recent studies suggest that students have little insight into cognitive processing and SA in clinical scenarios. Objective Structured Clinical Examinations (OSCEs) could be used to assess certain elements of situational awareness. The purpose of this paper is to review the literature with a view to identifying whether levels of SA based on Endsley's model can be assessed utilising OSCEs during undergraduate medical training. A systematic search was performed pertaining to SA and OSCEs, to identify studies published between January 1975 (first paper describing an OSCE) and February 2017, in peer reviewed international journals published in English. PUBMED, EMBASE, PsycINFO Ovid and SCOPUS were searched for papers that described the assessment of SA using OSCEs among undergraduate medical students. Key search terms included "objective structured clinical examination", "objective structured clinical assessment" or "OSCE" and "non-technical skills", "sense-making", "clinical reasoning", "perception", "comprehension", "projection", "situation awareness", "situational awareness" and "situation assessment". Boolean operators (AND, OR) were used as conjunctions to narrow the search strategy, resulting in the limitation of papers relevant to the research interest. Areas of interest were elements of SA that can be assessed by these examinations. The initial search of the literature retrieved 1127 publications. Upon removal of duplicates and papers relating to nursing, paramedical disciplines, pharmacy and veterinary education by title, abstract or full text, 11 articles were eligible for inclusion as related to the assessment of elements of SA in undergraduate medical students. Review of the literature suggests that whole-task OSCEs enable the evaluation of SA associated with clinical reasoning skills. If they address the levels of SA, these OSCEs can provide supportive feedback and strengthen educational measures associated with higher diagnostic accuracy and reasoning abilities. Based on the findings, the early exposure of medical students to SA is recommended, utilising OSCEs to evaluate and facilitate SA in dynamic environments.

Improving Primary Care Provider Practices in Youth Concussion Management.

PubMed

Arbogast, Kristy B; Curry, Allison E; Metzger, Kristina B; Kessler, Ronni S; Bell, Jeneita M; Haarbauer-Krupa, Juliet; Zonfrillo, Mark R; Breiding, Matthew J; Master, Christina L

2017-08-01

Primary care providers are increasingly providing youth concussion care but report insufficient time and training, limiting adoption of best practices. We implemented a primary care-based intervention including an electronic health record-based clinical decision support tool ("SmartSet") and in-person training. We evaluated consequent improvement in 2 key concussion management practices: (1) performance of a vestibular oculomotor examination and (2) discussion of return-to-learn/return-to-play (RTL/RTP) guidelines. Data were included from 7284 primary care patients aged 0 to 17 years with initial concussion visits between July 2010 and June 2014. We compared proportions of visits pre- and post-intervention in which the examination was performed or RTL/RTP guidelines provided. Examinations and RTL/RTP were documented for 1.8% and 19.0% of visits pre-intervention, respectively, compared with 71.1% and 72.9% post-intervention. A total of 95% of post-intervention examinations were documented within the SmartSet. An electronic clinical decision support tool, plus in-person training, may be key to changing primary care provider behavior around concussion care.

Diagnosis of brain death by transcranial Doppler sonography.

PubMed

Bode, H; Sauer, M; Pringsheim, W

1988-12-01

The blood flow velocities in the basal cerebral arteries can be recorded at any age by transcranial Doppler sonography. We examined nine children with either initial or developing clinical signs of brain death. Soon after successful resuscitation increased diastolic flow velocities indicated a probable decrease in cerebrovascular resistance; this was of no particular prognostic importance. As soon as there was a clinical deterioration, there was a reduction in flow velocities with retrograde flow during early diastole, probably due to an increase in cerebrovascular resistance; this indicated a doubtful prognosis. In eight of the nine children with clinical signs of brain death a typical reverberating flow pattern was found, which was characterised by a counterbalancing short forward flow in systole and a short retrograde flow in early diastole. This indicated arrest of cerebral blood flow. One newborn showed normal systolic and end diastolic flow velocities in the basal cerebral arteries for two days despite clinical and electroencephalographic signs of brain death. Shunting of blood through the circle of Willis without effective cerebral perfusion may explain this phenomenon. No patient had the typical reverberating flow pattern without being clinically brain dead. Transcranial Doppler sonography is a reliable technique, which can be used at the bedside for the confirmation or the exclusion of brain death in children in addition to the clinical examination.

Diagnosis of brain death by transcranial Doppler sonography.

PubMed Central

Bode, H; Sauer, M; Pringsheim, W

1988-01-01

The blood flow velocities in the basal cerebral arteries can be recorded at any age by transcranial Doppler sonography. We examined nine children with either initial or developing clinical signs of brain death. Soon after successful resuscitation increased diastolic flow velocities indicated a probable decrease in cerebrovascular resistance; this was of no particular prognostic importance. As soon as there was a clinical deterioration, there was a reduction in flow velocities with retrograde flow during early diastole, probably due to an increase in cerebrovascular resistance; this indicated a doubtful prognosis. In eight of the nine children with clinical signs of brain death a typical reverberating flow pattern was found, which was characterised by a counterbalancing short forward flow in systole and a short retrograde flow in early diastole. This indicated arrest of cerebral blood flow. One newborn showed normal systolic and end diastolic flow velocities in the basal cerebral arteries for two days despite clinical and electroencephalographic signs of brain death. Shunting of blood through the circle of Willis without effective cerebral perfusion may explain this phenomenon. No patient had the typical reverberating flow pattern without being clinically brain dead. Transcranial Doppler sonography is a reliable technique, which can be used at the bedside for the confirmation or the exclusion of brain death in children in addition to the clinical examination. PMID:3069052

Acquired toxoplasmosis of a submandibular lymph node in a 13-year-old boy: case report.

PubMed

Azaz, B; Milhem, I; Hasson, O; Kirsch, G

1994-01-01

Toxoplasmosis is a parasitic infection divided into congenital and acquired forms. In the latter form, malaise, fatigue, and lymphadenopathy are commonly found, and submandibular lymphadenopathy is sometimes a manifestation. In children, cervical lymph nodes usually are affected. This is a case of a 13-year-old boy suffering from acquired toxoplasmosis, in which submandibular lymphadenopathy was the only clinical sign of the disease. Meticulous history taking, clinical examination, and specific serological tests should be performed in these cases. Positive serological results will confirm toxoplasmosis infections. Conservative treatment must be attempted initially.

Tyrosine kinase gene rearrangements in epithelial malignancies

PubMed Central

Shaw, Alice T.; Hsu, Peggy P.; Awad, Mark M.; Engelman, Jeffrey A.

2014-01-01

Chromosomal rearrangements that lead to oncogenic kinase activation are observed in many epithelial cancers. These cancers express activated fusion kinases that drive the initiation and progression of malignancy, and often have a considerable response to small-molecule kinase inhibitors, which validates these fusion kinases as ‘druggable’ targets. In this Review, we examine the aetiologic, pathogenic and clinical features that are associated with cancers harbouring oncogenic fusion kinases, including anaplastic lymphoma kinase (ALK), ROS1 and RET. We discuss the clinical outcomes with targeted therapies and explore strategies to discover additional kinases that are activated by chromosomal rearrangements in solid tumours. PMID:24132104

Phacoemulsification with intravitreal bevacizumab injection in diabetic patients with macular edema and cataract.

PubMed

Akinci, Arsen; Batman, Cosar; Ozkilic, Ersel; Altinsoy, Ali

2009-01-01

The purpose of this study was to evaluate the results of phacoemulsification with intravitreal bevacizumab injection in patients with diabetic clinically significant macular edema and cataract. The records of 31 patients with diabetic clinically significant macular edema and cataract, which would interfere with macular laser photocoagulation, who have undergone phacoemulsification with intravitreal injection of 1.25 mg bevacizumab were retrospectively evaluated. All patients had undergone focal or modified grid laser photocoagulation 1 month after the surgery. All patients were evaluated by spectral optical coherence tomography/optical coherence tomography SLO before and 1 and 3 months after the surgery beyond complete ophthalmologic examination. The best-corrected visual acuity (BCVA) levels and central macular thickness (CMT) recorded at the first and third months after the surgery were compared with the initial values. Paired samples t test was used for statistical analysis. The mean initial BCVA was 0.10 +/- 0.04 (range, 0.05-0.2). The mean BCVA at the first and third months after the surgery were 0.47 +/- 0.16 (standard deviation) (range, 0.2-0.5) and 0.51 +/- 0.12 (standard deviation) (range, 0.3-0.6), respectively. The BCVA level recorded at the first and third months after the surgery were significantly higher than the initial BCVA (P = 0.004). The mean initial CMT was 387.5 +/- 109.5 microm. The mean CMT at the first and third months after the surgery were 292.7 +/- 57.2 and 275.5 +/- 40.3. The CMT recorded at the first and third months after the surgery were significantly lower than the initial CMT (P < 0.001, P < 0.001). Phacoemulsification with intravitreal injection of bevacizumab provides improvement in clinically significant macular edema with a gain in BCVA in patients with diabetes with clinically significant macular edema and cataract.

Episcleral cyclosporine A implants for the management of unilateral keratoconjunctivitis sicca in an 8-year-old mare.

PubMed

Mackenzie, Catriona J; Carslake, Harry B; Robin, Matthew; Kent, Rebecca J; Malalana, Fernando

2017-01-01

An 8-year-old mare was presented for investigation of a 1-month history of blepharospasm, eyelid swelling, corneal edema, and ocular discharge of the right eye (OD). Ophthalmic examination confirmed mucopurulent ocular discharge, conjunctival hyperemia, and a dry, dull appearance to the cornea OD. Schirmer tear test results confirmed an absence of tear production OD (0 mm/min) consistent with keratoconjunctivitis sicca. Treatment with topical 0.2% cyclosporine A resulted in an improvement in clinical signs. An episcleral cyclosporine A implant was placed under standing sedation 5 days after initial presentation. Re-examination 9 days post-operatively confirmed that the mare's tear production in the right eye had improved and no further clinical signs had been observed. Topical medications were gradually discontinued. Re-examinations performed up to 12 months postsurgery showed no recurrence of clinical signs and no adverse effects of the implant. To our knowledge, this is the first report of the use of a cyclosporine A implant in the management of KCS in a horse and highlights its potential as an effective, alternative therapy in the management of KCS in horses. © 2016 American College of Veterinary Ophthalmologists.

Hypervitaminosis A in the cat: a case report and review of the literature.

PubMed

Polizopoulou, Zoe S; Kazakos, George; Patsikas, Michael N; Roubies, Nikolaos

2005-12-01

A case of hypervitaminosis A with secondary entrapment and compression of the left brachial plexus nerve roots is described. A 9-year-old male castrated domestic shorthair, fed a home-made diet based on raw pork liver, was submitted for examination for a left forelimb lameness that evolved to paralysis over a 2-month period. Clinical examination revealed a flaccid paralysis and atrophy of all left forelimb muscles. An ipsilateral Horner's syndrome was also noted. Radiological examination of the cervical and thoracic spine showed massive new bone formation at the ventral aspect of the second cervical to sixth thoracic vertebra. The diagnosis of hypervitaminosis A was made, based on the clinical and radiographic findings, as well as the determination of serum vitamin A concentration, which was 630 microg/dl, three times above the upper normal limit for this species. Despite the unfavourable initial prognosis, the cat progressively regained function of the affected limb approximately 6 months after the diet was changed to a commercial canned food.

The value of physical examination in mental health nursing.

PubMed

Martin, Carolyn T

2016-03-01

This article explores the use of a physical examination assignment in a mental health general nursing clinical placement course that addresses the poor physical health of people with mental illness and the barriers traditionally impeding health care provision for this population. A descriptive qualitative approach utilizes inductive content analysis to investigate 145 student survey responses. The assignment assists student nurses in understanding that physical and mental well-being are intrinsically linked. Students report increased comfort performing a physical examination on patients with mental illness post assignment. Students' initial bias towards this population was minimized post the clinical assignment. Poor physical health is common among people with mental health problems. Many view the provision of care as a major public health issue. Nurses are the front line caregivers of mental health service consumers and are well positioned to assess their physical needs. Their assessment may be the first step in recognizing health care issues in this population. Copyright © 2015 Elsevier Ltd. All rights reserved.

The role of follow-up ultrasound and clinical parameters after abdominal MDCT in patients with multiple trauma.

PubMed

Geyer, Lucas L; Körner, M; Linsenmaier, U; Wirth, S; Reiser, M F; Meindl, T

2014-05-01

Beside its value during the initial trauma work-up (focused assessment with sonography for trauma), ultrasound (US) is recommended for early follow-up examinations of the abdomen in multiple injured patients. However, multidetector CT (MDCT) has proven to reliably diagnose traumatic lesions of abdominal organs, to depict their extent, and to assess their clinical relevance. To evaluate the diagnostic impact of follow-up US studies after MDCT of the abdomen and to identify possible clinical parameters indicating the need of a follow-up US. During a 30-month period, patients with suspected multiple trauma were allocated. Patients with admission to the ICU, an initial abdominal MDCT scan, and an US follow-up examination after 6 and 24 h were included. Two patient cohorts were defined: patients with normal abdominal MDCT (group 1), patients with trauma-related pathologic abdominal MDCT (group 2). In all patients, parameters indicating alteration of vital functions or hemorrhage within the first 24 h were obtained by reviewing the medical charts. Forty-four of 193 patients were included: 24 were categorized in group 1 (mean age, 41.1 years; range, 21-90 years), 20 in group 2 (mean age, 36.6 years; range, 16-71 years). In group 1, US did not provide new information compared to emergency MDCT. In group 2, there were no contradictory 6- and 24-h follow-up US findings. In patients with positive MDCT findings and alterations of clinical parameters, US did not detect progression of a previously diagnosed pathology or any late manifestation of such a lesion. In none of the patients with negative abdominal MDCT and pathological clinical parameters US indicated an abdominal injury. Routine US follow-up does not yield additional information after abdominal trauma. In patients with MDCT-proven organ lesions, follow-up MDCT should be considered if indicated by abnormal clinical and/or laboratory findings.

The epidemiology of ocular trauma in rural Nepal

PubMed Central

Khatry, S K; Lewis, A E; Schein, O D; Thapa, M D; Pradhan, E K; Katz, J

2004-01-01

Aims: To estimate the incidence of ocular injury in rural Nepal and identify details about these injuries that predict poor visual outcome. Methods: Reports of ocular trauma were collected from 1995 through 2000 from patients presenting to the only eye care clinic in Sarlahi district, Nepal. Patients were given a standard free eye examination and interviewed about the context of their injury. Follow up examination was performed 2–4 months after the initial injury. Results: 525 cases of incident ocular injury were reported, with a mean age of 28 years. Using census data, the incidence was 0.65 per 1000 males per year, and 0.38 per 1000 females per year. The most common types of injury were lacerating and blunt, with the majority occurring at home or in the fields. Upon presentation to the clinic, 26.4% of patients had a best corrected visual acuity worse than 20/60 in the injured eye, while 9.6% had visual acuity worse than 20/400. 82% were examined at follow up: 11.2% of patients had visual acuity worse than 20/60 and 4.6% had vision worse than 20/400. A poor visual outcome was associated with increased age, care sought at a site other than the eye clinic, and severe injury. 3% of patients were referred for further care at an eye hospital at the initial visit; 7% had sought additional care in the interim between visits, with this subset representing a more severe spectrum of injuries. Conclusions: The detrimental effects of delayed care or care outside of the specialty eye clinic may reflect geographic or economic barriers to care. For optimal visual outcomes, patients who are injured in a rural setting should recognise the injury and seek early care at a specialty eye care facility. Findings from our study suggest that trained non-ophthalmologists may be able to clinically manage many eye injuries encountered in a rural setting in the “developing” world, reducing the demand for acute services of ophthalmologists in remote locations of this highly agricultural country. PMID:15031153

When They Call, Will They Come? A Contextually Responsive Approach for Engaging Multistressed Families in an Urban Child Mental Health Center: A Randomized Clinical Trial

ERIC Educational Resources Information Center

Stern, Susan B.; Walsh, Margaret; Mercado, Micaela; Levene, Kathryn; Pepler, Debra J.; Carr, Ashley; Heppell, Allison; Lowe, Erin

2015-01-01

Objective: This study examines the effect of an ecological and contextually responsive approach, during initial intake call, on engagement for multistressed families seeking child mental health services in an urban setting. Methods: Using a randomized design, parents were allocated to phone Intake As Usual (IAU) or Enhanced Engagement Phone Intake…

Use of intravenous lipid emulsion to treat ivermectin toxicosis in a Border Collie.

PubMed

Clarke, Dana L; Lee, Justine A; Murphy, Lisa A; Reineke, Erica L

2011-11-15

A 2-year-old spayed female Border Collie was treated with IV lipid emulsion (ILE) after ingesting 6 mg/kg (2.73 mg/lb) of an equine ivermectin anthelmintic paste 8 hours prior to examination. On initial examination, the dog had stable cardiovascular signs but had diffuse muscle tremors and was hyperthermic. Neurologic evaluation revealed that the dog was ataxic and had mydriasis with bilaterally absent menace responses and pupillary light reflexes. The remaining physical examination findings were unremarkable. Results of CBC, serum biochemical analysis, venous blood gas analysis, and measurement of plasma lactate concentration were also within reference limits. The dog was treated with ILE in addition to supportive care with IV fluid therapy and cardiovascular, respiratory, and neurologic monitoring. The use of ILE treatment was initiated in this patient on the basis of previous clinical and experimental evidence supporting its use for toxicosis resulting from lipid-soluble agents. An initial bolus of 1.5 mL/kg (0.68 mL/lb) of a 20% sterile lipid solution was administered IV over 10 minutes, followed by a constant rate infusion of 0.25 mL/kg/min (0.11 mL/lb/min) over 60 minutes that was administered twice to treat clinical signs of ivermectin toxicosis. The dog was discharged from the hospital 48 hours after admission and was clinically normal within 4 days after ivermectin ingestion. Further diagnostic evaluation subsequently revealed that this dog was unaffected by the multidrug resistance gene (MDR-1) deletion, known as the ATP-binding cassette polymorphism. Ivermectin toxicosis in veterinary patients can result in death without aggressive treatment, and severe toxicosis often requires mechanical ventilation and intensive supportive care. This is particularly true in dogs affected by the ATP-binding cassette polymorphism. Novel ILE treatment has been shown to be effective in human patients with lipid-soluble drug toxicoses, although the exact mechanism is unknown. In the patient in the present report, ILE was used successfully to treat ivermectin toxicosis, and results of serial measurement of serum ivermectin concentration supported the proposed lipid sink mechanism of action.

Faculty Evaluations Correlate Poorly with Medical Student Examination Performance in a Fourth-Year Emergency Medicine Clerkship.

PubMed

Dubosh, Nicole M; Fisher, Jonathan; Lewis, Jason; Ullman, Edward A

2017-06-01

Clerkship directors routinely evaluate medical students using multiple modalities, including faculty assessment of clinical performance and written examinations. Both forms of evaluation often play a prominent role in final clerkship grade. The degree to which these modalities correlate in an emergency medicine (EM) clerkship is unclear. We sought to correlate faculty clinical evaluations with medical student performance on a written, standardized EM examination of medical knowledge. This is a retrospective study of fourth-year medical students in a 4-week EM elective at one academic medical center. EM faculty performed end of shift evaluations of students via a blinded online system using a 5-point Likert scale for 8 domains: data acquisition, data interpretation, medical knowledge base, professionalism, patient care and communication, initiative/reliability/dependability, procedural skills, and overall evaluation. All students completed the National EM M4 Examination in EM. Means, medians, and standard deviations for end of shift evaluation scores were calculated, and correlations with examination scores were assessed using a Spearman's rank correlation coefficient. Thirty-nine medical students with 224 discrete faculty evaluations were included. The median number of evaluations completed per student was 6. The mean score (±SD) on the examination was 78.6% ± 6.1%. The examination score correlated poorly with faculty evaluations across all 8 domains (ρ 0.074-0.316). Faculty evaluations of medical students across multiple domains of competency correlate poorly with written examination performance during an EM clerkship. Educators need to consider the limitations of examination score in assessing students' ability to provide quality patient clinical care. Copyright © 2016 Elsevier Inc. All rights reserved.

First-in-human Phase 1 CRISPR Gene Editing Cancer Trials: Are We Ready?

PubMed

Baylis, Francoise; McLeod, Marcus

2017-01-01

A prospective first-in-human Phase 1 CRISPR gene editing trial in the United States for patients with melanoma, synovial sarcoma, and multiple myeloma offers hope that gene editing tools may usefully treat human disease. An overarching ethical challenge with first-in-human Phase 1 clinical trials, however, is knowing when it is ethically acceptable to initiate such trials on the basis of safety and efficacy data obtained from pre-clinical studies. If the pre-clinical studies that inform trial design are themselves poorly designed - as a result of which the quality of pre-clinical evidence is deficient - then the ethical requirement of scientific validity for clinical research may not be satisfied. In turn, this could mean that the Phase 1 clinical trial will be unsafe and that trial participants will be exposed to risk for no potential benefit. To assist sponsors, researchers, clinical investigators and reviewers in deciding when it is ethically acceptable to initiate first-in-human Phase 1 CRISPR gene editing clinical trials, structured processes have been developed to assess and minimize translational distance between pre-clinical and clinical research. These processes draw attention to various features of internal validity, construct validity, and external validity. As well, the credibility of supporting evidence is to be critically assessed with particular attention to optimism bias, financial conflicts of interest and publication bias. We critically examine the pre-clinical evidence used to justify the first-inhuman Phase 1 CRISPR gene editing cancer trial in the United States using these tools. We conclude that the proposed trial cannot satisfy the ethical requirement of scientific validity because the supporting pre-clinical evidence used to inform trial design is deficient. Copyright© Bentham Science Publishers; For any queries, please email at epub@benthamscience.org.

Breslow depth of cutaneous melanoma: impact of factors related to surveillance of the skin, including prior skin biopsies and family history of melanoma.

PubMed

Fisher, Nina M; Schaffer, Julie V; Berwick, Marianne; Bolognia, Jean L

2005-09-01

Because the early detection of cutaneous melanoma can dramatically improve survival, identification and surveillance of persons at risk have received much attention. Our purpose was to examine the influences of personal or family history, patterns of detection, and prior skin biopsies (considered to be a measurement of surveillance by medical personnel) on the Breslow depth of cutaneous melanomas. A retrospective cohort analysis of 218 patients with a history of at least one invasive cutaneous melanoma who visited the Yale Pigmented Lesion Clinic between January 1995 and January 1996 was performed. Data on patterns of detection, melanocytic nevi, and skin biopsies before and after the initial diagnosis of melanoma were collected, and patients with a family history of melanoma were compared with sporadic patients. Initial melanomas discovered by dermatologists were more likely to be 0.75 mm or less in depth than those found by other physicians (P = .03). Although patients detected 45% of the initial primary melanomas (98/218), dermatologists discovered 80% of the second primary tumors (33/41; P = .001). A personal history of melanoma was predictive of a thinner Breslow depth (P = .01), but a family history of melanoma was not. Having a biopsy of any type or combination of types of skin lesion(s) performed in the 5 years, 2 years, or 1 year before the first diagnosis of melanoma did not predict a melanoma of thinner Breslow depth among either familial or sporadic patients. The mean number of skin biopsies performed per patient was 8 times higher in the 5-year period after (5.6) versus the 5-year period before (0.7) the initial diagnosis of melanoma, with a peak in the first year after the diagnosis (2.3 vs 0.25 in the prior year). In 27 patients, one or more skin biopsies were performed in the year before the initial diagnosis of melanoma; 41% of these biopsies (23/56) were of lesions in normally exposed sites (eg, the face, neck, and forearms) compared with 22% of the melanomas (6/27). Since an invasive melanoma (with the possible exception of a nodular melanoma) would likely have been present for at least a year, plausible explanations for why evidence of previous dermatologic care did not appear to result in earlier detection include performance of a limited rather than a total body skin examination as well as subtle clinical features of early melanomas. However, this study cannot give weight to these explanations because at the time new Pigmented Lesion Clinic patients were not routinely asked about previous total body skin examinations. The disappointing trends seen in this study, with neither the well-established risk factor of a family history of melanoma nor previously having a skin biopsy predicting thinner melanomas, highlight the need to establish criteria defining the subset of patients for whom appropriate management requires periodic total body skin examination.

Impact of a clinical trial initiative on clinical trial enrollment in a multidisciplinary prostate cancer clinic.

PubMed

Madsen, Lydia T; Kuban, Deborah A; Choi, Seungtaek; Davis, John W; Kim, Jeri; Lee, Andrew K; Domain, Delora; Levy, Larry; Pisters, Louis L; Pettaway, Curtis A; Ward, John F; Logothetis, Christopher; Hoffman, Karen E

2014-07-01

Clinical oncology trials are hampered by low accrual rates, with fewer than 5% of adult patients with cancer treated on study. Clinical trial enrollment was evaluated at The University of Texas MD Anderson Cancer Center's Multidisciplinary Prostate Cancer Clinic (MPCC) to assess whether a clinical trial initiative, introduced in 2006, impacted enrollment. The trial initiative included posting trial-specific information in clinic, educating patients about appropriate clinical trial options during the treatment recommendation discussion, and providing patients with trial-specific educational information. The investigators evaluated the frequency of clinical trial enrollment for men with newly diagnosed prostate cancer seen in the MPCC from 2004 to 2008. Logistic regression evaluated the impact of patient characteristics and the clinical trial initiative on trial enrollment. The median age of the 1370 men was 64 years; 32% had low-risk, 49% had intermediate-risk, and 19% had high-risk disease. Overall, 74% enrolled in at least one trial and 29% enrolled in more than one trial. Trial enrollment increased from 39% before the initiative (127/326) to 84% (880/1044) after the trial initiative. Patient enrollment increased in laboratory studies (from 25% to 80%), quality-of-life studies (from 10% to 26%), and studies evaluating investigational treatments and systemic agents (from 6% to 15%) after the trial initiative. In multivariate analysis, younger men (P<.001) and men seen after implementation of the clinical trial initiative (P<.001) were more likely to enroll in trials. Clinical trial enrollment in the MPCC was substantially higher than that seen nationally in adult patients with cancer, and enrollment rates increased after the introduction of a clinical trial initiative. Copyright © 2014 by the National Comprehensive Cancer Network.

Rates and Reasons for Early Change of First HAART in HIV-1-Infected Patients in 7 Sites throughout the Caribbean and Latin America

PubMed Central

Cesar, Carina; Shepherd, Bryan E.; Krolewiecki, Alejandro J.; Fink, Valeria I.; Schechter, Mauro; Tuboi, Suely H.; Wolff, Marcelo; Pape, Jean W.; Leger, Paul; Padgett, Denis; Madero, Juan Sierra; Gotuzzo, Eduardo; Sued, Omar; McGowan, Catherine C.; Masys, Daniel R.; Cahn, Pedro E.

2010-01-01

Background HAART rollout in Latin America and the Caribbean has increased from approximately 210,000 in 2003 to 390,000 patients in 2007, covering 62% (51%–70%) of eligible patients, with considerable variation among countries. No multi-cohort study has examined rates of and reasons for change of initial HAART in this region. Methodology Antiretroviral-naïve patients > = 18 years who started HAART between 1996 and 2007 and had at least one follow-up visit from sites in Argentina, Brazil, Chile, Haiti, Honduras, Mexico and Peru were included. Time from HAART initiation to change (stopping or switching any antiretrovirals) was estimated using Kaplan-Meier techniques. Cox proportional hazards modeled the associations between change and demographics, initial regimen, baseline CD4 count, and clinical stage. Principal Findings Of 5026 HIV-infected patients, 35% were female, median age at HAART initiation was 37 years (interquartile range [IQR], 31–44), and median CD4 count was 105 cells/uL (IQR, 38–200). Estimated probabilities of changing within 3 months and one year of HAART initiation were 16% (95% confidence interval (CI) 15–17%) and 28% (95% CI 27–29%), respectively. Efavirenz-based regimens and no clinical AIDS at HAART initiation were associated with lower risk of change (hazard ratio (HR) = 1.7 (95% CI 1.1–2.6) and 2.1 (95% CI 1.7–2.5) comparing neverapine-based regimens and other regimens to efavirenz, respectively; HR = 1.3 (95% CI 1.1–1.5) for clinical AIDS at HAART initiation). The primary reason for change among HAART initiators were adverse events (14%), death (5.7%) and failure (1.3%) with specific toxicities varying among sites. After change, most patients remained in first line regimens. Conclusions Adverse events were the leading cause for changing initial HAART. Predictors for change due to any reason were AIDS at baseline and the use of a non-efavirenz containing regimen. Differences between participant sites were observed and require further investigation. PMID:20531956

Reducing socioeconomic inequalities in COPD care in the hospital outpatient setting - A nationwide initiative.

PubMed

Tøttenborg, Sandra S; Lange, Peter; Thomsen, Reimar W; Nielsen, Henrik; Johnsen, Søren P

2017-04-01

Socioeconomic differences in quality of care have been suggested to contribute to inequality in clinical prognosis of COPD. We examined socioeconomic differences in the quality of COPD outpatient care and the potential of a systematic quality improvement initiative in reducing potential socioeconomic differences. A mandatory national quality improvement initiative has since 2008 monitored the quality of COPD care at all national pulmonary specialized outpatient clinics in Denmark using six evidence-based process performance measures. We followed patients aged ≥30 years with a first-ever outpatient contact for COPD during 2008-2012 (N = 23,741). Adjusted year-specific relative risks (RR) of fulfilling all relevant process performance measures was compared according to ethnicity, education, income, employment, and cohabitation using Poisson regression. Quality of care improved following the implementation of the clinical improvement initiative with 11% of COPD patients receiving optimal care in 2008 compared to 57% in 2012. Substantial socioeconomic differences were observed the first year: immigrants (RR 0.41, 95% CI 0.21-0.82), the unemployed (RR 0.37, 95% CI 0.18-0.74), disability pensioners (RR 0.63, 95% CI 0.46-0.87) and patients living alone (RR 0.80, 95% CI 0.60-0.97) were less likely to receive all relevant care processes, whereas those with highest education (RR 1.22, 95% CI 0.92-1.63) were more likely to receive these processes. These differences were eliminated during the study period. A systematic quality improvement initiative including regular audits, knowledge sharing, and detailed disease-specific recommendations for care improvement may increase the overall quality of care and considerably modify the substantial socioeconomic inequalities in COPD management. Copyright © 2017 Elsevier Ltd. All rights reserved.

How do children with attention deficit hyperactivity disorder interact in a clinical dental examination? A video analysis.

PubMed

Blomqvist, My; Augustsson, Mikael; Bertlin, Christine; Holmberg, Kirsten; Fernell, Elisabeth; Dahllöf, Göran; Ek, Ulla

2005-06-01

Attention deficit hyperactivity disorder (ADHD) is currently the most common behavioural disorder in school-age children. The aim of this study was to perform a detailed analysis of behavioural interactions between the dentist and the child patient with ADHD. All children born in 1991 (n = 555) in one Swedish municipality were screened for attention and learning problems, and assessed for ADHD. Twenty-two children with ADHD, and a control group of 47 children without attention and learning problems, were included in the study. The dental recall visit was recorded on video. The interaction between the dentist and the child was analysed in detail and scored as verbal and non-verbal initiatives and responses. Compared to the children in the control group, the children with ADHD made significantly more initiatives, especially initiatives that did not focus on the examination or the dentist. The children with ADHD had fewer verbal responses and more missing responses. In conclusion, the problems in communication resulted in less two-way communication between the dentist and the children with ADHD than the interaction between the dentist and the children in the control group. The children with ADHD had particular difficulties staying focused on the examination. (c) Eur J Oral Sci, 2005

Residents examine factors associated with 30-day, same-cause hospital readmissions on an internal medicine service.

PubMed

Moran, Jennifer; Colbert, Colleen Y; Song, Juhee; Hull, Joshua; Rajan, Sabitha; Varghees, Sunita; Arroliga, Alejandro C; Reddy, Santosh P

2013-01-01

In recent years, there has been increased interest in stemming the tide of hospital readmissions in an attempt to improve quality of care. This study presents the Phase I results of a resident-led quality improvement initiative to determine the percentage of and risk factors for same-cause readmissions (SCRs; defined as hospital readmission within 30 days of hospital discharge for treatment of the same condition) to the internal medicine service of a multispecialty teaching hospital in central Texas. Results indicate that patients diagnosed with chronic obstructive pulmonary disease/asthma or anemia may be at increased risk for SCRs. Those patients who are insured by Medicaid and those who require assistance from social services also demonstrated an increased risk for SCRs. This study appears to be the first resident-led initiative in the field to examine 30-day SCRs to an internal medicine service for demographic and clinical risk factors.

Respiratory assessment.

PubMed

Simpson, Heidi

The ability to carry out and document a full respiratory assessment is an essential skill for all nurses. The elements included are: an initial assessment, history taking, inspection, palpation, percussion, auscultation and further investigations. A prompt initial assessment allows immediate evaluation of severity of illness and appropriate treatment measures may warrant instigation at this point. Following this, a comprehensive patient history will be elicited. Clinical examination of the patient follows and involves inspection, palpation, percussion and auscultation. At this point, consideration must be given to preparation of a light, warm, quiet, private environment for examination and suitable patient positioning. Inspection is a comprehensive visual assessment, while palpation involves using touch to gather information. The next stages are percussion and auscultation. While percussion is striking the chest to determine the state of underlying tissues, auscultation entails listening to and interpreting sound transmission through the chest wall via a stethoscope. Finally, further investigations may be necessary to confirm or negate suspected diagnoses.

Thoracic sonography for pneumothorax: The clinical evaluation of an operational space medicine spin-off

NASA Astrophysics Data System (ADS)

Kirkpatrick, Andrew W.; Nicolaou, Savvas; Rowan, Kevin; Liu, David; Cunningham, Johan; Sargsyan, Ashot E.; Hamilton, Douglas; Dulchavsky, Scott A.

2005-05-01

The recent interest in the use of ultrasound (US) to detect pneumothoraces after acute trauma in North America was initially driven by an operational space medicine concern. Astronauts aboard the International Space Station (ISS) are at risk for pneumothoraces, and US is the only potential medical imaging available. Pneumothoraces are common following trauma, and are a preventable cause of death, as most are treatable with relatively simple interventions. While pneumothoraces are optimally diagnosed clinically, they are more often inapparent even on supine chest radiographs (CXR) with recent series reporting a greater than 50% rate of occult pneumothoraces. In the course of basic scientific investigations in a conventional and parabolic flight laboratory, investigators familiarized themselves with the sonographic features of both pneumothoraces and normal pulmonary ventilation. By examining the visceral-parietal pleural interface (VPPI) with US, investigators became confident in diagnosing pneumothoraces. This knowledge was subsequently translated into practice at an American and a Canadian trauma center. The sonographic examination was found to be more accurate and sensitive than CXR (US 96% and 100% versus US 74% and 36%) in specific circumstances. Initial studies have also suggested that detecting the US features of pleural pulmonary ventilation in the left lung field may offer the ability to exclude serious endotracheal tube malpositions such as right mainstem and esophageal intubations. Applied thoracic US is an example of a clinically useful space medicine spin-off that is improving health care on earth.

Patient participation in cancer clinical trials: A pilot test of lay navigation.

PubMed

Cartmell, Kathleen B; Bonilha, Heather S; Matson, Terri; Bryant, Debbie C; Zapka, Jane G; Bentz, Tricia A; Ford, Marvella E; Hughes-Halbert, Chanita; Simpson, Kit N; Alberg, Anthony J

2016-08-15

Clinical trials (CT) represent an important treatment option for cancer patients. Unfortunately, patients face challenges to enrolling in CTs, such as logistical barriers, poor CT understanding and complex clinical regimens. Patient navigation is a strategy that may help to improve the delivery of CT education and support services. We examined the feasibility and initial effect of one navigation strategy, use of lay navigators. A lay CT navigation intervention was evaluated in a prospective cohort study among 40 lung and esophageal cancer patients. The intervention was delivered by a trained lay navigator who viewed a 17-minute CT educational video with each patient, assessed and answered their questions about CT participation and addressed reported barriers to care and trial participation. During this 12-month pilot project, 85% (95% CI: 72%-93%) of patients eligible for a therapeutic CT consented to participate in the CT navigation intervention. Among navigated patients, CT understanding improved between pre- and post-test (means 3.54 and 4.40, respectively; p-value 0.004), and 95% (95% CI: 82%-98%) of navigated patients consented to participate in a CT. Navigated patients reported being satisfied with patient navigation services and CT participation. In this formative single-arm pilot project, initial evidence was found for the potential effect of a lay navigation intervention on CT understanding and enrollment. A randomized controlled trial is needed to examine the efficacy of the intervention for improving CT education and enrollment.

Comparing clinical effects of marbofloxacin and gamithromycin in goat kids with pneumonia.

PubMed

Kacar, Yigit; Batmaz, Hasan; Yilmaz, Ozge E; Mecitoglu, Zafer

2018-06-20

The aim of this study was to compare the clinical efficacy of a single-dose of gamithromycin (GM) or marbofloxacin (MR) in kids with naturally occurring pneumonia. Thirty-six kids, aged 2-2.5 months, with body weight ranging from 12 kg to 18 kg were presented with clinical signs of pneumonia. The most prominent clinical findings were an increase in the respiratory rate, crackling lung sounds on auscultation, coughing, nasal discharge and an increased rectal temperature. Mannheimia haemolytica and Mycoplasma spp. colonies were isolated from microbiological examination of six transtracheal washes and lung tissues of one necropsied kid. The severity of pneumonia was evaluated by using cumulative clinical score (CCS). The CCS of the 36 kids used in the study were four and above. Kids were randomly divided into two equal groups; the GM group received a single subcutaneous dose of GM at a dosage of 6 mg/kg and the MR group received MR intramuscularly at a dosage of 8 mg/kg as a single-dose. No side effects related to the drugs were detected in either group. All 36 kids were clinically examined 3 weeks after the initiation of the treatment. Clinical signs in both groups were almost completely absent at the end of the study. A single administration of GM or MR was successfully used in the treatment of kids with pneumonia.

A dedicated undergraduate gynaecology teaching clinic: The Keele experience.

PubMed

Katali, Hamza Mahamadu; Parry-Smith, William Rhys; Eliot, Rees L; O'Mahony, Fidelma

2016-01-01

Much discussion in the literature centres on how best to teach medical students the intricacies of gynaecological assessment and the subsequent formulation of a management plan. At Keele University skills are initially developed in a simulated setting and then transferred to the workplace where students continue to develop their skills. A dedicated undergraduate gynaecology teaching clinic has been developed and comprises of 2-3 students and a tutor. All 38 students rotating through the department between January and June 2013 were invited to complete an anonymous questionnaire to evaluate this clinic and 36 (95%) of them responded. Respondents felt significantly more comfortable taking a gynaecology history, ensuring privacy during examination and formulating a management plan post-clinic (all p < 0.001), with female students feeling significantly more comfortable than their male counterparts (p = 0.04). The use of this clinic shows great promise to help students learn an unfamiliar and challenging skill.

Community, Public Policy, and Recovery from Mental Illness: Emerging Research and Initiatives.

PubMed

Castillo, Enrico G; Chung, Bowen; Bromley, Elizabeth; Kataoka, Sheryl H; Braslow, Joel T; Essock, Susan M; Young, Alexander S; Greenberg, Jared M; Miranda, Jeanne; Dixon, Lisa B; Wells, Kenneth B

This commentary examines the roles that communities and public policies play in the definition and processes of recovery for adults with mental illness. Policy, clinical, and consumer definitions of recovery are reviewed, which highlight the importance of communities and policies for recovery. This commentary then presents a framework for the relationships between community-level factors, policies, and downstream mental health outcomes, focusing on macroeconomic, housing, and health care policies; adverse exposures such as crime victimization; and neighborhood characteristics such as social capital. Initiatives that address community contexts to improve mental health outcomes are currently under way. Common characteristics of such initiatives and select examples are discussed. This commentary concludes with a discussion of providers', consumers', and other stakeholders' roles in shaping policy reform and community change to facilitate recovery.

Florid cemento-osseous dysplasia: a report of two cases seen at the university college hospital ibadan.

PubMed

Lawal, A O; Adisa, A O; Lasisi, T J

2011-06-01

Florid cemento-osseous dysplasia (FCOD) is commonly seen in black women, but few cases have been reported in sub-Saharan Africa. This article presents two cases of FCOD seen at the University College Hospital Ibadan. Two women aged 70 and 60 years were initially diagnosed as chronic osteomyelitis but both were eventually diagnosed as florid cementoosseous dysplasia after radiological examination by orthopanthomogram. Diagnosis of florid cemento-osseous dysplasia is possible by clinical examination and the distinct radiological presentation, especially on orthopanthomogram and a biopsy may not be required.

FLORID CEMENTO-OSSEOUS DYSPLASIA: A REPORT OF TWO CASES SEEN AT THE UNIVERSITY COLLEGE HOSPITAL IBADAN

PubMed Central

Lawal, A.O.; Adisa, A.O.; Lasisi, T.J.

2011-01-01

SUMMARY Florid cemento-osseous dysplasia (FCOD) is commonly seen in black women, but few cases have been reported in sub-Saharan Africa. This article presents two cases of FCOD seen at the University College Hospital Ibadan. Two women aged 70 and 60 years were initially diagnosed as chronic osteomyelitis but both were eventually diagnosed as florid cementoosseous dysplasia after radiological examination by orthopanthomogram. Diagnosis of florid cemento-osseous dysplasia is possible by clinical examination and the distinct radiological presentation, especially on orthopanthomogram and a biopsy may not be required. PMID:25161487

The Skin Cancer Objective Structured Clinical Examination (SCOSCE): A multi-institutional collaboration to develop and validate a clinical skills assessment for melanoma.

PubMed

Garg, Amit; Biello, Katie; Hoot, Joyce W; Reddy, Shalini B; Wilson, Lindsay; George, Paul; Robinson-Bostom, Leslie; Belazarian, Leah; Domingues, Erik; Powers, Jennifer; Jacob, Reza; Powers, Michael; Besen, Justin; Geller, Alan C

2015-12-01

Assessing medical students on core skills related to melanoma detection is challenging in the absence of a well-developed instrument. We sought to develop an objective structured clinical examination for the detection and evaluation of melanoma among medical students. This was a prospective cohort analysis of student and objective rater agreement on performance of clinical skills and assessment of differences in performance across 3 schools. Kappa coefficients indicated excellent agreement for 3 of 5 core skills including commenting on the presence of the moulage (k = 0.87, 95% confidence interval 0.77-0.96), obtaining a history for the moulage (k = 0.84, 95% confidence interval 0.74-0.94), and making a clinical impression (k = 0.80, 95% confidence interval 0.68-0.92). There were no differences in performance across schools with respect to 3 of 5 core skills: commenting on the presence of the moulage (P = .15), initiating a history (P = .53), and managing the suspicious lesion (P value range .07-.17). Overall, 54.2% and 44.7% of students commented on the presence of the moulage and achieved maximum performance of core skills, respectively, with no difference in performance across schools. Limitations include overall sample size of students and schools. The Skin Cancer Objective Structured Clinical Examination represents a potentially important instrument to measure students' performance on the optimal step-by-step evaluation of a melanoma. Copyright © 2015 American Academy of Dermatology, Inc. Published by Elsevier Inc. All rights reserved.

Improving resident well-being and clinical learning environment through academic initiatives.

PubMed

Lee, Nathaniel; Appelbaum, Nital; Amendola, Michael; Dodson, Kelley; Kaplan, Brian

2017-07-01

Organizational effects on job satisfaction, burnout, work-life balance, and perceived support have not been studied in the context of the clinical learning environment. We evaluated the relationship between academic resources and resident well-being, the clinical learning environment, and in-service examination performance of surgical residents. Residents of general surgery and surgical specialty programs were recruited from March 2016 through June 2016 across the Southeast, Mid-Atlantic, and Northeast regions. Program directors were asked to allow distribution of a paper survey or to forward an electronic survey link onto residents. Five dichotomous questions were asked regarding access to academic resources. Validated measures were obtained assessing resident well-being and perceived clinical learning environment. Data were analyzed through t-tests and chi-squared test of independence. We received 276 respondents across 50 programs. Residents perceiving adequate support to succeed had less burnout (P = 0.008), better resilience (P = 0.009), better job satisfaction (P < 0.001), less work/life strain (P = 0.001), better workplace climate (P < 0.001), better organizational support (P < 0.001), and were more likely to have high performance on the in-service examination (P = 0.001). Specific resources including educational stipends, review questions, in-service board prep, and support for poor performers correlated with improved well-being and perceived clinical learning environment. Provision of academic resources has implications beyond in-service examination performance, correlating with improved resident well-being and perceptions of the clinical learning environment. Copyright © 2017 Elsevier Inc. All rights reserved.

Diagnosis and Management of Diabetes Mellitus in a Bali Mynah (Leucopsar rothschildi).

PubMed

Bartlett, Susan L; Bailey, Ryan; Baitchman, Eric

2016-06-01

An 18-year-old female Bali mynah (Leucopsar rothschildi) was presented for polyphagia, weight loss, and incoordination. Diabetes mellitus was diagnosed based on the history and clinical findings, including persistent hyperglycemia with concurrent hypoinsulinemia and glucosuria. A treatment protocol was developed that led to improvement of clinical signs and management of hyperglycemia over several months. Because of the advanced age of the animal, difficulty in maintaining euglycemia, and the stress of handling and treatment, euthanasia was elected 167 days after initial presentation. At postmortem examination, no pancreatic lesions were detected histologically that would account for the diabetes mellitus. To our knowledge this is the first reported case of diabetes mellitus and clinical management of this condition in a passerine species.

Toxoplasmosis: A history of clinical observations.

PubMed

Weiss, Louis M; Dubey, Jitender P

2009-07-01

It has been 100 years since Toxoplasma gondii was initially described in Tunis by Nicolle and Manceaux (1908) in the tissues of the gundi (Ctenodoactylus gundi) and in Brazil by Splendore (1908) in the tissues of a rabbit. Toxoplasma gondii is a ubiquitous, Apicomplexan parasite of warm-blooded animals that can cause several clinical syndromes including encephalitis, chorioretinitis, congenital infection and neonatal mortality. Fifteen years after the description of T. gondii by Nicolle and Manceaux a fatal case of toxoplasmosis in a child was reported by Janků. In 1939 Wolf, Cowen and Paige were the first to conclusively identify T. gondii as a cause of human disease. This review examines the clinical manifestations of infection with T. gondii and the history of the discovery of these manifestations.

Surgical stabilization of shoulder luxation in a pot-bellied pig.

PubMed

Rubio-Martínez, Luis M; Rioja, Eva; Shakespeare, A S

2013-03-15

Case Description-A 4.6-month-old pot-bellied pig was evaluated because of non-weight-bearing lameness (grade 5/5) in the right forelimb of 4 days' duration. Clinical Findings-Clinical and radiographic examination revealed a closed, lateral luxation of the right shoulder joint. Treatment and Outcome-Initial attempts at closed reduction failed to provide adequate stability of the shoulder joint. Open reduction and internal fixation by placement of 2 lateral tension sutures with a system designed for canine cranial cruciate ligament repair provided adequate joint stability and a successful outcome. Conclusions and Clinical Relevance-Stabilization of the shoulder joint with lateral tension sutures after open reduction should be considered for management of lateral shoulder luxation in pot-bellied pigs.

Clinical classification in low back pain: best-evidence diagnostic rules based on systematic reviews.

PubMed

Petersen, Tom; Laslett, Mark; Juhl, Carsten

2017-05-12

Clinical examination findings are used in primary care to give an initial diagnosis to patients with low back pain and related leg symptoms. The purpose of this study was to develop best evidence Clinical Diagnostic Rules (CDR] for the identification of the most common patho-anatomical disorders in the lumbar spine; i.e. intervertebral discs, sacroiliac joints, facet joints, bone, muscles, nerve roots, muscles, peripheral nerve tissue, and central nervous system sensitization. A sensitive electronic search strategy using MEDLINE, EMBASE and CINAHL databases was combined with hand searching and citation tracking to identify eligible studies. Criteria for inclusion were: persons with low back pain with or without related leg symptoms, history or physical examination findings suitable for use in primary care, comparison with acceptable reference standards, and statistical reporting permitting calculation of diagnostic value. Quality assessments were made independently by two reviewers using the Quality Assessment of Diagnostic Accuracy Studies tool. Clinical examination findings that were investigated by at least two studies were included and results that met our predefined threshold of positive likelihood ratio ≥ 2 or negative likelihood ratio ≤ 0.5 were considered for the CDR. Sixty-four studies satisfied our eligible criteria. We were able to construct promising CDRs for symptomatic intervertebral disc, sacroiliac joint, spondylolisthesis, disc herniation with nerve root involvement, and spinal stenosis. Single clinical test appear not to be as useful as clusters of tests that are more closely in line with clinical decision making. This is the first comprehensive systematic review of diagnostic accuracy studies that evaluate clinical examination findings for their ability to identify the most common patho-anatomical disorders in the lumbar spine. In some diagnostic categories we have sufficient evidence to recommend a CDR. In others, we have only preliminary evidence that needs testing in future studies. Most findings were tested in secondary or tertiary care. Thus, the accuracy of the findings in a primary care setting has yet to be confirmed.

Digital Rectal Examination Reduces Hospital Admissions, Endoscopies, and Medical Therapy in Patients with Acute Gastrointestinal Bleeding.

PubMed

Shrestha, Manish P; Borgstrom, Mark; Trowers, Eugene

2017-07-01

Although digital rectal examination is an established part of physical examinations in patients with acute gastrointestinal bleeding, clinicians are reluctant to perform a rectal examination. We intended to assess whether rectal examination affects the clinical management decision in these patients. We performed a single-center, retrospective, cross-sectional study using data from electronic health records of patients aged ≥18 years presenting to the emergency department with acute gastrointestinal bleeding. Hospital admissions, intensive care unit admissions, gastroenterology consultation, initiation of medical therapy (proton pump inhibitor or octreotide), and inpatient endoscopy (upper endoscopy or colonoscopy) were assessed as outcomes. Univariate and multivariate logistic regression analyses were performed. Of 1237 patients with acute gastrointestinal bleeding, 549 (44.4%) did not have a rectal examination. Patients who had a rectal examination were less likely to be admitted than patients who did not have a rectal examination (adjusted odds ratio [AOR], 0.49; 95% confidence interval [CI], 0.30-0.79; P = .004). Patients who had a rectal examination were less likely to be started on medical therapy (AOR, 0.64; 95% CI, 0.41-0.98; P = .04) and to have endoscopy (AOR, 0.64; 95% CI, 0.44-0.94; P = .02) than patients who did not have a rectal examination. Rectal examination in patients with acute gastrointestinal bleeding can assist clinicians with clinical management decision and reduce admissions, endoscopies, and medical therapy in these patients. Copyright © 2017 Elsevier Inc. All rights reserved.

Different usage of the same oncology information system in two hospitals in Sydney--lessons go beyond the initial introduction.

PubMed

Yu, Ping; Gandhidasan, Senthilkumar; Miller, Alexis A

2010-06-01

The experience of clinicians at two public hospitals in Sydney, Australia, with the introduction and use of an oncology information system (OIS) was examined to extract lessons to guide the introduction of clinical information systems in public hospitals. Semi-structured interviews were conducted with 12 of 15 radiation oncologists employed at the two hospitals. The personnel involved in the decision making process for the introduction of the system were contacted and their decision making process revisited. The transcribed data were analyzed using NVIVO software. Themes emerged included implementation strategies and practices, the radiation oncologists' current use and satisfaction with the OIS, project management and the impact of the OIS on clinical practice. The hospitals had contrasting experiences in their introduction and use of the OIS. Hospital A used the OIS in all aspects of clinical documentation. Its implementation was associated with strong advocacy by the Head of Department, input by a designated project manager, and use and development of the system by all staff, with timely training and support. With no vision of developing a paperless information system, Hospital B used the OIS only for booking and patient tracking. A departmental policy that data entry for the OIS was centrally undertaken by administrative staff distanced clinicians from the system. All the clinicians considered that the OIS should continuously evolve to meet changing clinical needs and departmental quality improvement initiatives. This case study indicates that critical factors for the successful introduction of clinical information systems into hospital environment were an initial clear vision to be paperless, strong clinical leadership and management at the departmental level, committed project management, and involvement of all staff, with appropriate training. Clinician engagement is essential for post-adoption evolution of clinical information systems. Copyright 2010 Elsevier Ireland Ltd. All rights reserved.

[Emotional stress as a clinical model to study the pathogenesis of the initial phase of the general adaptation syndrome].

PubMed

Anikhovskaya, I A; Dvoenosov, V G; Zhdanov, R I; Koubatiev, A A; Mayskiy, I A; Markelova, M M; Meshkov, M V; Oparina, O N; Salakhov, I M; Yakovlev, M Yu

2015-01-01

General adaptation syndrome (GAS), the basis of the development of which is stress phenomenon, is an essential component of the pathogenesis of many diseases and syndromes. However, the patho genesis of GAS hitherto is considered exclusively from the endocrinological viewpoint. This relates primarily to the initial phase of the GAS, a clinical model for the study of which may be psycho-emotional stress (PES), which we studied using three groups of volunteers. The first one consists of 25 students who were waiting for unaccustomed physical activity (17 men) and play debut on the stage (8 women). The second group consists of 48 children (2-14 years) who expected for "planned" surgery. The third group of volunteers is made up of 80 students (41 women and 39 men) during the first exam. The concentration of cortisol, endotoxin (ET), the activity of antiendotoxin immunity (AEI) and the haemostatic system parameters were determined in the blood serum of volunteers in various combinations. We found laboratory evidence for PES at 92% of students of the first group, 58% of children of the second one and in 21% of students of the third group of volunteers (mostly women). The concentration of ET increased at 13 (52%) volunteers of the first group with a significant increase of average indicators in the whole group (from 0.84 ± 0.06 to 1.19 ± 0.04 EU/ml). At children of the second group, the average concentration of ET increased even more significantly (from 0.42 ± 0.02 to 1.63 ± 0.11 EU/ml), which was accompanied by the activation of the hemostasis system. A degree of the activation was directly dependent on the level of ET in the general circulation and on an activity of AEI. Examination stress in the third group of volunteers is accompanied by activation of plasma hemostasis (increased initial thrombosis rate and reduced the time it starts, lag-period) in 26% of female students and 15% of male students. We suggest that it is possible to use the PES as a clinical model for studying the initial phase of the GAS, examine the role of excess of intestinal ET in the general blood circulation (endotoxin aggression) in the induction of systemic inflammation, which is very likely participated in the initiation of the GAS.

Home-based pre-exposure prophylaxis (PrEP) services for gay and bisexual men: An opportunity to address barriers to PrEP uptake and persistence

PubMed Central

Rendina, H. Jonathon; Grov, Christian

2017-01-01

Gay, bisexual, and other men who have sex with men (GBM) are disproportionately affected by the HIV epidemic. Despite the promise of pre-exposure prophylaxis (PrEP) in reducing HIV transmission risk, barriers for uptake and persistence exist. We sought to identify whether GBM in a nationwide cohort who have not yet initiated PrEP (n = 906) would prefer to get PrEP-related care from a primary care provider (PCP) compared to a specialist clinic or provider. We then sought to identify their level of interest and factors associated with preference for using home-based PrEP services (i.e., HB-PrEP), defined to participants as conducting HIV/STI self-testing from home with PrEP prescription mailing after an initial in-person clinic visit. We examined the associations of demographics, sexual HIV transmission risk, concern about frequent medical checkups associated with PrEP, health care access, and PrEP intentions with preferences for healthcare provider type and HB-PrEP. Concern about frequent medical checkups were associated with preferring a PCP for PrEP-related care, but men who perceived a barrier to bringing up the topic of PrEP with a doctor preferred a specialist clinic or provider more than a PCP. HB-PrEP was more appealing for younger men and those engaged in sexual HIV transmission risk, suggesting HB-PrEP could help reach GBM most vulnerable to HIV and in need of PrEP. HB-PrEP expansion has potential to increase PrEP uptake and persistence among GBM, particularly for men with barriers to clinic-based care and higher intentions to initiate PrEP. Clinical guidelines regarding HB-PrEP are needed to expand its use. PMID:29281688

Most routine laboratory testing of pediatric psychiatric patients in the emergency department is not medically necessary.

PubMed

Donofrio, J Joelle; Horeczko, Timothy; Kaji, Amy; Santillanes, Genevieve; Claudius, Ilene

2015-05-01

We examined the patient characteristics and hospital charges associated with routine medical clearance laboratory screening tests in 1,082 children younger than age eighteen who were brought to the emergency department (ED) for involuntary mental health holds--that is, each patient was brought to the ED to be evaluated for being a danger to him- or herself or to others, for being gravely disabled (unable to meet his or her basic needs due to a mental disorder), or both--from July 2009 to December 2010. Testing was performed on 871 of the children; all patients also received a clinical examination. The median charge for blood and urine testing together was $1,235, and the most frequent ordering pattern was the full comprehensive panel of tests. Of the patients with a nonconcerning clinical examination, 94.3 percent also had clinically nonsignificant test results. When we extrapolated cost savings to the national level, omitting routine screening laboratory tests in the population of pediatric patients presenting to the ED on an involuntary psychiatric hold with nonconcerning clinical exams could represent up to $90 million in savings annually, without reducing the ability to screen for emergency medical conditions. Provider-initiated diagnostic testing instead of routine screening would lead to significantly lower charges to the ED and the patient. Project HOPE—The People-to-People Health Foundation, Inc.

Interim Methadone and Patient Navigation in Jail: Rationale and Design of a Randomized Clinical Trial

PubMed Central

Schwartz, Robert P.; Kelly, Sharon M.; Mitchell, Shannon G.; Dunlap, Laura; Zarkin, Gary A.; Sharma, Anjalee; O’Grady, Kevin E.; Jaffe, Jerome H.

2016-01-01

Background Methadone maintenance is an effective treatment for opioid dependence but is rarely initiated in US jails. Patient navigation is a promising approach to improve continuity of care but has not been tested in bridging the gap between jail- and community-based drug treatment programs. Methods This is an open-label randomized clinical trial among 300 adult opioid dependent newly-arrested detainees that will compare three treatment conditions: methadone maintenance without routine counseling (termed Interim Methadone; IM) initiated in jail v. IM and patient navigation v. enhanced treatment-as-usual. The two primary outcomes will be: (1) the rate of entry into treatment for opioid use disorder within 30 days from release and (2) frequency of opioid positive urine tests over the 12-month follow-up period. An economic analysis will examine the costs, cost-effectiveness, and cost-benefit ratio of the study interventions. Results We describe the background and rationale for the study, its aims, hypotheses, and study design. Conclusions Given the large number of opioid dependent detainees in the US and elsewhere, initiating IM at the time of incarceration could be a significant public health and clinical approach to reducing relapse, recidivism, HIV-risk behavior, and criminal behavior. An economic analysis will be conducted to assist policy makers in determining the utility of adopting this approach. PMID:27282117

Patient Utilization of Cognitive-Behavioral Therapy for OCD

PubMed Central

Mancebo, Maria C.; Eisen, Jane L.; Sibrava, Nicholas; Dyck, Ingrid R.; Rasmussen, Steven A.

2012-01-01

The current study examined utilization of cognitive-behavioral therapy (CBT) by individuals receiving treatment for obsessive-compulsive disorder (OCD). Participants were 202 adults with primary DSM-IV OCD who enrolled in a longitudinal, observational study of the course of OCD and completed 2 years of annual follow-up interviews using the Longitudinal Interval Follow-Up Evaluation. One hundred twenty participants reported that a mental health professional recommended CBT for their OCD symptoms at some point during the 2-year follow-up period. One quarter (n = 31) of these participants did not initiate CBT despite receiving a treatment recommendation. Thirty-one percent of the 89 participants who entered CBT endorsed dropping out of CBT prematurely and less than one third received an adequate “dose” of CBT sessions. Self-reported CBT drop-out rates were significantly greater than attrition rates reported in clinical trials using intensive schedules of exposure and ritual prevention (EX/RP). Perceived environmental barriers and fears regarding treatment participation were the most frequently endorsed reasons for not participating or dropping out of CBT. Despite its efficacy for OCD, many individuals with clinically significant symptoms fail to initiate CBT when recommended by a mental health professional, receive treatments that are less intensive than those used in clinical trials, or drop out of treatment prematurely. Financial costs of CBT, difficulty attending sessions, and fears regarding treatment are significant barriers to initiating and completing therapy. PMID:21658523

Teaching communication in clinical clerkships: models from the macy initiative in health communications.

PubMed

Kalet, Adina; Pugnaire, Michele P; Cole-Kelly, Kathy; Janicik, Regina; Ferrara, Emily; Schwartz, Mark D; Lipkin, Mack; Lazare, Aaron

2004-06-01

Medical educators have a responsibility to teach students to communicate effectively, yet ways to accomplish this are not well-defined. Sixty-five percent of medical schools teach communication skills, usually in the preclinical years; however, communication skills learned in the preclinical years may decline by graduation. To address these problems the New York University School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School collaborated to develop, establish, and evaluate a comprehensive communication skills curriculum. This work was funded by the Josiah P. Macy, Jr. Foundation and is therefore referred to as the Macy Initiative in Health Communication. The three schools use a variety of methods to teach third-year students in each school a set of effective clinical communication skills. In a controlled trial this cross-institutional curriculum project proved effective in improving communication skills of third-year students as measured by a comprehensive, multistation, objective structured clinical examination. In this paper the authors describe the development of this unique, collaborative initiative. Grounded in a three-school consensus on the core skills and critical components of a communication skills curriculum, this article illustrates how each school tailored the curriculum to its own needs. In addition, the authors discuss the lessons learned from conducting this collaborative project, which may provide guidance to others seeking to establish effective cross-disciplinary skills curricula.

Can a limited double reading/second opinion of initially recalled breast ultrasound screening examinations improve radiologists' performances?

NASA Astrophysics Data System (ADS)

Gur, David; Harnist, Kimberly; Gizienski, Terri-Ann; Zuley, Margarita; Hakim, Christiane; Lu, Amy; Sumkin, Jules; Abrams, Gordon; Ganott, Marie A.; Kelly, Amy E.; Tyma, Cathy S.; Chang, Thomas; BÓ§hm-Vélez, Marcella; Sobolewski, Robin

2018-03-01

Interpretations of breast ultrasound screening examinations result in high recall rates and large inter-radiologist variability, frequently leading to "conservative" recommendations. Double reading of all breast ultrasound screening examinations is cost prohibitive, but double reading of only "initially recalled" cases may prove efficacious. We assessed changes in recommendations, if any, by providing a consensus second opinion in a limited subset of examinations initially recommended for recall. We performed a retrospective reader study with 197 ultrasound examinations (97 not recalled and 100 recalled clinically). First, we generated a consensus "second opinion" consisting of the majority vote of three independent readings of each case by experienced ultrasound interpreters. During the reader study that followed, if the reader recommended a "recall" and the "consensus second opinion" did not, a message to that effect was displayed and the reader was asked to re-review the exam and re-assess if, knowing the second opinion, a re-rating of the case was warranted. We compared performance levels pre- and post- the second opinion. The second opinion resulted in "no recall" recommendations of 141 cases in the entire set, including four cancer cases missed by all three readers. On average, radiologists received "warning" messages in 30 cases (range 15-50), or in 15% of cases. Rating changes (downgrades to no recall) occurred in 36 of these cases. These changes resulted in a possible recall rate reduction of 28% in prompted cases or 14% overall recall reduction, while increasing the false negative rate by only one case missed by 2 readers ( 1%).

Epidemic optic neuropathy in Cuba. Eye findings.

PubMed

Sadun, A A; Martone, J F; Muci-Mendoza, R; Reyes, L; DuBois, L; Silva, J C; Roman, G; Caballero, B

1994-05-01

To characterize and establish a clinical definition of the optic neuropathy that appeared in epidemic form in Cuba in 1992 and 1993. At the invitation of the Cuban Ministry of Health, Havana, members of ORBIS International and the Pan American Health Organization, assembled teams that traveled to Cuba in May 1993. We were initially briefed by Cuban national experts in the areas of virology, nutrition, toxicology, ophthalmology, neurology, and public health. We then examined 20 patients on our own. Thirteen of these patients underwent a comprehensive neuro-ophthalmologic examination, including neurologic examination, ophthalmologic examination, visual fields, optic nerve function studies, contrast sensitivity studies, and funduscopy. We returned 4 months later to perform an additional 12 comprehensive neuro-ophthalmologic and follow-up examinations. Only seven of the 13 patients who were alleged to have the optic form of the epidemic and who were rigorously and systematically examined on the first visit demonstrated a bilateral optic neuropathy. These seven patients had several features that included decreased visual acuity, poor color vision, central scotomas, decreased contrast sensitivity, saccadic eye movements, and most prominent and distinctive of all, nerve fiber layer wedge defects of the papillomacular bundle. Our clinical definition was then implemented by the Cuban ophthalmologists and epidemiologists. On returning 4 months later, we found that all newly presented patients were correctly diagnosed to have the epidemic disease. With the new case definition and the application of a few simple psychophysical tests, the false-positive rate of diagnosis became much lower. After vitamin therapy, we reexamined the patients seen on our initial visit, and all showed marked improvement. The Cuban epidemic was characterized by an optic neuropathy with features that were similar to those of tobacco/alcohol amblyopia and Leber's optic atrophy. Recent political, economic, and social changes in Cuba may have contributed to the nutritional and/or toxic compromise of mitochondrial function of an acquired nature, which led to selective retinal ganglion cell damage. We have termed this condition Cuban epidemic optic neuropathy.

A Re-Examination of Neuropsychological Functioning in Persian Gulf War Era Veterans

DTIC Science & Technology

2003-08-01

neuropsychological evaluations and a group of individuals seeking treatment or diagnostic evaluation for any purpose. Controls were treatment -seeking non deployed...GW-era veterans studied between 1995-1998. The prior finding of differences between the deployed and non-deployed treatment seeking GW-era veterans in...included patients who were initially referred for clinical neuropsychological evaluations and a group of individuals who were seeking treatment or

Exploring Clinical Reasoning in Novices: A Self-Regulated Learning Microanalytic Approach

DTIC Science & Technology

2013-07-05

important medical school performance outcomes. Self-Regulated Learning Microanalysis Social-cognitive researchers have defined SRL as “the...It is important to note at the outset, however, that our plan was not to use SRL microanalysis to comprehensively assess students’ reasoning skills...2.97 1.31 .29* 1.39 .51 .32 † 22 Discussion This study was important because it represents an initial attempt to examine SRL

The Role of Fundus Autofluorescence in Late-Onset Retinitis Pigmentosa (LORP) Diagnosis

PubMed Central

Lee, Tamara J.; Hwang, John C.; Chen, Royce W. S.; Lima, Luiz H.; Wang, Nan-Kai; Tosi, Joaquin; Freund, K. Bailey; Yannuzzi, Lawrence A.; Tsang, Stephen H.

2015-01-01

Purpose To demonstrate the utility and characteristics of fundus autofluorescence in late-onset retinitis pigmentosa. Methods Observational case series. Patients diagnosed with late-onset retinitis pigmentosa were identified retrospectively in an institutional setting. Twelve eyes of six patients were identified and medical records were reviewed. Results All patients presented with slowly progressive peripheral field loss and initial clinical examination revealed only subtle retinal changes. There was a notable lack of intraretinal pigment migration in all patients. Five out of six patients underwent magnetic resonance imaging of the brain to rule out intracranial processes and all were referred from another ophthalmologist for further evaluation. Fundus autofluorescence was ultimately employed in all patients and revealed more extensive retinal pathology than initially appreciated on clinical examination. Fundus autofluorescence directed the workup toward a retinal etiology in all cases and led to the eventual diagnosis of late-onset retinitis pigmentosa through electroretinogram testing. Conclusion Fundus autofluorescence may be a more sensitive marker for retinal pathology than stereo fundus biomicroscopy alone in late-onset retinitis pigmentosa. Early use of fundus autofluorescence imaging in the evaluation of patients with subtle retinal lesions and complaints of peripheral field loss may be an effective strategy for timely and cost-efficient diagnosis. PMID:23899229

Motivational tools to improve probationer treatment outcomes.

PubMed

Taxman, Faye S; Walters, Scott T; Sloas, Lincoln B; Lerch, Jennifer; Rodriguez, Mayra

2015-07-01

Motivational interviewing (MI) is a promising practice to increase motivation, treatment retention, and reducing recidivism among offender populations. Computer-delivered interventions have grown in popularity as a way to change behaviors associated with drug and alcohol use. Motivational Assistance Program to Initiate Treatment (MAPIT) is a three arm, multisite, randomized controlled trial, which examines the impact of Motivational interviewing (MI), a motivational computer program (MC), and supervision as usual (SAU) on addiction treatment initiation, engagement, and retention. Secondary outcomes include drug/alcohol use, probation progress, recidivism (i.e., criminal behavior) and HIV/AIDS testing and treatment among probationers. Participant characteristics are measured at baseline, 2, and 6 months after assignment. The entire study will include 600 offenders, with each site recruiting 300 offenders (Baltimore City, Maryland and Dallas, Texas). All participants will go through standard intake procedures for probation and participate in probation requirements as usual. After standard intake, participants will be recruited and screened for eligibility. The results of this clinical trial will fill a gap in knowledge about ways to motivate probationers to participate in addiction treatment and HIV care. This randomized clinical trial is innovative in the way it examines the use of in-person vs. technological approaches to improve probationer success. NCT01891656. Copyright © 2015. Published by Elsevier Inc.

Uveitis as an initial manifestation of acquired immunodeficiency syndrome.

PubMed

Tsen, Chui-Lien; Chen, Shih-Chou; Chen, Yao-Shen; Sheu, Shwu-Jiuan

2017-10-01

Human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) is a multisystem disease that can involve the human eyes. Using ophthalmic examination records from January 2006 to November 2015, we retrospectively reviewed all patients who were diagnosed with HIV/AIDS in our hospital. The study was performed at a tertiary referral center in southern Taiwan. Data included age, gender, ophthalmic examinations, systemic conditions, CD4 cell counts, course, and treatment. Eleven patients were identified as having AIDS with uveitis as their presenting manifestation. All were men, with a mean age of 39.5 ± 11.4 years (range 24-56). The mean CD4 + T-cell counts were 91.7 ± 50.3 cells/μl (range 27-169). Ocular diagnoses included cytomegalovirus (CMV) retinitis in five patients, ocular syphilis in four patients, and ocular toxoplasmosis in two patients. Uveitis resolved in all patients after medical treatment. However, a retinal detachment developed in two eyes in CMV retinitis and one eye in ocular syphilis. Ocular manifestations are among the most common clinical features in patients with HIV/AIDS who have varying clinical presentations that affect almost all ocular structures. This study demonstrated that ocular findings could be an initial manifestation of an underlying disease. Awareness of ocular lesions in HIV/AIDS is important for early recognition and management.

Overgeneral Autobiographical Memory as a Predictor of the Course of Depression: A Meta-Analysis

PubMed Central

Sumner, Jennifer A.; Griffith, James W.; Mineka, Susan

2010-01-01

Overgeneral autobiographical memory (OGM) is a robust phenomenon in depression, but the extent to which OGM predicts the course of depression is not well-established. This meta-analysis synthesized data from 15 studies to examine the degree to which OGM 1) correlates with depressive symptoms at follow-up, and 2) predicts depressive symptoms at follow-up over and above initial depressive symptoms. Although the effects are small, specific and categoric/overgeneral memories generated during the Autobiographical Memory Test significantly predicted the course of depression. Fewer specific memories and more categoric/overgeneral memories were associated with higher follow-up depressive symptoms, and predicted higher follow-up symptoms over and above initial symptoms. Potential moderators were also examined. The age and clinical depression status of participants, as well as the length of follow-up between the two depressive symptom assessments, significantly moderated the predictive relationship between OGM and the course of depression. The predictive relationship between specific memories and follow-up depressive symptoms became greater with increasing age and a shorter length of follow-up, and the predictive relationship was stronger for participants with clinical depression diagnoses than for nonclinical participants. These findings highlight OGM as a predictor of the course of depression, and future studies should investigate the mechanisms underlying this relationship. PMID:20399418

Reported Systems Changes and Sustainability Perceptions of Three State Departments of Health Implementing Multi-Faceted Evidence-Based Fall Prevention Efforts.

PubMed

Smith, Matthew Lee; Schneider, Ellen C; Byers, Imani N; Shubert, Tiffany E; Wilson, Ashley D; Towne, Samuel D; Ory, Marcia G

2017-01-01

Although the concepts of systems change and sustainability are not new, little is known about the factors associated with systems change sustaining multi-state, multi-level fall prevention efforts. This exploratory study focuses on three State Departments of Health (DOH) that were awarded 5-year funding from the Centers for Disease Control and Prevention to simultaneously implement four separate yet related evidence-based fall prevention initiatives at the clinical, community, and policy level. The purpose of this study was to examine changes in partnerships and collaborative activities that occurred to accomplish project goals (examining changes in the context of "before funding" and "after funding was received"). Additionally, this study explored changes in State DOH perceptions about action related to sustainability indicators in the context of "during funding" and "after funding ends." Findings from this study document the partnership and activity changes necessary to achieve defined fall prevention goals after funding is received, and that the importance of sustainability indicator documentation is seen as relevant during funding, but less so after the funding ends. Findings from this study have practice and research implications that can inform future funded efforts in terms of sector and stakeholder engagement necessary for initiating, implementing, and sustaining community- and clinical-based fall prevention interventions.

Recurrence of Phaeochromocytoma and Abdominal Paraganglioma After Initial Surgical Intervention.

PubMed

Johnston, Philip C; Mullan, Karen R; Atkinson, A Brew; Eatock, Fiona C; Wallace, Helen; Gray, Moyra; Hunter, Steven J

2015-05-01

Clinical and biochemical follow up after surgery for phaeochromocytoma is essential with long term studies demonstrating recurrence frequencies between 6% and 23%. To examine the characteristics and frequency of tumour recurrence in a regional endocrine referral centre, in patients with surgical resection of phaeochromocytoma (P) and abdominal paraganglioma (AP). We identified a cohort of 52 consecutive patients who attended our Regional Endocrinology & Diabetes Centre and retrospectively reviewed their clinical, biochemical and radiological data (between 2002 and 2013). After confirmation of early post-operative remission by negative biochemical testing, tumour recurrence was defined by demonstration of catecholamine excess with confirmatory imaging. Phaeochromocytoma was confirmed histologically in all cases (43:P, 9:AP, mean-age:53 years). Open adrenalectomy was performed in 20 cases and laparoscopically in 32. Hereditary phaeochromocytoma was confirmed by genetic analysis in 12 (23%) patients. Median follow up time from initial surgery was 47 months, (range: 12 - 296 months), 49 patients had no evidence of tumour recurrence at latest follow-up. Three patients (6%) demonstrated tumour development, one in a patient with VHL which occurred in a contralateral adrenal gland, one sporadic case had local recurrence, and an adrenal tumour occurred in a patient with a SDHB gene mutation who had a previous bladder tumour. After initial surgery, the tumours occurred at 8.6, 12.0 and 17.7 years respectively. In this study tumour development occurred in 6% of patients. Although tumour rates were low, careful and sustained clinical and biochemical follow up is advocated, as new tumour development or recurrence may occur long after the initial surgery is performed.

Mortality after nasogastric tube feeding initiation in long-term care elderly with oropharyngeal dysphagia--the contribution of refeeding syndrome.

PubMed

Lubart, Emilia; Leibovitz, Arthur; Dror, Yosef; Katz, Elena; Segal, Refael

2009-01-01

The refeeding syndrome (RS) is an underappreciated but clinically important entity characterized by acute electrolyte abnormalities, mainly hypophosphatemia, fluid retention and dysfunction of various organs and systems, which can result in significant morbidity and occasionally death. To examine the incidence of death cases and death causes following nasogastric tube (NGT) feeding initiation in frail elderly with particular reference to RS. Forty patients with feeding problems for at least 72 h before restarting of alimentation by NGT were included. Excluded were those in any critical clinical situation. Clinical parameters and nutritional assessment were recorded before and after refeeding. Blood samples were taken before, daily for the first 3 days and 1 week after refeeding initiation. During the 1st week of refeeding, 9 patients (22.5%) died and within 1 month 10 more, summing to 47.5%. Most deaths were due to infectious causes [15 out of 19, (79%)]; some were due to no obvious reason [4 out of 19, (21%)]. Significant electrolyte changes were observed in the 2-3 days following refeeding. Significant were the decreases in phosphorus and elevations in potassium and lymphocytes (day 7). We found no correlations between the severity of decreases in levels of phosphorus and mortality. Mortality after NGT feeding initiation was high, mainly due to infectious complications. However, in a considerable number of patients hypophosphatemia was noted, suggesting that RS could be a contributory factor of mortality. Since this is a treatable condition, more attention should be paid to detecting and coping with this problem. Copyright 2009 S. Karger AG, Basel.

Health promotion practice and its implementation in Swedish health care.

PubMed

Brobeck, E; Odencrants, S; Bergh, H; Hildingh, C

2013-09-01

Health promotion practice is an important work assignment within the entire health and medical care sector. Nurses are important for the development and implementation of health promotion in clinical practice. The aim was to describe how district nurses view health promotion practice and how it was implemented in clinical practice following a training initiative. The study has a descriptive design and a qualitative method. The sample consisted of three focus groups with 16 participants. The interviews were conducted as a conversation with focus on the district nurses view of health promotion and its implementation in clinical practice. The data have been processed using manifest qualitative content analysis. Three categories, titled Training as motivation, Lack of grounding and Lack of scope were identified. The result demonstrated that training provides motivation, but also the importance of grounding in the organization and the need for scope in performing health promotion practice. Our results show that the training initiative has contributed positively to the district nurses' view of health promotion practice, but that they also feel that there are obstacles. The district nurses in our study suggest that health promotion practice should be more visible, and not something that is done when time permits. The district nurses feel motivated and have an enthusiasm for health promotion practice but more time and resources are required to design successful health-promoting initiatives. Before implementing a major training initiative for healthcare personnel in health promotion, it is essential to examine whether the conditions for this exist in the organization. © 2013 International Council of Nurses.

Do early career indicators of clinical skill predict subsequent career outcomes and practice characteristics for general internists?

PubMed

Gray, Bradley; Reschovsky, James; Holmboe, Eric; Lipner, Rebecca

2013-06-01

To study relationships between clinical skill measures assessed at the beginning of general internists' careers and their career outcomes and practice characteristics. General Internist Community Tracking Study Physician Survey respondents (2000-2001, 2004-2005) linked with residency program evaluations and American Board of Internal Medicine board certification examination score records; n = 2,331. Cross-sectional regressions of career outcome and practice characteristic measures on board examination scores/success, residency evaluations interacted with residency type, and potential confounding variables. Failure to achieve board certification was associated with $27,206 (18 percent, p < .05) less income and 14.9 percent more minority patients relative to physicians scoring in the bottom quartile on their initial examination who eventually became certified (p < .01). Other skill measures were not associated with income. Scoring in the top rather than bottom quartile on the board certification examination was associated with 9 percent increased likelihood of reporting high career satisfaction (p < .05). Among physicians trained in community hospital residency programs, lower evaluations were associated with 14.5 percent higher share of minority patients (p < .05). Both skill measures were associated with practice type. There are associations between early career skill measures and career outcomes. In addition, minority patients are more likely to be treated by physicians with lower early career clinical skills measures than nonminority patients. © Health Research and Educational Trust.

The role of abdominal ultrasound in the diagnosis of typhoid fever: an observational study.

PubMed

Younis, Saeed Nadhim

2014-01-01

To study the usefulness of abdominal ultrasound in the diagnosis of typhoid fever and to determine the common ultrasound findings early in the course of the disease. Abdominal ultrasound examination was performed within the first week of initiation of symptoms in 350 cases with clinical diagnosis of typhoid fever. Subsequent ultrasound follow-up examination was done 15 days later (beginning of the third week). All the patients proved to have positive Widal test and Sallmonella culture. The study was performed in Erbil-Iraq from the period January 1993 to October 2010. The following ultrasound findings were reported: hepatomegaly (31.4%), prominent intrahepatic bile ducts (64.85%), splenomegaly (100%), mesenteric lymphadenopathy (42.85%), bowel wall thickening (35.71%), acalculous cholecystitis (16.28%), perforations (1.14%), and ascites in (3.4%). The current study showed that the findings are typical enough to justify initiation of treatment for typhoid fever when serology is equivocal and culture is negative, and is fairly safe to say that normal ultrasound examination early in the course of febrile illness rules out typhoid fever. Copyright © 2013 Elsevier Ltd. All rights reserved.

Whipple's disease. Report of five cases with different clinical features.

PubMed

Ferrari, M de L; Vilela, E G; Faria, L C; Couto, C A; Salgado, C J; Leite, V R; Brasileiro Filho, G; Bambirra, E A; Mendes, C M; Carvalho, S de C; de Oliveira, C A; da Cunha, A S

2001-01-01

Whipple's disease (WD) is a rare systemic disease of infectious etiology which involves the small intestine but can virtually affect any organ. We present here five cases (four males and one female) ranging in age from 20 to 59 years. All patients had intestinal involvement associated or not with clinical manifestations linked to this organ. Vegetation in the tricuspid valve was observed in one patient, suggesting endocarditis caused by Tropheryma whippelii, with disappearance of the echocardiographic alterations after treatment. In one of the male patients the initial clinical manifestation was serologically negative spondylitis, with no diarrhea occurring at any time during follow-up. Ocular involvement associated with intestinal malabsorption and significant weight loss were observed in one case. In the other two cases, diarrhea was the major clinical manifestation. All patients were diagnosed by histological examination of the jejunal mucosa and, when indicated, of extraintestinal tissues by light and electron microscopy. After antibiotic treatment, full remission of symptoms occurred in all cases. A control examination of the intestinal mucosa performed after twelve months of treatment with sulfamethoxazole-trimethoprim revealed the disappearance of T. whippelii in four patients. The remaining patient was lost to follow-up.

Vulval lichen planus-lichen sclerosus overlap.

PubMed

Howard, Matthew; Hall, Anthony

2018-01-01

Vulval lichen planus-lichen sclerosus overlap is an emerging observation. Few clinical reports exist with no reviews of literature. We present a focused update of this phenomenon and discuss a clinical case. We report a 63-year-old woman with a 20-year history of ulcerative vulvo-vaginitis, initially diagnosed as benign mucous membrane (cicatricial) pemphigoid. This led to prolonged treatment with oral corticosteroids with minimal improvement in symptoms. Subsequent complications of long-term use of systemic corticosteroid ensued. A clinico-pathological diagnosis of severe erosive lichen planus was made on clinical findings and on non-specific biopsy changes of ulceration and inflammation. Treatment with topical clobetasol propionate 0.05% ointment twice daily led to dramatic improvement of ulceration, easing of discomfort and marked improvement in quality of life. Clinical examination revealed Wickham's striae on the labia majora supporting the diagnosis. Six years after commencement of topical clobetasol, white plaques were noticed on the labia majora, perineum and peri-anal region consistent with lichen sclerosus, confirmed by repeat vulval skin biopsy and on vulvectomy. This case highlights the challenge of diagnosis of extensive vulvo-vaginal ulceration and the necessity to re-examine a previous diagnosis if there is poor response to treatment.

Familial early-onset dementia with tau intron 10 + 16 mutation with clinical features similar to those of Alzheimer disease.

PubMed

Doran, Mark; du Plessis, Daniel G; Ghadiali, Eric J; Mann, David M A; Pickering-Brown, Stuart; Larner, Andrew J

2007-10-01

Frontotemporal dementia with parkinsonism linked to chromosome 17 (FTDP-17) owing to the tau intron 10 + 16 mutation usually occurs with a prototypical frontotemporal dementia phenotype with prominent disinhibition and affective disturbances. To report a new FTDP-17 pedigree with the tau intron 10 + 16 mutation demonstrating a clinical phenotype suggestive of Alzheimer disease. Case reports. Regional neuroscience centers in northwest England. Patients We examined 4 members of a kindred in which 8 individuals were affected in 3 generations. All 4 patients reported memory difficulty. Marked anomia was also present, but behavioral disturbances were conspicuously absent in the early stages of disease. All patients had an initial clinical diagnosis of Alzheimer disease. No mutations were found in the presenilin or amyloid precursor protein genes. Pathologic examination of the proband showed features typical of FTDP-17, and tau gene analysis showed the intron 10 + 16 mutation. This pedigree illustrates the phenotypic variability of tau intron 10 + 16 mutations. In pedigrees with a clinical diagnosis of Alzheimer disease but without presenilin or amyloid precursor protein gene mutations, tau gene mutations may be found.

Painless thyroiditis associated to thyroid carcinoma: role of initial ultrasonography evaluation.

PubMed

Valentini, Raisa Bressan; Macedo, Bruno Mussoi de; Izquierdo, Rogério Friedrich; Meyer, Erika Laurini Souza

2016-04-01

Even though it is a rare event, most associations of thyroid carcinoma with subacute thyroiditis described in the literature are related to its granulomatous form (Quervain's thyroiditis). We present a patient with subacute lymphocytic thyroiditis (painless thyroiditis) and papillary thyroid cancer that was first suspected in an initial ultrasound evaluation. A 30-year old female patient who was referred to the emergency room due to hyperthyroidism symptoms was diagnosed with painless thyroiditis established by physical examination and laboratory findings. With the presence of a palpable painless thyroid nodule an ultrasound was prescribed and the images revealed a suspicious thyroid nodule, microcalcification focus in the heterogeneous thyroid parenquima and cervical lymphadenopathy. Fine needle aspiration biopsy was taken from this nodule; cytology was assessed for compatibility with papillary thyroid carcinoma. Postsurgical pathology evaluation showed a multicentric papillary carcinoma and lymphocytic infiltration. Subacute thyroiditis, regardless of type, may produce transitory ultrasound changes that obscure the coexistence of papillary carcinoma. Due to this, initial thyroid ultrasound evaluation should be delayed until clinical recovery. We recommended a thyroid ultrasound exam for initial evaluation of painless thyroiditis, particularly in patients with palpable thyroid nodule. Further cytological examination is recommended in cases presenting with suspect thyroid nodule and/or non-nodular hypoechoic (> 1 cm) or heterogeneous areas with microcalcification focus.

Fiberoptic endoscopic evaluation of swallowing in intensive care unit patients

PubMed Central

Hafner, Gert; Neuhuber, Andreas; Hirtenfelder, Sylvia; Schmedler, Brigitte

2007-01-01

Aspiration in critically ill patients frequently causes severe co-morbidity. We evaluated a diagnostic protocol using routine FEES in critically ill patients at risk to develop aspiration following extubation. We instructed intensive care unit physicians on specific risk factors for and clinical signs of aspiration following extubation in critically ill patients and offered bedside FEES for such patients. Over a 45-month period, we were called to perform 913 endoscopic examinations in 553 patients. Silent aspiration or aspiration with acute symptoms (cough or gag reflex as the bolus passed into the trachea) was detected in 69.3% of all patients. Prolonged non-oral feeding via a naso-gastric tube was initiated in 49.7% of all patients. In 13.2% of patients, a percutaneous endoscopic gastrostomy was initiated as a result of FEES findings, and in 6.3% an additional tracheotomy to prevent aspiration had to be initiated. In 59 out of 258 patients (22.9%), tracheotomies were closed, and 30.7% of all 553 patients could be managed with the immediate onset of an oral diet and compensatory treatment procedures. Additional radiological examinations were not required. FEES in critically ill patients allows for a rapid evaluation of deglutition and for the immediate initiation of symptom-related rehabilitation or for an early resumption of oral feeding. PMID:17968575

Implementation of an oxygen therapy clinic to manage users of long-term oxygen therapy.

PubMed

Chaney, John C; Jones, Kevin; Grathwohl, Kurt; Olivier, Kenneth N

2002-11-01

To evaluate the initial benefits of establishing an oxygen therapy clinic (OTC) to manage users of long-term oxygen therapy (LTOT). Cross-sectional observational study. Military-affiliated, tertiary care hospital. Current users of LTOT at our institution and patients with new oxygen prescriptions between June 2000 and May 2001. The OTC evaluation consisted of a focused medical interview and physical examination by a respiratory therapist. Demographic data, indications for supplemental oxygen, oxygen-related diagnoses, cardiopulmonary review of systems, pertinent physical examination findings, pulmonary function testing, and oximetry data were recorded. Patients prescribed oxygen during hospitalization were followed up for recertification within 90 days based on the recommendations of the Fifth Oxygen Consensus Conference. Also, patients with existing oxygen prescriptions and new oxygen prescriptions during the study period were evaluated in the OTC. Data are provided for the initial evaluation in this clinic. A total of 283 patients were evaluated in the OTC during the study period. Ninety-seven patients with a new oxygen prescription during hospitalization were evaluated, with a mean +/- SE time from discharge to evaluation of 2.6 +/- 0.4 months. At follow-up, 50.5% of these patients no longer met Medicare guidelines for LTOT. A significant change in oxygen prescription was required in 27.9% of these patients. A total of 95 outpatients with existing oxygen prescriptions were contacted for recertification in the OTC. Of these patients, 31.6% no longer met Medicare criteria for LTOT and 26% required a significant change to their oxygen prescription. Oxygen therapy was discontinued in 22% of the 91 patients who were referred from other outpatient clinics, and the oxygen prescription was changed in another 29.7%. Results of this initial evaluation suggest that the institution of a respiratory therapist-managed OTC to manage home oxygen patients can significantly decrease inappropriate supplemental oxygen use, which can result in significant cost savings while providing improved health-care delivery. Further evaluation is necessary to identify the long-term benefits and cost savings in this population.

Olfactory Hallucinations without Clinical Motor Activity: A Comparison of Unirhinal with Birhinal Phantosmia

PubMed Central

Henkin, Robert I.; Potolicchio, Samuel J.; Levy, Lucien M.

2013-01-01

Olfactory hallucinations without subsequent myoclonic activity have not been well characterized or understood. Herein we describe, in a retrospective study, two major forms of olfactory hallucinations labeled phantosmias: one, unirhinal, the other, birhinal. To describe these disorders we performed several procedures to elucidate similarities and differences between these processes. From 1272, patients evaluated for taste and smell dysfunction at The Taste and Smell Clinic, Washington, DC with clinical history, neurological and otolaryngological examinations, evaluations of taste and smell function, EEG and neuroradiological studies 40 exhibited cyclic unirhinal phantosmia (CUP) usually without hyposmia whereas 88 exhibited non-cyclic birhinal phantosmia with associated symptomology (BPAS) with hyposmia. Patients with CUP developed phantosmia spontaneously or after laughing, coughing or shouting initially with spontaneous inhibition and subsequently with Valsalva maneuvers, sleep or nasal water inhalation; they had frequent EEG changes usually ipsilateral sharp waves. Patients with BPAS developed phantosmia secondary to several clinical events usually after hyposmia onset with few EEG changes; their phantosmia could not be initiated or inhibited by any physiological maneuver. CUP is uncommonly encountered and represents a newly defined clinical syndrome. BPAS is commonly encountered, has been observed previously but has not been clearly defined. Mechanisms responsible for phantosmia in each group were related to decreased gamma-aminobutyric acid (GABA) activity in specific brain regions. Treatment which activated brain GABA inhibited phantosmia in both groups. PMID:24961619

Real-time evaluation and visualization of learner performance in a mixed-reality environment for clinical breast examination.

PubMed

Kotranza, Aaron; Lind, D Scott; Lok, Benjamin

2012-07-01

We investigate the efficacy of incorporating real-time feedback of user performance within mixed-reality environments (MREs) for training real-world tasks with tightly coupled cognitive and psychomotor components. This paper presents an approach to providing real-time evaluation and visual feedback of learner performance in an MRE for training clinical breast examination (CBE). In a user study of experienced and novice CBE practitioners (n = 69), novices receiving real-time feedback performed equivalently or better than more experienced practitioners in the completeness and correctness of the exam. A second user study (n = 8) followed novices through repeated practice of CBE in the MRE. Results indicate that skills improvement in the MRE transfers to the real-world task of CBE of human patients. This initial case study demonstrates the efficacy of MREs incorporating real-time feedback for training real-world cognitive-psychomotor tasks.

Metastatic renal cell carcinoma in the nasopharynx.

PubMed

Atar, Yavuz; Topaloglu, Ilhan; Ozcan, Deniz

2013-01-01

Metastatic renal cell carcinoma of the nasopharynx, nasal cavity, and paranasal sinuses can be misdiagnosed as primary malignant or benign diseases. A 33-year-old male attended our outpatient clinic complaining of difficulty breathing through the nose, bloody nasal discharge, postnasal drop, snoring, and discharge of phlegm. Endoscopic nasopharyngeal examination showed a vascularized nasopharyngeal mass. Under general anesthesia, multiple punch biopsies were taken from the nasopharynx. Pathologically, the tumor cells had clear cytoplasm and were arranged in a trabecular pattern lined by a layer of endothelial cells. After the initial pathological examination, the pathologist requested more information about the patient's clinical status. A careful history revealed that the patient had undergone left a nephrectomy for a kidney mass diagnosed as renal cell carcinoma 3 years earlier. Subsequently, nasopharyngeal metastatic renal cell carcinoma was diagnosed by immunohistochemical staining with CD10 and vimentin. Radiotherapy was recommended for treatment.

Standardisation of role players for the Clinical Skills Assessment of the MRCGP.

PubMed

Russell, David; Simpson, Robin; Rendel, Sue

2011-05-01

This paper describes the processes used to prepare the role players who simulate the 'patients' in the MRCGP Clinical Skills Assessment (CSA) examination, one of the licensing qualifications for GPs completing their training. Because it is such a high-stakes exam, the CSA must be seen to be fair and trustworthy, and such attributes could be compromised by inadequate role player performance. On a CSA examination day, three role players simulate the same 'patient' simultaneously on three different exam floors, each playing the same case up to 26 times on the day, and these 'patients' must present in a consistent and reliable manner to ensure that all candidates face the same test situation. The paper describes the initial selection and training of the actors, how they are prepared on the day of the exam itself, and the quality assurance processes designed to ensure that the exam has excellent role players performing as the simulated 'patients'.

Association of HIV diversity and virologic outcomes in early antiretroviral treatment: HPTN 052.

PubMed

Palumbo, Philip J; Wilson, Ethan A; Piwowar-Manning, Estelle; McCauley, Marybeth; Gamble, Theresa; Kumwenda, Newton; Makhema, Joseph; Kumarasamy, Nagalingeswaran; Chariyalertsak, Suwat; Hakim, James G; Hosseinipour, Mina C; Melo, Marineide G; Godbole, Sheela V; Pilotto, Jose H; Grinsztejn, Beatriz; Panchia, Ravindre; Chen, Ying Q; Cohen, Myron S; Eshleman, Susan H; Fogel, Jessica M

2017-01-01

Higher HIV diversity has been associated with virologic outcomes in children on antiretroviral treatment (ART). We examined the association of HIV diversity with virologic outcomes in adults from the HPTN 052 trial who initiated ART at CD4 cell counts of 350-550 cells/mm3. A high resolution melting (HRM) assay was used to analyze baseline (pre-treatment) HIV diversity in six regions in the HIV genome (two in gag, one in pol, and three in env) from 95 participants who failed ART. We analyzed the association of HIV diversity in each genomic region with baseline (pre-treatment) factors and three clinical outcomes: time to virologic suppression after ART initiation, time to ART failure, and emergence of HIV drug resistance at ART failure. After correcting for multiple comparisons, we did not find any association of baseline HIV diversity with demographic, laboratory, or clinical characteristics. For the 18 analyses performed for clinical outcomes evaluated, there was only one significant association: higher baseline HIV diversity in one of the three HIV env regions was associated with longer time to ART failure (p = 0.008). The HRM diversity assay may be useful in future studies exploring the relationship between HIV diversity and clinical outcomes in individuals with HIV infection.

Root coverage using acellular dermal matrix and comparing a coronally positioned tunnel with and without platelet-rich plasma: a pilot study in humans.

PubMed

Shepherd, Neal; Greenwell, Henry; Hill, Margaret; Vidal, Ricardo; Scheetz, James P

2009-03-01

The primary aim of this randomized, controlled, blinded clinical pilot study was to compare the percentage of recession defect coverage obtained with a coronally positioned tunnel (CPT) plus an acellular dermal matrix allograft (ADM) to that of a CPT plus ADM and platelet-rich plasma (CPT/PRP) 4 months post-surgically. Eighteen patients with Miller Class I or II recession >or=3 mm at one site were treated and followed for 4 months. Nine patients received a CPT plus ADM and were considered the positive control group. The test group consisted of nine patients treated with a CPT plus ADM and PRP. Patients were randomly selected by a coin toss to receive the test or positive control treatment. The mean recession at the initial examination for the CPT group was 3.6 +/- 1.0 mm, which was reduced to 1.0 +/- 1.0 mm at the 4-month examination for a gain of 2.6 +/- 1.5 mm or 70% defect coverage (P <0.05). The mean recession at the initial examination for the CPT/PRP group was 3.3 +/- 0.7 mm, which was reduced to 0.4 +/- 0.7 mm at the 4-month examination for a gain of 2.9 +/- 0.5 mm or 90% defect coverage (P <0.05). There were no statistically significant differences between the groups (P >0.05). The CPT plus ADM and PRP produced defect coverage of 90%, whereas the CPT with ADM produced only 70% defect coverage. This difference was not statistically significant, but it may be clinically significant.

Automated and objective action coding of facial expressions in patients with acute facial palsy.

PubMed

Haase, Daniel; Minnigerode, Laura; Volk, Gerd Fabian; Denzler, Joachim; Guntinas-Lichius, Orlando

2015-05-01

Aim of the present observational single center study was to objectively assess facial function in patients with idiopathic facial palsy with a new computer-based system that automatically recognizes action units (AUs) defined by the Facial Action Coding System (FACS). Still photographs using posed facial expressions of 28 healthy subjects and of 299 patients with acute facial palsy were automatically analyzed for bilateral AU expression profiles. All palsies were graded with the House-Brackmann (HB) grading system and with the Stennert Index (SI). Changes of the AU profiles during follow-up were analyzed for 77 patients. The initial HB grading of all patients was 3.3 ± 1.2. SI at rest was 1.86 ± 1.3 and during motion 3.79 ± 4.3. Healthy subjects showed a significant AU asymmetry score of 21 ± 11 % and there was no significant difference to patients (p = 0.128). At initial examination of patients, the number of activated AUs was significantly lower on the paralyzed side than on the healthy side (p < 0.0001). The final examination for patients took place 4 ± 6 months post baseline. The number of activated AUs and the ratio between affected and healthy side increased significantly between baseline and final examination (both p < 0.0001). The asymmetry score decreased between baseline and final examination (p < 0.0001). The number of activated AUs on the healthy side did not change significantly (p = 0.779). Radical rethinking in facial grading is worthwhile: automated FACS delivers fast and objective global and regional data on facial motor function for use in clinical routine and clinical trials.

Medical students as health educators at a student-run free clinic: improving the clinical outcomes of diabetic patients.

PubMed

Gorrindo, Phillip; Peltz, Alon; Ladner, Travis R; Reddy, India; Miller, Bonnie M; Miller, Robert F; Fowler, Michael J

2014-04-01

Student-run free clinics (SRFCs) provide service-learning opportunities for medical students and care to underserved patients. Few published studies, however, support that they provide high-quality care. In this study, the authors examined the clinical impact of a medical student health educator program for diabetic patients at an SRFC. In 2012, the authors retrospectively reviewed the electronic medical records of diabetic patients who established care at Shade Tree Clinic in Nashville, Tennessee, between 2008 and 2011. They compared clinical outcomes at initial presentation to the clinic and 12 months later. They analyzed the relationship between the number of patient-student interactions (touchpoints) and change in hemoglobin A1c values between these two time points and compared the quality of care provided to best-practice benchmarks (process and outcomes measures). The authors studied data from 45 patients. Mean hemoglobin A1c values improved significantly from 9.6 to 7.9, after a mean of 12.5 ± 1.5 months (P < .0001). A trend emerged between increased number of touchpoints and improvement in A1c values (r = 0.06, P = .10). A high percentage of patients were screened during clinic visits, whereas a low to moderate percentage met benchmarks for A1c, LDL, and blood pressure levels. These findings demonstrate that a medical student health educator program at an SRFC can provide high-quality diabetes care and facilitate clinical improvement one year after enrollment, despite inherent difficulties in caring for underserved patients. Future studies should examine the educational and clinical value of care provided at SRFCs.

Early treatment with laronidase improves clinical outcomes in patients with attenuated MPS I: a retrospective case series analysis of nine sibships.

PubMed

Al-Sannaa, Nouriya A; Bay, Luisa; Barbouth, Deborah S; Benhayoun, Youssef; Goizet, Cyril; Guelbert, Norberto; Jones, Simon A; Kyosen, Sandra Obikawa; Martins, Ana Maria; Phornphutkul, Chanika; Reig, Celia; Pleat, Rebecca; Fallet, Shari; Ivanovska Holder, Iva

2015-10-07

Enzyme replacement therapy (ERT) with laronidase, (recombinant human α-L-iduronidase; Aldurazyme) is the primary treatment option for patients with attenuated mucopolysaccharidosis type I (MPS I). This study examined the effect of early ERT on clinical manifestations. This multinational, retrospective case series abstracted data from records of 20 patients with Hurler-Scheie syndrome within nine sibships that included older siblings treated with laronidase after the development of significant clinical symptoms, and younger siblings treated before significant symptomatology. Median age at diagnosis was 5.6 and 0.5 years for older and younger siblings, respectively. Median age at ERT initiation was 7.9 and 1.9 years for older and younger siblings, respectively. Improvement or stabilization of somatic signs and symptoms was more notable in younger siblings. Organomegaly present at onset of ERT improved in the majority of both older and younger siblings. Analysis of physician-rated symptom severity demonstrated that cardiac, musculoskeletal, and cognitive symptoms, when absent or mild in younger siblings at ERT initiation, generally did not develop or progress. The majority of older siblings had height/length Z-scores greater than two standard deviations below the mean (less than -2) at both time points. In general, Z-scores for younger siblings were closer to the sex- and age-matched means at follow-up. These findings suggest early initiation of laronidase, prior to the onset of symptoms in patients with attenuated MPS I, can slow or prevent the development of severe clinical manifestations.

Hypophosphatemia in Enterally Fed Patients in the Surgical Intensive Care Unit.

PubMed

Fuentes, Eva; Yeh, D Dante; Quraishi, Sadeq A; Johnson, Emily A; Kaafarani, Haytham; Lee, Jarone; King, David R; DeMoya, Marc; Fagenholz, Peter; Butler, Kathryn; Chang, Yuchiao; Velmahos, George

2017-04-01

Hypophosphatemia has been associated with refeeding malnourished patients, but its clinical significance is unclear. We investigated the incidence of refeeding hypophosphatemia (RH) in the surgical intensive care unit (SICU) and its association with early enteral nutrition (EN) administration and clinical outcomes. We performed a retrospective review of a 2-year database of patients receiving EN in the SICU. RH was defined as a post-EN phosphorus (PHOS) level decrement of >0.5 mg/dL to a nadir <2.0 mg/dL within 8 days from EN initiation. We investigated the risk factors for RH and examined its association with clinical outcomes using multivariable regression analyses. In total, 213 patients comprised our analytic cohort. Eighty-three of 213 (39%) individuals experienced RH and 43 of 130 (33%) of the remaining patients experienced non-RH hypophosphatemia (nadir PHOS level <2.0 mg/dL). Overall, there was a total 59% incidence of hypophosphatemia of any cause (N = 126). Nutrition parameters did not differ between groups; most patients were initiated on EN within 48 hours of SICU admission, and timing of EN initiation was not a significant predictor for the development of RH. The median hospital length of stay (LOS) was 21 and 24 days for those with and without RH, respectively ( P = .79); RH remained a nonsignificant predictor for hospital LOS in the multivariable analysis. RH is common in the SICU but is not related to timing or amount of EN. Hypophosphatemia is also common in the critically ill, but regardless of etiology, it was not found to be a predictor of worse clinical outcomes.

Impact of Chest Radiography on Antibiotic Treatment for Children With Suspected Pneumonia.

PubMed

Nelson, Kyle A; Morrow, Christopher; Wingerter, Sarah L; Bachur, Richard G; Neuman, Mark I

2016-08-01

National guidelines discourage routine chest radiographs (CXRs) to confirm suspected pneumonia in children managed as outpatients. However, limiting CXRs may lead to antibiotic overuse. We examined the impact of CXRs and clinical suspicion on antibiotic treatment for children with suspected pneumonia. Children aged 3 months to 18 years undergoing CXR for suspected pneumonia in a pediatric emergency department were prospectively enrolled. Before CXR, physicians indicated their initial plan for antibiotics (yes or no) and clinical suspicion for radiographic pneumonia (<5%, 5-10%, 11-20%, 21-50%, 51-75%, >75%). Subjects had radiographic pneumonia if their CXRs demonstrated definite or possible findings of pneumonia. We compared antibiotic treatment according to pre-CXR antibiotic plan and suspicion for pneumonia and CXR results. Among the 107 children with a plan for antibiotics before CXR, 72% ultimately received antibiotics compared with 19% of the 1503 children without a pre-CXR plan for antibiotics (P < 0.001). Among those patients with a pre-CXR plan for antibiotics, 96% of children with radiographic pneumonia were ultimately treated compared with 54% without radiographic pneumonia (P < 0.001). If antibiotics were not initially planned, 37% with radiographic pneumonia were treated compared with 8% without radiographic pneumonia (P < 0.001). The use of CXR was more likely to influence antibiotic prescribing patterns when the clinical suspicion of pneumonia was low (<20%). Among children with high suspicion for pneumonia, CXRs infrequently altered the initial plan for antibiotics. However, when clinical suspicion for pneumonia was low, the use of CXR may reduce unnecessary antibiotic use.

Longitudinal evaluation of Patient Reported Outcomes Measurement Information Systems (PROMIS) measures in pediatric chronic pain

PubMed Central

Kashikar-Zuck, Susmita; Carle, Adam; Barnett, Kimberly; Goldschneider, Kenneth R.; Sherry, David D.; Mara, Constance A.; Cunningham, Natoshia; Farrell, Jennifer; Tress, Jenna; DeWitt, Esi Morgan

2015-01-01

The Patient Reported Outcomes Measurement Information System (PROMIS) initiative is a comprehensive strategy by the National Institutes of Health to support the development and validation of precise instruments to assess self-reported health domains across healthy and disease-specific populations. Much progress has been made in instrument development but there remains a gap in the validation of PROMIS measures for pediatric chronic pain. The purpose of this study was to investigate the construct validity and responsiveness to change of seven PROMIS domains for the assessment of children (ages 8-18) with chronic pain – Pain Interference, Fatigue, Anxiety, Depression, Mobility, Upper Extremity Function and Peer Relationships. PROMIS measures were administered at the initial visit and two follow-up visits at an outpatient chronic pain clinic (CPC; N=82) and at an intensive amplified pain day-treatment program (AMP; N= 63). Aim 1 examined construct validity of PROMIS measures by comparing them with corresponding “legacy” measures administered as part of usual care in the CPC sample. Aim 2 examined sensitivity to change in both CPC and AMP samples. Longitudinal growth models showed that PROMIS Pain Interference, Anxiety, Depression, Mobility, Upper Extremity and Peer Relationship measures and legacy instruments generally performed similarly with slightly steeper slopes of improvement in legacy measures. All seven PROMIS domains showed responsiveness to change. Results offered initial support for the validity of PROMIS measures in pediatric chronic pain. Further validation with larger and more diverse pediatric pain samples and additional legacy measures would broaden the scope of use of PROMIS in clinical research. PMID:26447704

Clinical and Demographic Characteristics Related to Onset

PubMed Central

Norris, Scott A; Jinnah, H A; Espay, Alberto J.; Klein, Christine; Brüggemann, Norbert; Barbano, Richard L.; Malaty, Irene; Rodriguez, Ramon L.; Vidailhet, Marie; Roze, Emmanuel; Reich, Stephen G.; Berman, Brian D.; LeDoux, Mark S.; Richardson, Sarah Pirio; Agarwal, Pinky; Mari, Zoltan; Ondo, William; Shih, Ludy C; Fox, Susan; Berardelli, Alfredo; Testa, Claudia M; Chang, Florence CF; Troung, Daniel; Nahab, Fatta; Xie, Tao; Hallett, Mark; Rosen, Ami R; Wright, Laura J; Perlmutter, JS

2016-01-01

Background Clinical characteristics of isolated, idiopathic cervical dystonia such as onset site and spread to and from additional body regions have been addressed in single-site studies with limited data and incomplete or variable dissociation of focal and segmental subtypes. Objectives To characterize clinical characteristics and demographics of isolated, idiopathic cervical dystonia in the largest standardized, multicenter cohort. Methods The Dystonia Coalition, through a consortium of 37 recruiting sites in North America, Europe and Australia recruited 1477 participants with focal (60.7%) or segmental (39.3%) cervical dystonia on examination. Clinical and demographic characteristics were evaluated in terms of the body region of dystonia onset and spread. Results Site of dystonia onset was: a) focal neck only (78.5%), b) focal onset elsewhere with later segmental spread to neck (13.3%), and c) segmental onset with initial neck involvement (8.2%).Frequency of spread from focal cervical to segmental dystonia (22.8%) was consistent with prior reports, but frequency of segmental onset with initial neck involvement was substantially higher than 3% previously reported. Cervical dystonia with focal neck onset, more than other subtypes, is associated with spread and tremor of any type. Sensory tricks were less frequent in cervical dystonia with segmental components, and segmental cervical onset occurred at an older age. Conclusions Subgroups had modest but significant differences in the clinical characteristics that may represent different clinical entities or pathophysiologic subtypes. These findings are critical for design and implementation of studies to describe, treat, or modify disease progression in idiopathic isolated cervical dystonia. PMID:27753188

The effect of telemedicine on cognitive decline in patients with dementia.

PubMed

Kim, Heeseok; Jhoo, Jin Hyeong; Jang, Jae-Won

2017-01-01

Introduction Telemedicine has the advantage of providing medical resources in rural areas, but few studies have been conducted to investigate its efficacy in dementia care, compared to face-to-face care. This study evaluated the effectiveness of telemedicine in relation to cognitive changes in patients with dementia. Methods We evaluated cognitive changes over time, according to care modality, in 188 patients with dementia who were registered at our university-based dementia clinic. We followed 98 patients using telemedicine services and 90 patients who attended the dementia clinic in person. Patients in the telemedicine group also visited a public health center located in a rural area about 50 km from the dementia clinic. Results Changes in the mean annualized Mini-Mental State Examination (MMSE) score were not significantly different between the telemedicine group and the face-to-face dementia clinic group ( p = 0.291), with changes of 0.60 and 1.03 points, respectively. However, cognitive decline was significantly lower in the telemedicine group for the less severe initial cognitive performance subgroup than more severe cognitive performance subgroup ( p = 0.049), with changes of 0.62 and 1.59 points, respectively. Higher initial Clinical Dementia Rating (CDR) scores, MMSE scores, and age were found to be independent predictive factors of subsequent cognitive changes, as indicated by mean annualized MMSE scores. Discussion These findings suggest that telemedicine may be a useful alternative to face-to-face clinical visits for management of dementia in patients who are located in rural areas.

Multiple cutaneous melanomas associated with gastric and brain metastases*

PubMed Central

Grander, Lara Caroline; Cabral, Fernanda; Lisboa, Alice Paixão; Vale, Gabrielle; Barcaui, Carlos Baptista; Maceira, Juan Manuel Pineiro

2016-01-01

The occurrence of multiple primary melanomas in a single individual is rare. Most commonly, malignant melanocytic lesions subsequent to the initial diagnosis of melanoma are secondary cutaneous metastases. We report a patient with gastrointestinal bleeding from gastric metastasis of cutaneous melanoma. During clinical evaluation and staging, we discovered a brain metastasis associated with 3 synchronous primary cutaneous melanomas. We suggest the research on the mutation in the cyclin-dependent kinase inhibitor 2A (CDKN2A) (INK4a) in such cases. We also emphasize the importance of clinical examination and dermoscopy of the entire tegument, even after a malignant melanocytic lesion is identified. PMID:28300909

Peer coaching: the next step in staff development.

PubMed

Waddell, Donna L; Dunn, Nancy

2005-01-01

A common problem in continuing nursing education and staff development is the transfer of learning to clinical practice. Peer coaching offers a solution to this problem. Initiated by educators, peer coaching has been researched in educational settings and found to be effective in facilitating the transfer of newly acquired knowledge and skill into classroom teaching strategies. This article describes the background, components, process, characteristics, and benefits of peer coaching. A specific example of using peer coaching to teach clinical breast examination skills is used to illustrate the application of peer coaching to the staff development of healthcare professionals. Peer coaching is the next step in nursing staff development.

Solitary breast mass as initial presentation of clinically silent metastatic renal cell carcinoma.

PubMed

McLauglin, Sarah A; Thiel, David D; Smith, Stephen L; Wehle, Michael J; Menke, David M

2006-06-01

Metastasis to the breast from extramammary tumors is rare. Breast metastases of renal cell carcinoma (RCC) origin have been described in sporadic case reports. We present a patient with a solitary breast mass representing the manifestation of clinically silent, metastatic RCC. A 76-year-old female was 12 years prior removed from radical nephrectomy for localized RCC. Her new breast mass was identified on physical examination. Pathology of the resected mass was diagnostic of metastatic RCC and subsequent imaging studies demonstrated a 1.9 cm renal mass in her solitary kidney. The patient elected subcutaneous Interleukin-2 immunotherapy as primary treatment for her recurrent RCC.

Pregnant women with HIV in rural Nigeria have higher rates of antiretroviral treatment initiation, but similar loss to follow-up as non-pregnant women and men

PubMed Central

Aliyu, Muktar H.; Blevins, Meridith; Megazzini, Karen M.; Parrish, Deidra D.; Audet, Carolyn M.; Chan, Naomi; Odoh, Chisom; Gebi, Usman I.; Muhammad, Mukhtar Y.; Shepherd, Bryan E.; Wester, C. William; Vermund, Sten H.

2015-01-01

Background We examined antiretroviral therapy (ART) initiation and retention by sex and pregnancy status in rural Nigeria. Methods We studied HIV-infected ART-naïve patients aged ≥15 years entering care from June 2009 to September 2013. We calculated the probability of early ART initiation and cumulative incidence of loss to follow-up (LTFU) during the first year of ART, and examined the association between LTFU and sex/pregnancy using Cox regression. Results The cohort included 3813 ART-naïve HIV-infected adults (2594 women [68.0%], 273 [11.8%] of them pregnant). The proportion of pregnant clients initiating ART within 90 days of enrollment (78.0%, 213/273) was higher than among non-pregnant women (54.3%,1261/2321) or men (53.0%, 650/1219), both p<0.001. Pregnant women initiated ART sooner than non-pregnant women and men (median [IQR] days from enrollment to ART initiation for pregnant women=7 days [0–21] vs 14 days [7–49] for non-pregnant women and 14 days [7–42] for men; p<0.001). Cumulative incidence of LTFU during the first year post-ART initiation was high and did not differ by sex and pregnancy status. Persons who were unemployed, bedridden, had higher CD4+ counts, and/or in earlier WHO clinical stages were more likely to be LTFU. Conclusions Pregnant women with HIV in rural Nigeria were more likely to initiate ART but were no more likely to be retained in care. Our findings underscore the importance of effective retention strategies across all patient groups, regardless of sex and pregnancy status. PMID:26012740

Outcomes in Thoracolumbar Burst Fractures With a Thoracolumbar Injury Classification Score (TLICS) of 4 Treated With Surgery Versus Initial Conservative Management.

PubMed

Nataraj, Andrew; Jack, Andrew S; Ihsanullah, Ihsan; Nomani, Shawn; Kortbeek, Frank; Fox, Richard

2018-05-25

This is a single-center, retrospective, observational cohort study. To determine whether surgery or nonoperative treatment has better clinical outcomes in neurologically intact patients with an intermediate severity thoracolumbar burst fracture. Optimal management, whether initial operative or nonoperative treatment, for thoracolumbar injury classification score (TLICS) 4 burst fractures remains controversial. Better insight into the treatment which affords patients a better clinical outcome could significantly affect patient care. This retrospective study included consecutive cases of TLICS 4 burst fracture patients from 2007 to 2013 and minimum 6-month follow-up. Potential confounders examined included age, sex, injury severity score, initial kyphotic angle, injured facets, and interspinous widening. Outcomes were determined by standardized questionnaires [Oswestry Disability Index (ODI), 12-item Short Form Physical Component Score (SF-12 PCS), and back pain Visual Analog Scale (VAS)] and analyzed using regression analysis. A total of 230 patients with burst fractures were identified, of which 67/230 (29%) were TLICS 4 and 47/67 (70%) had completed follow-up. No difference on univariate analysis was found between nonsurgical and surgical groups in mean ODI scores (P=0.27, t test), nor mean time to return to work (P=0.10, t test).Regarding outcomes, linear regression analysis revealed no association between having surgery and ODI (P=0.29), SF-12 PCS (P=0.59), or VAS (P=0.33). Furthermore, no difference was found between groups for employed patients working versus not working (P=0.09, the Fisher test), nor in mean time to return to work (P=0.30, Cox regression). This is one of the largest studies examining TLICS 4 burst fracture patients, adjusting for both clinical and radiologic confounders and reporting patient outcomes with minimum 6-month follow-up. No differences were found in outcomes between patients treated either surgically or nonsurgically. Studies focusing on early postoperative differences or cost-effectiveness might help in decision making. Level III.

Dorsal laminectomy for treatment of cervical vertebral stenotic myelopathy in an alpaca.

PubMed

Barker, W H J; Witte, T H; Driver, C J; Jull, P; Whitehead, C E; Volk, H A

2015-05-15

An 11-year-old male breeding alpaca was evaluated for a 2-day history of lowered head carriage and lethargy. On initial examination, the alpaca had signs of lethargy and lowered carriage of the head and neck, but no specific neurologic deficits. Medical management improved the clinical signs, but 8 months later, the alpaca developed acute, progressive general proprioceptive ataxia affecting all 4 limbs and was referred for further evaluation and treatment. Magnetic resonance imaging and CT identified disruption of the normal osseous architecture of C7 and T1. Medical management was attempted, but because of a lack of improvement, the patient underwent surgery 14 months after initial examination. A dorsal laminectomy of C7 and T1 via a dorsal midline approach was performed, and the spinous processes of both vertebrae were removed prior to removal of the overlying lamina. Free dorsal expansion of the spinal cord was ensured by resection of the ligamentum flavum. Six months after surgery, the alpaca had returned to successful breeding with 7 hembra bred in the first year after surgery, producing 6 crias, and 4 crias in the second year. The patient was eventually euthanized 28 months after surgery because of neurologic deterioration but was still ambulatory at that time. A good outcome with adequate alleviation of clinical signs and breeding soundness for > 2 years following dorsal laminectomy was achieved in this camelid patient. The surgical approach was similar to that in other species and was associated with mild postoperative morbidity. Veterinarians treating camelids should be aware of the initial clinical signs and treatment options for cervical vertebral stenotic myelopathy. In acute cases, the signs of reduced cervical mobility and pain on manipulation should prompt investigation including appropriate diagnostic imaging. Timely surgical intervention should be considered in patients that respond poorly to medical treatment to avoid irreversible spinal cord injury and optimize outcome.

Semantic Role Labeling of Clinical Text: Comparing Syntactic Parsers and Features

PubMed Central

Zhang, Yaoyun; Jiang, Min; Wang, Jingqi; Xu, Hua

2016-01-01

Semantic role labeling (SRL), which extracts shallow semantic relation representation from different surface textual forms of free text sentences, is important for understanding clinical narratives. Since semantic roles are formed by syntactic constituents in the sentence, an effective parser, as well as an effective syntactic feature set are essential to build a practical SRL system. Our study initiates a formal evaluation and comparison of SRL performance on a clinical text corpus MiPACQ, using three state-of-the-art parsers, the Stanford parser, the Berkeley parser, and the Charniak parser. First, the original parsers trained on the open domain syntactic corpus Penn Treebank were employed. Next, those parsers were retrained on the clinical Treebank of MiPACQ for further comparison. Additionally, state-of-the-art syntactic features from open domain SRL were also examined for clinical text. Experimental results showed that retraining the parsers on clinical Treebank improved the performance significantly, with an optimal F1 measure of 71.41% achieved by the Berkeley parser. PMID:28269926

Treatment Attrition: Associations with Negative Affect Smoking Motives and Barriers to Quitting Among Treatment-Seeking Smokers

PubMed Central

Garey, Lorra; Kauffman, Brooke Y.; Neighbors, Clayton; Schmidt, Norman B.; Zvolensky, Michael J.

2016-01-01

Introduction Pre-treatment attrition and perceived barriers for quitting are clinically important processes involved in early phases of quitting smoking. However, less is known about the constructs that may contribute to these processes such as negative affect reduction smoking motives. Method The current study sought to evaluate the relation between negative affect reduction smoking motives with pre-treatment attrition and perceived barriers for quitting in a sample of 425 treatment-seeking smokers (48.5% female; Mage = 37.69; SD = 13.61) enrolled in a smoking cessation study examining the efficacy of a transdiagnostic panic-smoking cessation treatment relative to a standard smoking cessation treatment. Results Results indicated that greater negative affect reduction smoking motives was associated with an increased likelihood of treatment initiation (Odds Ratio = 1.49, CI: 1.09, 2.04). Additionally, negative affect reduction smoking motives was associated with greater perceived barriers for cessation among pre-treatment drop-outs and treatment initiators. Conclusions This initial investigation provides evidence for the possible clinical utility in addressing negative affect reduction smoking motives during early stages of quitting. Additionally, such findings could potentially inform the development of personalized, early stages of quitting interventions for smoking cessation. PMID:27518764

Initial development and preliminary validation of a new negative symptom measure: the Clinical Assessment Interview for Negative Symptoms (CAINS).

PubMed

Forbes, Courtney; Blanchard, Jack J; Bennett, Melanie; Horan, William P; Kring, Ann; Gur, Raquel

2010-12-01

As part of an ongoing scale development process, this study provides an initial examination of the psychometric properties and validity of a new interview-based negative symptom instrument, the Clinical Assessment Interview for Negative Symptoms (CAINS), in outpatients with schizophrenia or schizoaffective disorder (N = 37). The scale was designed to address limitations of existing measures and to comprehensively assess five consensus-based negative symptoms: asociality, avolition, anhedonia (consummatory and anticipatory), affective flattening, and alogia. Results indicated satisfactory internal consistency reliability for the total CAINS scale score and promising inter-rater agreement, with clear areas identified in need of improvement. Convergent validity was evident in general agreement between the CAINS and alternative negative symptom measures. Further, CAINS subscales significantly correlated with relevant self-report emotional experience measures as well as with social functioning. Discriminant validity of the CAINS was strongly supported by its small, non-significant relations with positive symptoms, general psychiatric symptoms, and depression. These preliminary data on an early beta-version of the CAINS provide initial support for this new assessment approach to negative symptoms and suggest directions for further scale development. Copyright © 2010 Elsevier B.V. All rights reserved.

10-Minute Delayed Recall from the Modified Mini-Mental State Test Predicts Alzheimer’s Disease Pathology

PubMed Central

Lyness, Scott A.; Lee, Ae Young; Zarow, Chris; Teng, Evelyn L.; Chui, Helena C.

2014-01-01

We compared the sensitivity and specificity of two delayed recall scores from the Modified Mini-Mental State (3MS) test with consensus clinical diagnosis to differentiate cognitive impairment due to Alzheimer’s disease (AD) versus non-AD pathologies. At a memory disorders clinic, 117 cognitively impaired patients were administered a baseline 3MS test and received a contemporaneous consensus clinical diagnosis. Their brains were examined after death about 5 years later. Using logistic regression with forward selection to predict pathologically defined AD versus non-AD, 10-min delayed recall entered first (p = 0.001), followed by clinical diagnosis (p = 0.02); 1-min delayed recall did not enter. 10-min delayed recall scores ≤4 (score range = 0–9) were 87% sensitive and 47% specific in predicting AD pathology; consensus clinical diagnosis was 82% sensitive and 45% specific. For the 57 patients whose initial Mini-Mental State Examination scores were ≥19 (the median), 3MS 10-min delayed recall scores ≤4 showed some loss of sensitivity (80%) but a substantial gain in specificity (77%). In conclusion, 10-min delayed recall score on the brief 3MS test distinguished between AD versus non-AD pathology about 5 years before death at least as well as consensus clinical diagnosis that requires much more comprehensive information and complex deliberation. PMID:24240637

Dimensions of clinical nurse specialist work in the UK.

PubMed

Leary, Alison; Crouch, Heather; Lezard, Anthony; Rawcliffe, Chris; Boden, Louise; Richardson, Alison

To model the work of clinical nurse specialists (CNSs) in the UK. This article examines data mined as part of a national project. The Pandora database was initially collected on a Microsoft Office Access database and subsequently, a Structured Query Language database in several iterations from June 2006 to September 2008. Pandora recorded CNS activity as a series of events with eight dimensions to each event. Data from this were mined to examine the complexity of CNS work. This study represents the work of 463 CNSs over 2,778 days in England, Scotland and Wales. Clinical work, including physical assessment, referral, symptom control and 'rescue' work, accounted for a large part of the CNS's role. Administration was the second highest workload, with about half of these administrative tasks identified as being suitable for secretarial staff to undertake. Research, education and consultation accounted for less time. A significant proportion of the nurses' clinical work is undertaken by telephone. CNSs in this study spent much of their time doing complex clinical work. Payment by Results (Department of Health 2006) should recognise the work undertaken by CNSs, particularly that done on the telephone. Complex clinical work by CNSs takes place in many different contexts using a wide range of interventions. The role of the CNS is complex and diverse, making comparisons of it difficult. More research needs to be done in relation to quality, safety and efficiency.

Patterns of Clinical Reasoning in Physical Therapist Students.

PubMed

Gilliland, Sarah; Wainwright, Susan Flannery

2017-05-01

Clinical reasoning is a complex, nonlinear problem-solving process that is influenced by models of practice. The development of physical therapists' clinical reasoning abilities is a crucial yet underresearched aspect of entry-level (professional) physical therapist education. The purpose of this qualitative study was to examine the types of clinical reasoning strategies physical therapist students engage in during a patient encounter. A qualitative descriptive case study design involving within and across case analysis was used. Eight second-year, professional physical therapist students from 2 different programs completed an evaluation and initial intervention for a standardized patient followed by a retrospective think-aloud interview to explicate their reasoning processes. Participants' clinical reasoning strategies were examined using a 2-stage qualitative method of thematic analysis. Participants demonstrated consistent signs of development of physical therapy-specific reasoning processes, yet varied in their approach to the case and use of reflection. Participants who gave greater attention to patient education and empowerment also demonstrated greater use of reflection-in-action during the patient encounter. One negative case illustrates the variability in the rate at which students may develop these abilities. Participants demonstrated development toward physical therapist--specific clinical reasoning, yet demonstrated qualitatively different approaches to the patient encounter. Multiple factors, including the use of reflection-in-action, may enable students to develop greater flexibility in their reasoning processes. © 2017 American Physical Therapy Association

10-minute delayed recall from the modified mini-mental state test predicts Alzheimer's disease pathology.

PubMed

Lyness, Scott A; Lee, Ae Young; Zarow, Chris; Teng, Evelyn L; Chui, Helena C

2014-01-01

We compared the sensitivity and specificity of two delayed recall scores from the Modified Mini-Mental State (3MS) test with consensus clinical diagnosis to differentiate cognitive impairment due to Alzheimer's disease (AD) versus non-AD pathologies. At a memory disorders clinic, 117 cognitively impaired patients were administered a baseline 3MS test and received a contemporaneous consensus clinical diagnosis. Their brains were examined after death about 5 years later. Using logistic regression with forward selection to predict pathologically defined AD versus non-AD, 10-min delayed recall entered first (p = 0.001), followed by clinical diagnosis (p = 0.02); 1-min delayed recall did not enter. 10-min delayed recall scores ≤4 (score range = 0-9) were 87% sensitive and 47% specific in predicting AD pathology; consensus clinical diagnosis was 82% sensitive and 45% specific. For the 57 patients whose initial Mini-Mental State Examination scores were ≥19 (the median), 3MS 10-min delayed recall scores ≤4 showed some loss of sensitivity (80%) but a substantial gain in specificity (77%). In conclusion, 10-min delayed recall score on the brief 3MS test distinguished between AD versus non-AD pathology about 5 years before death at least as well as consensus clinical diagnosis that requires much more comprehensive information and complex deliberation.

Pre-existing central nervous system lesions negate cytokine requirements for regional experimental autoimmune encephalomyelitis development.

PubMed

Li, Xin; Lees, Jason R

2013-03-01

In region-specific forms of experimental autoimmune encephalomyelitis (EAE), lesion initiation is regulated by T-cell-produced interferon-γ (IFN-γ) resulting in spinal cord disease in the presence of IFN-γ and cerebellar disease in the absence of IFN-γ. Although this role for IFN-γ in regional disease initiation is well defined, little is known about the consequences of previous tissue inflammation on subsequent regional disease, information vital to the development of therapeutics in established disease states. This study addressed the hypothesis that previous establishment of regional EAE would determine subsequent tissue localization of new T-cell invasion and associated symptoms regardless of the presence or absence of IFN-γ production. Serial transfer of optimal or suboptimal doses of encephalitogenic IFN-γ-sufficient or -deficient T-cell lines was used to examine the development of new clinical responses associated with the spinal cord and cerebellum at various times after EAE initiation. Previous inflammation within either cerebellum or spinal cord allowed subsequent T-cell driven inflammation within that tissue regardless of IFN-γ presence. Further, T-cell IFN-γ production after initial lesion formation exacerbated disease within the cerebellum, suggesting that IFN-γ plays different roles at different stages of cerebellar disease. For the spinal cord, IFN-γ-deficient cells (that are ordinarily cerebellum disease initiators) were capable of driving new spinal-cord-associated clinical symptoms more than 60 days after the initial acute EAE resolution. These data suggest that previous inflammation modulates the molecular requirements for new neuroinflammation development. © 2012 Blackwell Publishing Ltd.

The maternal health clinic: an initiative for cardiovascular risk identification in women with pregnancy-related complications.

PubMed

Cusimano, Maria C; Pudwell, Jessica; Roddy, Michelle; Cho, Chan-Kyung Jane; Smith, Graeme N

2014-05-01

Women who develop certain common pregnancy complications have a greater chance of developing cardiovascular disease (CVD) later in life. However, most health care providers do not provide postpartum cardiovascular risk counselling or follow-up. The Maternal Health Clinic was established to address this gap in care. It targets women at increased risk of CVD to inspire lifestyle changes, encourage long-term follow-up, and initiate primary prevention. Here, we summarize results from the first 17 months of completed clinic visits. Patients experiencing at least one relevant complication in their index pregnancy were referred to the Maternal Health Clinic through standard postpartum order sheets. Patients underwent a complete assessment including screening history, physical examination, fasting bloodwork, and urinalysis. Lifetime and 30-year CVD risk estimates, along with a metabolic syndrome calculation, were determined for each patient. Complications most commonly leading to referral were gestational diabetes or impaired glucose tolerance (32.7%), preeclampsia (29.3%), preterm birth (29.3%), and gestational hypertension (19.6%). The clinic analysis group (n = 92) was compared with a healthy control group from the PreEclampsia New Emerging Team study (n = 118). Patients in the clinic analysis group had significantly increased lifetime and 30-year CVD risk estimates compared with healthy controls (P < .0001). Furthermore, 17.4% of the clinic analysis group had metabolic syndrome, compared with 6.78% of healthy controls (P < .05). This study demonstrates that the Maternal Health Clinic accurately identifies postpartum patients that have underlying cardiovascular risks which make them susceptible to CVD. The clinic may serve as an effective primary prevention strategy. Copyright © 2014 Mosby, Inc. All rights reserved.

Standardized training in nurse model travel clinics.

PubMed

Sofarelli, Theresa A; Ricks, Jane H; Anand, Rahul; Hale, Devon C

2011-01-01

International travel plays a significant role in the emergence and redistribution of major human diseases. The importance of travel medicine clinics for preventing morbidity and mortality has been increasingly appreciated, although few studies have thus far examined the management and staff training strategies that result in successful travel-clinic operations. Here, we describe an example of travel-clinic operation and management coordinated through the University of Utah School of Medicine, Division of Infectious Diseases. This program, which involves eight separate clinics distributed statewide, functions both to provide patient consult and care services, as well as medical provider training and continuing medical education (CME). Initial training, the use of standardized forms and protocols, routine chart reviews and monthly continuing education meetings are the distinguishing attributes of this program. An Infectious Disease team consisting of one medical doctor (MD) and a physician assistant (PA) act as consultants to travel nurses who comprise the majority of clinic staff. Eight clinics distributed throughout the state of Utah serve approximately 6,000 travelers a year. Pre-travel medical services are provided by 11 nurses, including 10 registered nurses (RNs) and 1 licensed practical nurse (LPN). This trained nursing staff receives continuing travel medical education and participate in the training of new providers. All nurses have completed a full training program and 7 of the 11 (64%) of clinic nursing staff serve more than 10 patients a week. Quality assurance measures show that approximately 0.5% of charts reviewed contain a vaccine or prescription error which require patient notification for correction. Using an initial training program, standardized patient intake forms, vaccine and prescription protocols, preprinted prescriptions, and regular CME, highly trained nurses at travel clinics are able to provide standardized pre-travel care to international travelers originating from Utah. © 2010 International Society of Travel Medicine.

Can heart rate predict blood pressure response to anti-hypertensive drug therapy?

PubMed

Owens, P E; Lyons, S; O'Brien, E

1998-04-01

The use of heart rate in clinical practice is limited by its variability under measurement situations. The mean heart rate on ambulatory monitoring provides a more robust statistic for clinical use. We examined the relationship between mean heart rate on initial referral ambulatory blood pressure monitoring (ABPM) to the BP-lowering efficacy of the four main groups of anti-hypertensive medications, in a referral hypertensive population. Patients were retrospectively identified by review of the BP database, and data collected from the initial referral BP monitor off medication, and the subsequent ABPM after treatment with either beta-blockers, diuretics, calcium antagonists or angiotensin-converting enzyme (ACE) inhibitors. The change in mean arterial BP from the initial to the subsequent ABPM (ie, as a result of treatment) was correlated with the mean heart rate on the initial ABPM. A moderate association was found for initial daytime heart rate and BP response to beta-blockers (r = 0.24, P = 0.02), and ACE inhibitors (r = 0.14, P = 0.05). No such association was found for calcium antagonists or diuretics. When the groups were divided into those with a mean daytime heart rate <75 and > or =75 beats per min, BP reduction from beta-blocker and ACE inhibitor therapy was significantly greater in those patients with a higher daytime heart rate. We conclude that average daytime heart rate on pre-treatment ABPM can be useful as a predictor of BP response to beta-blockade or ACE inhibition.

Clinical and ERG data in a family with autosomal dominant RP and Pro-347-Arg mutation in the rhodopsin gene.

PubMed

Niemeyer, G; Trüb, P; Schinzel, A; Gal, A

1992-01-01

In a family with autosomal dominant retinitis pigmentosa, documented over six generations, a previously undescribed point mutation in the rhodopsin gene could be identified. The mutation found in the six affected members examined but in none of the controls, including healthy members of the family, was a point mutation in codon 347 predicting a substitution of the amino acid arginine for proline, designated Pro-347-Arg. Six affected members from two generations were examined clinically and with ganzfeld rod and cone electroretinography. The cone and, more dramatically, the rod electroretinograms were reduced to residual b-wave amplitudes or were non-detectable as early as ages 18 to 22 years. The Pro-347-Arg mutation resulted in a subjectively and clinically homogeneous phenotype: early onset of night blindness before age 11, relatively preserved usable visual fields until about age 30, blindness at ages 40 to 60, and change from an initial apparently sine pigmento to a hyperpigmented and atrophic fundus picture between 30 and 50 years of age.

Use of demographic and pharmacy data to identify patients included within both the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN).

PubMed

Carbonari, Dena M; Saine, M Elle; Newcomb, Craig W; Blak, Betina; Roy, Jason A; Haynes, Kevin; Wood, Jennifer; Gallagher, Arlene M; Bhullar, Harshvinder; Cardillo, Serena; Hennessy, Sean; Strom, Brian L; Lo Re, Vincent

2015-09-01

Pharmacoepidemiology researchers often utilize data from two UK electronic medical record databases, the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN), and may choose to combine the two in an effort to increase sample size. To minimize duplication of data, previous studies examined the practice-level overlap between these databases. However, the proportion of overlapping patients remains unknown. We developed a method using demographic and pharmacy variables to identify patients included in both CPRD and THIN, and applied this method to measure the proportion of overlapping patients who initiated the oral anti-diabetic drug saxagliptin. We conducted a cross-sectional study among patients initiating saxagliptin in CPRD and THIN between October 2009 and September 2012. Within both databases, we identified patients: (i) ≥18 years, (ii) newly prescribed saxagliptin, and (iii) with ≥180 days enrollment prior to saxagliptin initiation. Demographic data (birth year, sex, patient registration date, family number, and marital status) and prescriptions (including dates) for the first two oral anti-diabetic drugs prescribed within the study period were used to identify matching patients. Among 4202 CPRD and 3641 THIN patients initiating saxagliptin, 2574 overlapping patients (61% of CPRD saxagliptin initiators; 71% of THIN saxagliptin initiators) were identified. Among these patients, 2474 patients (96%) perfectly matched on all demographic and prescription data. Within each database, over 60% of patients initiating saxagliptin were included within both CPRD and THIN. Combined demographic and prescription data can be used to identify patients included in both CPRD and THIN. Copyright © 2015 John Wiley & Sons, Ltd.

Patient-initiated Electronic Messages and Quality of Care for Patients With Diabetes and Hypertension in a Large Fee-for-Service Medical Group: Results From a Natural Experiment.

PubMed

McClellan, Sean R; Panattoni, Laura; Chan, Albert S; Tai-Seale, Ming

2016-03-01

Few studies have examined the association between patient-initiated electronic messaging (e-messaging) and clinical outcomes in fee-for-service settings. To estimate the association between patient-initiated e-messages and quality of care among patients with diabetes and hypertension. Longitudinal observational study from 2009 to 2013. In March 2011, the medical group eliminated a $60/year patient user fee for e-messaging and established a provider payment of $3-5 per patient-initiated e-message. Quality of care for patients initiating e-messages was compared before and after March 2011, relative to nonmessaging patients. Propensity score weighting accounted for differences between e-messaging and nonmessaging patients in generalized estimating equations. Large multispecialty practice in California compensating providers' fee-for-service. Patients with diabetes (N=4232) or hypertension (N=15,463) who had activated their online portal but not e-messaged before e-messaging became free. Quality of care included HEDIS-based process measures for hemoglobin (Hb) A1c, blood pressure, low-density lipoprotein (LDL), nephropathy, and retinopathy tests, and outcome measures for HbA1c, blood pressure, and LDL. E-messaging was measured as counts of patient-initiated e-message threads sent to providers. Patients were categorized into quartiles by e-messaging frequency. The probability of annually completing indicated tests increased by 1%-7% for e-messaging patients, depending on the outcome and e-messaging frequency. E-messaging was associated with small improvements in HbA1c and LDL for some patients with diabetes. Patient-initiated e-messaging may increase the likelihood of completing recommended tests, but may not be sufficient to improve clinical outcomes for most patients with diabetes or hypertension without additional interventions.

Diagnosis and treatment of lumbosacral discospondylitis in a calf

PubMed Central

2011-01-01

Background The aim of this case report was to describe the clinical findings, treatment and outcome of lumbosacral discospondylitis in a calf. Case Presentation A 5.5-month-old calf was presented with difficulty in rising, a stiff and slightly ataxic gait in the hind limbs and a shortened stride. The lumbosacral region was severely painful on palpation. Radiographic examination confirmed lumbosacral discospondylitis. Medical treatment with stall rest was instituted over six weeks. Radiographic and ultrasonographic follow-up examinations showed lysis of the endplates initially, then collapse of the intervertebral space at the lumbosacral junction and progressive sclerosis in the periphery of the lytic zones. Four weeks after institution of treatment, the calf could rise normally and the general condition gradually had returned to normal. The calf was discharged after 6 weeks and was sound at 3.5 months clinical and radiographic follow up examination. Thereafter, it was kept on alpine pastures without problems and was pregnant 1 year after the last examination. Conclusions This report shows that recovery from lumbosacral discospondylitis is possible in heifers, provided that treatment is started before major neurologic deficits have developed and is continued for an extended period of time. PMID:21910913

The Counseling Center Assessment of Psychological Symptoms (CCAPS-62): Acceptance, feasibility, and initial psychometric properties in a UK student population.

PubMed

Broglia, Emma; Millings, Abigail; Barkham, Michael

2017-09-01

The burden and severity of student mental health continue to increase in parallel with increasing financial pressures on students and services alike. There is a need for a student-specific measure of distress that acknowledges their unique context. This study examined the feasibility, acceptance, and initial psychometric properties of a US measure, the Counseling Center Assessment of Psychological Symptoms (CCAPS), in a UK student sample. A sample of 294 UK help-seeking students from two universities completed the CCAPS-62 and Clinical Outcomes in Routine Evaluation (CORE-10) as a comparator. The factor solution and reliability of the CCAPS-62 were examined. Correlations and clinical boundaries were determined between the CCAPS-62 subscales and CORE-10, and comparisons were made with US published norms. The CCAPS-62 demonstrated a strong factor solution that matched the intended subscales. All subscales had good reliability and correlated significantly with the CORE-10. The agreement on caseness between the two measures was 92.8% with 86.3% reaching clinical threshold on both the CCAPS-62 and CORE-10. Severity was most noticeable for academic distress, depression, anxiety, and social anxiety. Compared to US data, UK students showed higher clinical severity for all psychological symptoms. The CCAPS-62 is a reliable and psychometrically valid assessment measure to use with UK students without revision. The overall distress indicated is similar to that of the CORE-10, but the individual subscales are more informative of specific student concerns including academic distress, social anxiety, and substance abuse. Potential benefits of administering a student-focused assessment measure in student counselling services are discussed. University students attending counselling in the UK demonstrate clinical severity for academic distress, depression, anxiety, and social anxiety. Compared to university students in the US, UK students present with higher clinical severity on all contextual measures of student psychological distress. It is advantageous for university counselling services to administer a student-specific clinical measure over measures intended for the general clinical population. CCAPS-62 is an acceptable, feasible, and psychometrically valid measure of student psychological distress that can be used in the UK without revision. It is important for university counselling services to continue to provide support from therapists that are trained and experienced in the university context over services intended for the general clinical population. Copyright © 2017 John Wiley & Sons, Ltd.

Sjögren syndrome presenting with hypopotassemic periodic paralysis due to renal tubular acidosis

PubMed Central

Ataoglu, Esra Hayriye; Demir, Betul; Tuna, Mazhar; Çavus, Bilger; Cetin, Faik; Temiz, Levent Umit; Ozturk, Savas; Yenigun, Mustafa

2012-01-01

Summary Background: Sjögren syndrome (SS) is an autoimmune-lymphoproliferative disorder characterized by mononuclear cell infiltration of exocrine glands. Clinically, Sjögren syndrome (SS) has a wide spectrum, varying from autoimmune exocrinopathy to systemic involvement. There have been few cases reporting that primary SS developed with distal renal tubular acidosis clinically. Case Report: Here, we present a case with primary Sjögren syndrome accompanied by hypopotassemic paralysis due to renal tubular acidosis. Severe hypopotassemia, hyperchloremic metabolic acidosis, alkaline urine and disorder in urinary acidification test were observed in the biochemical examination of the 16-year-old female patient, who had applied to our clinic for extreme loss of muscle force. After the examinations it was determined that the patient had developed Type 1 RTA (distal RTA) due to primary Sjögren syndrome. Potassium and alkaline replacement was made and an immediate total recovery was achieved. Conclusions: Hypopotassemic paralysis due to primary Sjögren syndrome is a rare but severe disorder that could lead to death if not detected early and cured appropriately. Thus, effective treatment should be immediately initiated in cases where severe hypopotassemia is accompanied by metabolic acidosis, and the cases should also be examined for extraglandular involvement of SS. PMID:23569525

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Prediction of Treatment Entry and Completion in Prison

PubMed Central

GORDON, MICHAEL S.; KINLOCK, TIMOTHY W.; COUVILLION, KATHRYN A.; SCHWARTZ, ROBERT P.; O’GRADY, KEVIN

2014-01-01

The present report is an intent-to-treat analysis involving secondary data drawn from the first randomized clinical trial of prison-initiated methadone in the United States. This study examined predictors of treatment entry and completion in prison. A sample of 211 adult male prerelease inmates with preincarceration heroin dependence were randomly assigned to one of three treatment conditions: counseling only (counseling in prison; n= 70); counseling plus transfer (counseling in prison with transfer to methadone maintenance treatment upon release; n= 70); and counseling plus methadone (methadone maintenance in prison, continued in a community-based methadone maintenance program upon release; n= 71). Entered prison treatment (p <. 01), and completed prison treatment (p< .001) were significantly predicted by the set of 10 explanatory variables and favored the treatment conditions receiving methadone. The present results indicate that individuals who are older in age and have longer prison sentences may have better outcomes than younger individuals with shorter sentences, meaning they are more likely to enter and complete prison-based treatment. Furthermore, implications for the treatment of prisoners with prior heroin dependence and for conducting clinical trials may indicate the importance of examining individual characteristics and the possibility of the examination of patient preference. PMID:25392605

A family with Wagner syndrome with uveitis and a new versican mutation

PubMed Central

Rothschild, Pierre-Raphaël; Brézin, Antoine P.; Nedelec, Brigitte; des Roziers, Cyril Burin; Ghiotti, Tiffany; Orhant, Lucie; Boimard, Mathieu

2013-01-01

Purpose To report the clinical and molecular findings of a kindred with Wagner syndrome (WS) revealed by intraocular inflammatory features. Methods Eight available family members underwent complete ophthalmologic examination, including laser flare cell meter measurements. Collagen, type II, alpha 1, versican (VCAN), frizzled family receptor 4, low density lipoprotein receptor-related protein 5, tetraspanin 12, and Norrie disease (pseudoglioma) genes were screened with direct sequencing. Results The index case was initially referred for unexplained severe and chronic postoperative bilateral uveitis following a standard cataract surgery procedure. Clinical examination of the proband revealed an optically empty vitreous with avascular vitreous strands and veils, features highly suggestive of WS. The systematic familial ophthalmologic examination identified three additional unsuspected affected family members who also presented with the WS phenotype, including uveitis for one of them. We identified a novel c.4004–6T>A nucleotide substitution at the acceptor splice site of intron 7 of the VCAN gene that segregated with the disease phenotype. Conclusions We present a family with WS with typical WS features and intraocular inflammatory manifestations associated with a novel splice site VCAN mutation. Beyond the structural role in the retinal-vitreous architecture, versican is also emerging as a pivotal mediator of the inflammatory response, supporting uveitis predisposition as a clinical manifestation of WS. PMID:24174867

A family with Wagner syndrome with uveitis and a new versican mutation.

PubMed

Rothschild, Pierre-Raphaël; Brézin, Antoine P; Nedelec, Brigitte; Burin des Roziers, Cyril; Ghiotti, Tiffany; Orhant, Lucie; Boimard, Mathieu; Valleix, Sophie

2013-01-01

To report the clinical and molecular findings of a kindred with Wagner syndrome (WS) revealed by intraocular inflammatory features. Eight available family members underwent complete ophthalmologic examination, including laser flare cell meter measurements. Collagen, type II, alpha 1, versican (VCAN), frizzled family receptor 4, low density lipoprotein receptor-related protein 5, tetraspanin 12, and Norrie disease (pseudoglioma) genes were screened with direct sequencing. The index case was initially referred for unexplained severe and chronic postoperative bilateral uveitis following a standard cataract surgery procedure. Clinical examination of the proband revealed an optically empty vitreous with avascular vitreous strands and veils, features highly suggestive of WS. The systematic familial ophthalmologic examination identified three additional unsuspected affected family members who also presented with the WS phenotype, including uveitis for one of them. We identified a novel c.4004-6T>A nucleotide substitution at the acceptor splice site of intron 7 of the VCAN gene that segregated with the disease phenotype. We present a family with WS with typical WS features and intraocular inflammatory manifestations associated with a novel splice site VCAN mutation. Beyond the structural role in the retinal-vitreous architecture, versican is also emerging as a pivotal mediator of the inflammatory response, supporting uveitis predisposition as a clinical manifestation of WS.

A Randomized Clinical Trial of Methadone Maintenance for Prisoners: Prediction of Treatment Entry and Completion in Prison.

PubMed

Gordon, Michael S; Kinlock, Timothy W; Couvillion, Kathryn A; Schwartz, Robert P; O'Grady, Kevin

2012-05-01

The present report is an intent-to-treat analysis involving secondary data drawn from the first randomized clinical trial of prison-initiated methadone in the United States. This study examined predictors of treatment entry and completion in prison. A sample of 211 adult male prerelease inmates with preincarceration heroin dependence were randomly assigned to one of three treatment conditions: counseling only (counseling in prison; n= 70); counseling plus transfer (counseling in prison with transfer to methadone maintenance treatment upon release; n= 70); and counseling plus methadone (methadone maintenance in prison, continued in a community-based methadone maintenance program upon release; n= 71). Entered prison treatment (p <. 01), and completed prison treatment (p< .001) were significantly predicted by the set of 10 explanatory variables and favored the treatment conditions receiving methadone. The present results indicate that individuals who are older in age and have longer prison sentences may have better outcomes than younger individuals with shorter sentences, meaning they are more likely to enter and complete prison-based treatment. Furthermore, implications for the treatment of prisoners with prior heroin dependence and for conducting clinical trials may indicate the importance of examining individual characteristics and the possibility of the examination of patient preference.

Linking academic and clinical missions: UC Davis' integrated AHC.

PubMed

Pomeroy, Claire; Rice, Ann; McGowan, William; Osburn, Nathan

2008-09-01

Academic health centers (AHCs) rely on cross-subsidization of education and research programs by the clinical enterprise, but this is becoming more challenging as clinical reimbursements decline. These new realities provide an important opportunity to reevaluate the relationships between medical schools and academic medical centers. The authors examine the benefits of their ongoing commitment to create a fully integrated AHC at the University of California (UC) Davis, discussing strategies that serve as catalysts for continued growth. They explore how investments of proceeds from the clinical enterprise directly enhance educational and research initiatives, which, in turn, increase the success of patient-care programs. This has created a cycle of excellence that leads to an enhanced reputation for the entire health system. One strategy involves using clinical margins to "prime the pump" in anticipation of major research initiatives, resulting in rapid increases in external research funding and academic recognition. In turn, this facilitates recruitment of high-quality faculty and staff, improving the ability to deliver expert clinical care. The overall enhanced institutional reputation positions both the clinical and academic programs for further success. The authors posit that such approaches require executive-level commitment to a single strategic vision, unified leadership, and collaborative financial and operational decision making. Adopting such changes is not without challenges, which are discussed, but the authors suggest that an integrated AHC fosters optimized operations, enhanced reputation, and stronger performance across all mission areas. They also provide examples of how the UC Davis Health System has thus attracted philanthropists and investments from the private sector.

Encopresis: long-term clinical outcome of 67 cases.

PubMed

Unal, Fatih; Pehlivantürk, Berna

2005-01-01

In this study we attempted to investigate the outcome of encopresis and to determine factors affecting prognosis. The sample consisted of 52 boys (77.6%) and 15 girls (22.4%) diagnosed as encopresis according to DSM IV diagnostic criteria. These patients were evaluated six years after their initial examination in the Department of Child Psychiatry. Clinical and demographical data were compared between initial and follow-up interviews and between patients with complete recovery and others. Fifty-six patients (83.6%) recovered completely and 11 (16.4%) continued to be encopretic after six years. Good school performance (p<0.005), high levels of parental education (p<0.005) and absence of constipation (p<0.05) were associated with favorable outcome. In addition, secondary encopretics who were diagnosed within a year from onset of the symptom recovered significantly earlier (p<0.001). Encopresis is a chronic disorder and complete recovery rates tend to increase with time. Families and primary health care providers should be informed about the treatment possibilities of encopresis for early intervention.

Nonsurgical Outpatient Therapies for the Management of Female Stress Urinary Incontinence: Long-Term Effectiveness and Durability

PubMed Central

Davila, G. Willy

2011-01-01

Objective. To evaluate long-term effectiveness and safety of conservative and minimally invasive outpatient treatments for female stress urinary incontinence (SUI) through a review of the literature. Methods. PubMed was searched for reports on prospective clinical trials with at least 12-month follow-up of minimally invasive treatments, pelvic floor rehabilitation, or pharmacotherapy in women with SUI. Each report was examined for long-term rates of effectiveness and safety. Results. Thirty-two clinical trial reports were included. Prospective long-term studies of pelvic floor rehabilitation were limited but indicated significant improvements with treatment adherence for at least 12 months. Poor initial tolerability with duloxetine resulted in substantial discontinuation. Most patients receiving transurethral radiofrequency collagen denaturation or urethral bulking agents reported significant long-term improvements, generally good tolerability, and safety. Conclusions. Conservative therapy is an appropriate initial approach for female SUI, but if therapy fails, radiofrequency collagen denaturation or bulking agents may be an attractive intermediate management step or alternative to surgery. PMID:21738529

Assessment of clinical co-morbidities

PubMed Central

Basu, Debasish; Basu, Aniruddha; Ghosh, Abhishek

2018-01-01

A large proportion of patients with substance use disorders have clinical comorbidities, either medical or psychiatric. An initial assessment is necessary initially for prompt identification and management of any psychiatric or medical emergency, and thereafter a more detailed assessment for the comprehensive understanding of the individual. This should be done keeping in mind the goals of both immediate and long term assessment so that a comprehensive but individualized, context and culture sensitive, reality based, recovery-oriented management plan can be formulated. Assessment should consist of not only history-taking, physical and mental status examination but also laboratory and instrument based assessment as needed. During assessment, collateral reports and past medical records are valuable additions along with self-report. Since substance use disorders influence various aspects of daily life, hence medical, social, occupational, religious, spiritual, financial and legal aspects should be evaluated. Overall, the assessment needs to be diagnosis and management focused, covering the various bio-psycho-social domains relevant to the individual. PMID:29540914

[Clinical picture, differential diagnosis and forensic psychiatric assessment of the delirious variant of the Kandinskiĭ-Clérambault syndrome in patients with schizophrenia].

PubMed

Kolotilin, G F; Vasil'ev, V D

1988-01-01

Using clinico-psychopathological methods of examination the authors studied 93 schizophrenics with a delirious variant of the Kandinsky-Clérambaut syndrome who had committed violent antisocial actions (VAA). It has been ascertained that peculiarities of the clinical course at the time when the VAA was committed reflect the stages of the development of the syndrome: the initial stage, the stage of delirious personification of psychic automatisms and the stage of involution of the delirious variant of the Kandinsky-Clérambaut syndrome. It has been established that the more acute the psychosis the higher the significance in the psychopathological mechanisms of VAA of clinical manifestations of the syndrome and lower the role of social and personality factors.

[Mild head injury in children and adults: Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-06-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

[Mild head injury in children and adults. Diagnostic challenges in the emergency department].

PubMed

Leidel, B A; Lindner, T; Wolf, S; Bogner, V; Steinbeck, A; Börner, N; Peiser, C; Audebert, H J; Biberthaler, P; Kanz, K-G

2015-01-01

Mild head injuries are one of the most frequent reasons for attending emergency departments and are particularly challenging in different ways. While clinically important injuries are infrequent, delayed or missed injuries may lead to fatal consequences. The initial mostly inconspicuous appearance may not reflect the degree of intracranial injury and computed tomography (CT) is necessary to rule out covert injuries. Furthermore, infants and young children with a lack of or rudimentary cognitive and language development are challenging, especially for those examiners not familiar with pediatric care. Established check lists of clinical risk factors for children and adults regarding traumatic brain injuries allow specific and rational decision-making for cranial CT imaging. Clinically important intracranial injuries can be reliably detected and unnecessary radiation exposure avoided at the same time.

Toxoplasmosis: a history of clinical observations

PubMed Central

Weiss, Louis M.; Dubey, Jitender. P.

2009-01-01

It has been 100 years since Toxoplasma gondii was initially described in Tunis by Nicolle and Manceaux (1908) in the tissues of the gundi (Ctenodoactylus gundi) and in Brazil by Splendore (1908) in the tissues of a rabbit. Toxoplasma gondii is a ubiquitous, Apicomplexan parasite of warm-blooded animals that can cause several clinical syndromes including encephalitis, chorioretinitis, congenital infection and neonatal mortality. Fifteen years after the description of T. gondii by Nicolle and Manceaux a fatal case of toxoplasmosis in a child was reported by Janků. In 1939 Wolf, Cowen and Paige were the first to conclusively identify T. gondii as a cause of human disease. This review examines the clinical manifestations of infection with T. gondii and the history of the discovery of these manifestations. PMID:19217908

Clinically granulomatous cheilitis with plasma cells

PubMed Central

Sarkar, Somenath; Ghosh, Sarmistha; Sengupta, Dipayan

2016-01-01

Plasma cell cheilitis, also known as plasma cell orificial mucositis is a benign inflammatory condition clinically characterized by erythematous plaque on lips that may be ulcerated. Histopathologically it is characterized by dense plasma cell infiltrates in a band-like pattern in dermis, which corresponds to Zoon's plasma cell balanitis. On the other hand, granulomatous cheilitis, as a part of orofacial granulomatosis, manifests as sudden diffuse or nodular swelling involving lip and cheek. Initial swelling is soft to firm, but with recurrent episodes swelling gradually become firm rubbery in consistency. We hereby report a case of cheilitis in a 52-year-old man with diffuse swelling involving lower lip, which clinically resembles granulomatous cheilitis, but histopathological examination showed diffuse infiltrate of plasma cells predominantly in upper and mid-dermis. PMID:27057489

A Novel Approach to Assay DNA Methylation in Prostate Cancer

DTIC Science & Technology

2015-10-01

genome; a recent study comprehensively examined over 7000 RNA-seq libraries and uncovered nearly 60,000 lncRNAs from the human transcriptome.6 Out of...patients, development of tamoxifen resistance (TamR) is persistently seen in the clinic and is a major cause of breast cancer recurrence and mortality ...all breast cancers.12 Despite its initial success in reducing disease mortality and improving survival, tamoxifen therapy frequently led to the onset of

Surgical management of maxillary and premaxillary osteomyelitis in a reticulated python (Python reticulatus).

PubMed

Latney, La'Toya V; McDermott, Colin; Scott, Gregory; Soltero-Rivera, Maria M; Beguesse, Kyla; Sánchez, Melissa D; Lewis, John R

2016-05-01

CASE DESCRIPTION A 1-year-old reticulated python (Python reticulatus) was evaluated because of a 2-week history of wheezing and hissing. CLINICAL FINDINGS Rostral facial cellulitis and deep gingival pockets associated with missing rostral maxillary teeth were evident. Tissues of the nares were swollen, resulting in an audible wheeze during respiration. Multiple scars and superficial facial wounds attributed to biting by live prey were apparent. Radiographic examination revealed bilateral, focal, rostral maxillary osteomyelitis. TREATMENT AND OUTCOME Wound irrigation, antimicrobials, and anti-inflammatory drug treatment resulted in reduced cellulitis. A 3-week regimen that included empirical antimicrobial treatment and improved husbandry resulted in resolution of the respiratory sounds and partial healing of bite wounds, but radiographic evaluation revealed progressive maxillary osteomyelitis. Microbial culture of blood yielded scant gram-positive cocci and Bacillus spp, which were suspected sample contaminants. Bilateral partial maxillectomies were performed; microbial culture and histologic examination of resected bone confirmed osteomyelitis with gram-positive cocci. Treatment with trimethoprim-sulfamethoxazole was initiated on the basis of microbial susceptibility tests. Four months later, follow-up radiography revealed premaxillary osteomyelitis; surgery was declined, and treatment with trimethoprim-sulfamethoxazole was reinstituted. Eight months after surgery, the patient was reevaluated because of recurrent clinical signs; premaxillectomy was performed, and treatment with trimethoprim-sulfamethoxazole was prescribed on the basis of microbial culture of bone and microbial susceptibility testing. Resolution of osteomyelitis was confirmed by CT 11 months after the initial surgery. CONCLUSIONS AND CLINICAL RELEVANCE Focal maxillectomies and premaxillectomy were successfully performed in a large python. Surgical management and appropriate antimicrobial treatment resulted in a good outcome.

Depressive symptoms and incidence of mild cognitive impairment and probable dementia in elderly women: the Women's Health Initiative Memory Study.

PubMed

Goveas, Joseph S; Espeland, Mark A; Woods, Nancy F; Wassertheil-Smoller, Sylvia; Kotchen, Jane M

2011-01-01

To examine whether significant depressive symptoms in postmenopausal women increases the risk of subsequent mild cognitive impairment (MCI) and dementia. Prospective cohort study. Thirty nine of the 40 Women's Health Initiative (WHI) clinical centers that participated in a randomized clinical trial of hormone therapy. Six thousand three hundred seventy-six postmenopausal women without cognitive impairment aged 65 to 79 at baseline. Depressive disorders were assessed using an eight-item Burnam algorithm and followed annually for a mean period of 5.4 years. A central adjudication committee classified the presence of MCI and probable dementia based on an extensive neuropsychiatric examination. Eight percent of postmenopausal women in this sample reported depressive symptoms above a 0.06 cut point on the Burnam algorithm. Depressive disorder at baseline was associated with greater risk of incident MCI (hazard ratio (HR)=1.98, 95% confidence interval (CI)=1.33-2.94), probable dementia (HR=2.03, 95% CI=1.15-3.60), and MCI or probable dementia (HR=1.92, 95% CI=1.35-2.73) after controlling for sociodemographic characteristics, lifestyle and vascular risk factors, cardiovascular and cerebrovascular disease, antidepressant use, and current and past hormone therapy status. Assignment to hormone therapy and baseline cognitive function did not affect these relationships. Women without depression who endorsed a remote history of depression had a higher risk of developing dementia. Clinically significant depressive symptoms in women aged 65 and older are independently associated with greater incidence of MCI and probable dementia. © 2011, Copyright the Authors. Journal compilation © 2011, The American Geriatrics Society.

The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows.

PubMed

Prince, Lisa K; Campbell, Ruth C; Gao, Sam W; Kendrick, Jessica; Lebrun, Christopher J; Little, Dustin J; Mahoney, David L; Maursetter, Laura A; Nee, Robert; Saddler, Mark; Watson, Maura A; Yuan, Christina M

2018-04-01

Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than 'important'. The content validity index was 0.91. Ninety-five percent of positive-point items were easy-medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46-51], κ = 0.68 (95% CI 0.59-0.77), Cronbach's α = 0.84. We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43-45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful. The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress.

Initiation, desistance, and persistence of men's sexual coercion.

PubMed

Hall, Gordon C Nagayama; DeGarmo, David S; Eap, Sopagna; Teten, Andra L; Sue, Stanley

2006-08-01

Patterns of sexually coercive behavior were examined among 266 Asian American and 299 European American men over 1 year. Noncoercer (n = 358), desister (n = 120), initiator (n = 39), and persistent (n = 48) sexually coercive groups were identified. The strongest predictor of sexual coercion was past sexual coercion. Persistent sexual coercers were higher than the other groups in delinquency and hostile masculinity and were nearly twice as likely to engage in laboratory sexual harassment. Loss of face attenuated self-reported sexual coercion and laboratory sexual harassment risk among Asian Americans and attenuated only laboratory sexual harassment risk among European Americans. These findings suggest that the heterogeneity of sexually coercive behavior and ethnicity are important research and clinical considerations.

Childhood- and later-onset vitiligo have diverse epidemiologic and clinical characteristics.

PubMed

Nicolaidou, Electra; Antoniou, Christina; Miniati, Alexandra; Lagogianni, Eirini; Matekovits, Athina; Stratigos, Alex; Katsambas, Andreas

2012-06-01

Vitiligo onset during childhood is common. There are limited data regarding childhood-onset vitiligo. We sought to provide an epidemiologic and clinical comparison between childhood- and later-onset vitiligo. Two groups of patients were included in this cross-sectional study. Consecutive patients examined at the Vitiligo Clinic of Andreas Sygros Hospital for Skin and Venereal Diseases, Athens, Greece, from January 2005 to December 2009 with a disease onset before the age of 12 years were included in the childhood-onset group. The later-onset group included randomly selected patients who were examined at the same period and had a disease onset after the age of 12 years. After clinical examination, a standardized questionnaire was completed for each patient. In all, 126 patients were included in the childhood-onset and 107 patients in the later-onset group. Childhood-onset vitiligo: (1) involved different sites at initial presentation, (2) included more cases of segmental type, and (3) was characterized by a higher prevalence of allergic diseases and a lower prevalence of thyroid diseases. Longer duration of disease and a positive family history of thyroid disease were associated with the presence of thyroid disease only in the childhood-onset group. In the later-onset group, only female sex was associated with the presence of thyroid disease. The study was conducted in a hospital specializing in skin diseases and a selection bias toward more severe vitiligo cases is possible. Childhood-onset vitiligo had distinct epidemiologic and clinical characteristics, compared with later-onset disease. Copyright © 2011 American Academy of Dermatology, Inc. Published by Mosby, Inc. All rights reserved.

Long-term prognosis of depression in primary care.

PubMed Central

Simon, G. E.

2000-01-01

This article uses longitudinal data from a primary care sample to examine long-term prognosis of depression. A sample of 225 patients initiating antidepressant treatment in primary care completed assessments of clinical outcome (Hamilton Depression Rating Scale and the mood module of the Structured Clinical Interview for DSM-IIIR) 1, 3, 6, 9, 12, 18 and 24 months after initiating treatment. The proportion of patients continuing to meet criteria for major depression fell rapidly to approximately 10% and remained at approximately that level throughout follow-up. The proportion meeting criteria for remission (Hamilton Depression score of 7 or less) rose gradually to approximately 45%. Long-term prognosis (i.e. probability of remission at 6 months and beyond) was strongly related to remission status at 3 months (odds ratio 3.65; 95% confidence interval, 2.81-4.76) and only modestly related to various clinical characteristics assessed at baseline (e.g. prior history of recurrent depression, medical comorbidity, comorbid anxiety symptoms). The findings indicate that potentially modifiable risk factors influence the long-term prognosis of depression. This suggests that more systematic and effective depression treatment programmes might have an important effect on long-term course and reduce the overall burden of chronic and recurrent depression. PMID:10885162

Overcoming barriers to HPV vaccination: A randomized clinical trial of a culturally-tailored, media intervention among African American girls.

PubMed

DiClemente, Ralph J; Murray, Colleen Crittenden; Graham, Tracie; Still, Julia

2015-01-01

Although genital HPV is the most prevalent STI in the US, rates of vaccination uptake among high-risk subgroups remain low. Investigations of vaccine compliance have mainly targeted mother-daughter dyads, which in some settings may prove difficult. This study examines an innovative culturally tailored, computer-delivered media-based strategy to promote HPV vaccine uptake. Data, inclusive of sociodemographics, sexual behaviors, knowledge, attitudes, and beliefs about HPV and vaccination were collected via ACASI from 216 African American adolescent females (ages 14-18 years) seeking services in family planning and STI public health clinics in metropolitan Atlanta. Data were obtained prior to randomization and participation in an interactive media-based intervention designed to increase HPV vaccination uptake. Medical record abstraction was conducted 7 month post-randomization to assess initial vaccine uptake and compliance. Participants in the intervention were more compliant to vaccination relative to a placebo comparison condition (26 doses vs. Seventeen doses; p=0.12). However, vaccination series initiation and completion were lower than the national average. Thorough evaluation is needed to better understand factors facilitating HPV vaccine uptake and compliance, particularly perceived susceptibility and the influence of the patient-provider encounter in a clinical setting.

Assessing health seeking behaviour among tuberculosis patients in rural South Africa.

PubMed

Pronyk, R M; Makhubele, M B; Hargreaves, J R; Tollman, S M; Hausler, H P

2001-07-01

South Africa's rural Northern Province. To examine patterns of health seeking behaviour among hospitalised tuberculosis patients. Information on personal characteristics, health seeking behaviour and delays to presentation and hospitalisation was collected from hospitalised TB patients. Analysis of rates was used to investigate factors associated with delay. Among 298 patients, median total delay to hospitalisation was 10 weeks, with patient delay contributing a greater proportion than service provider delay. Patients more often presented initially to public hospitals (41%) or clinics (31 %) than to spiritual/traditional healers (15%) or private GPs (13%). Total delay was shorter amongst those presenting to hospitals than those presenting to clinics (rate ratio 1.33, 95%CI 1.13-1.85), with a significantly smaller proportion of the total delay attributable to the health service provider (18% vs. 42%). Those exhibiting a conventional risk profile for TB (migrants, alcohol drinkers, history of TB) were diagnosed most quickly by health services, while women remained undiagnosed for longer. Considerable delay exists between symptom onset and treatment initiation among pulmonary tuberculosis patients. While a substantial delay was attributable to late patient presentation, an important, preventable period of infectiousness was caused by the failure of recognised clinical services to diagnose tuberculosis among symptomatic individuals.

Phaeochromocytoma masquerading as anxiety and depression.

PubMed

Zardawi, Ibrahim M

2013-01-01

Patient: Female, 36 Final Diagnosis: Pheochromocytoma Symptoms: Anxiety • depression Medication: - Clinical Procedure: - Specialty: Oncology • endocrinology. Unusual clinical course, Mistake in diagnosis. Pheochromocytoma is a rare catecholamine-producing neuroendocrine tumour with protean clinical manifestations, which can mimic a variety of conditions, often resulting in erroneous and delayed diagnosis. A case of undiagnosed pheochromocytoma in a 36 year old female with a 15 year history of anxiety and depression is described. The patient collapsed while on the phone to the next of kin and stopped breathing. She was initially revived but suffered a cardiac arrest and died. At autopsy an undiagnosed adrenal pheochromocytoma was found. When considering a diagnosis of anxiety and depression, medical causes of the symptoms must be excluded. Common conditions, such as thyroid disorders, stimulant abuse, asthma, cardiac arrhythmias, alcohol withdrawal and rarely pheochromocytoma, causing a similar spectrum of symptoms should be excluded by history and clinical examination.

Feline chronic renal failure: clinical findings in 80 cases diagnosed between 1992 and 1995.

PubMed

Elliott, J; Barber, P J

1998-02-01

Clinical and laboratory findings at the time of first diagnosis in 80 cats with chronic renal failure (CRF) were examined in a prospective study to determine the survival time of these animals and identify possible factors contributing to the progression of feline CRF. On the basis of clinical presentation, animals were assigned to one of three groups; compensated (n = 15), uraemic (n = 39) and end-stage (n = 26) CRF. Loss of renal concentrating ability was a common finding, even before clinical signs of renal disease were evident. The plasma creatinine concentration at initial presentation was a poor predictor of survival time and the presence of significant anaemia was indicative of a poor prognosis. The study demonstrated the highly variable degree of renal impairment present at the time of diagnosis and the potentially long survival time of many compensated and uraemic cases.

Scientific ways to study intercessory prayer as an intervention in clinical research.

PubMed

Rath, Linda L

2009-01-01

The purpose of this article is to share a "research journey" to study the somewhat controversial subject of Christian intercessory prayer (CIP) utilized as a clinical intervention, and the knowledge gained along the way. This article will explore the steps in the development and implementation of clinical research to scientifically examine a phenomenon that many say cannot--and should not--be studied. The sequential steps in developing this area of study are detailed and explained from the conception of the initial idea through utilization of concept analysis and literature review to develop the researchable topic. The subsequent development of both qualitative and quantitative pilot studies to investigate CIP in depth is presented to illustrate how the intervention of CIP can successfully be incorporated into clinical research. This article provides guidelines for future researchers who may want to utilize CIP as an intervention.

Various Manifestations of Hyperthyroidism in an Ambulatory Clinic: Case Studies

PubMed Central

Tripp, Warren; Rao, Vijaya; Creary, Ludlow B.

1987-01-01

This study reviews five cases of women with hyperthyroidism, three black women and two Hispanic women. Initially, two patients presented with voice changes, weight loss, and increased appetite. Only two patients presented with classical symptoms of hyperthyroidism. Examination showed all patients had diffusely enlarged thyroids and exaggerated reflexes. Two patients showed Graves' opthalmopathy. These cases document the variety of presentations of hyperthyroidism. Hence, a high index of suspicion must exist for this disease, even in the absence of a number of the classical manifestations of hyperthyroidism. When patients present to primary care centers with a constellation of symptoms, an examination of the thyroid gland is essential. PMID:3694696

Maturation of auditory neural processes in autism spectrum disorder - A longitudinal MEG study.

PubMed

Port, Russell G; Edgar, J Christopher; Ku, Matthew; Bloy, Luke; Murray, Rebecca; Blaskey, Lisa; Levy, Susan E; Roberts, Timothy P L

2016-01-01

Individuals with autism spectrum disorder (ASD) show atypical brain activity, perhaps due to delayed maturation. Previous studies examining the maturation of auditory electrophysiological activity have been limited due to their use of cross-sectional designs. The present study took a first step in examining magnetoencephalography (MEG) evidence of abnormal auditory response maturation in ASD via the use of a longitudinal design. Initially recruited for a previous study, 27 children with ASD and nine typically developing (TD) children, aged 6- to 11-years-old, were re-recruited two to five years later. At both timepoints, MEG data were obtained while participants passively listened to sinusoidal pure-tones. Bilateral primary/secondary auditory cortex time domain (100 ms evoked response latency (M100)) and spectrotemporal measures (gamma-band power and inter-trial coherence (ITC)) were examined. MEG measures were also qualitatively examined for five children who exhibited "optimal outcome", participants who were initially on spectrum, but no longer met diagnostic criteria at follow-up. M100 latencies were delayed in ASD versus TD at the initial exam (~ 19 ms) and at follow-up (~ 18 ms). At both exams, M100 latencies were associated with clinical ASD severity. In addition, gamma-band evoked power and ITC were reduced in ASD versus TD. M100 latency and gamma-band maturation rates did not differ between ASD and TD. Of note, the cohort of five children that demonstrated "optimal outcome" additionally exhibited M100 latency and gamma-band activity mean values in-between TD and ASD at both timepoints. Though justifying only qualitative interpretation, these "optimal outcome" related data are presented here to motivate future studies. Children with ASD showed perturbed auditory cortex neural activity, as evidenced by M100 latency delays as well as reduced transient gamma-band activity. Despite evidence for maturation of these responses in ASD, the neural abnormalities in ASD persisted across time. Of note, data from the five children whom demonstrated "optimal outcome" qualitatively suggest that such clinical improvements may be associated with auditory brain responses intermediate between TD and ASD. These "optimal outcome" related results are not statistically significant though, likely due to the low sample size of this cohort, and to be expected as a result of the relatively low proportion of "optimal outcome" in the ASD population. Thus, further investigations with larger cohorts are needed to determine if the above auditory response phenotypes have prognostic utility, predictive of clinical outcome.

A Novel Model for Teaching Primary Care in a Community Practice Setting: Tufts at Tech Community Veterinary Clinic.

PubMed

McCobb, Emily; Rozanski, Elizabeth A; Malcolm, Elizabeth L; Wolfus, Gregory; Rush, John E

Providing veterinary students with opportunities to develop clinical skills in a realistic, hands-on environment remains a challenge for veterinary education. We have developed a novel approach to teaching clinical medicine to fourth-year veterinary students and technical high school students via development of a primary care clinic embedded within a technical high school. The primary care clinic targets an underserved area of the community, which includes many of the participating high school students. Support from the veterinary community for the project has been strong as a result of communication, the opportunity for veterinarians to volunteer in the clinic, and the careful targeting of services. Benefits to veterinary students include the opportunity to build clinical competencies and confidence, as well as the exposure to a diverse client population. The financial model of the clinic is described and initial data on outcomes for case load, clinic income, veterinary student evaluations, and high school students' success in passing the veterinary assisting examination are reported. This clinical model, involving a partnership between a veterinary school and a technical high school, may be adoptable to other clinical teaching situations.

Gender as a variable in the assessment of final year degree-level communication skills.

PubMed

Wiskin, Connie M D; Allan, Teresa F; Skelton, John R

2004-02-01

To investigate possible bias due to gender combination of students, role players and examiners in a high-stakes assessment. Valid oral interactive contextualized examinations (VOICEs) is a long-station OSCE-style exam in general practice (GP). At the time of writing it consisted of 65% of the student's final GP mark. In the VOICE, students undertake six tasks--four vivas and two role-plays. "Patient" roles are taken by professional role players who work regularly on the undergraduate curriculum. During the role-play, the student's clinical competence is assessed by an observing GP examiner. The communication skills marks are awarded by the role player and the examiner together, by negotiation. Data have been recorded detailing the role player's initial marks, the examiner's initial marks and their final (awarded) agreed marks for 1024 consultations. 512 final year medical students, 28 role players and 48 examiners. There were no inclusion or exclusion criteria. All those present on exam day became part of the data. There was a significant relationship between gender and performance for some, but not all, stations. Correlations for multiple comparisons removed the significance. Female students perform better across the board than male students. While not always significant, this did affect grading. There was no significant association between the genders of role players and examiners with the question choices. There has been a significant worsening of male results since 1999. Differences exist in the way that pairs of mixed or single genders score students.

A preliminary model of work during initial examination and treatment planning appointments.

PubMed

Irwin, J Y; Torres-Urquidy, M H; Schleyer, T; Monaco, V

2009-01-10

Objective This study's objective was to formally describe the work process for charting and treatment planning in general dental practice to inform the design of a new clinical computing environment.Methods Using a process called contextual inquiry, researchers observed 23 comprehensive examination and treatment planning sessions during 14 visits to 12 general US dental offices. For each visit, field notes were analysed and reformulated as formalised models. Subsequently, each model type was consolidated across all offices and visits. Interruptions to the workflow, called breakdowns, were identified.Results Clinical work during dental examination and treatment planning appointments is a highly collaborative activity involving dentists, hygienists and assistants. Personnel with multiple overlapping roles complete complex multi-step tasks supported by a large and varied collection of equipment, artifacts and technology. Most of the breakdowns were related to technology which interrupted the workflow, caused rework and increased the number of steps in work processes.Conclusion Current dental software could be significantly improved with regard to its support for communication and collaboration, workflow, information design and presentation, information content, and data entry.

[Heterotopic ossification spinal cord injury. Management through early diagnosis and therapy].

PubMed

Maier, D

2005-02-01

Heterotopic ossification is a frequent and potentially disastrous complication of acute spinal cord injury. Pathogenesis and etiology are not well described, initial clinical symptoms are uncharacteristic, specific laboratory findings do not exist. Between March 1997 and May 2000 all 290 patients admitted to our facility with acute spinal cord injury underwent standardized sonographic examinations of the soft tissue around the hip joint every three weeks, starting as early as two weeks after injury. In 12% of the patient population characteristic sonographic findings for heterotopic ossification were present while the regular x-ray examination was still unremarkable. Laboratory findings (alkaline phosphatase, C-reactive protein, anorganic phosphate) were unspecific. Clinical findings were present only in a few patients. All patients underwent radiotherapy consisting of the administration of 5 times 3 Gy to the area as soon as possible. Follow up demonstrated no progression of the heterotopic bone formation in these cases. In conclusion, regular ultrasound examination proved to be a secure, fast and reproducible method for the very early diagnosis of heterotopic ossification after acute spinal cord injury.

Sleep patterns and the risk for unipolar depression: a review

PubMed Central

Wiebe, Sabrina T; Cassoff, Jamie; Gruber, Reut

2012-01-01

Psychological disorders, particularly mood disorders, such as unipolar depression, are often accompanied by comorbid sleep disturbances, such as insomnia, restless sleep, and restricted sleep duration. The nature of the relationship between unipolar depression and these sleep disturbances remains unclear, as sleep disturbance may be a risk factor for development, an initial manifestation of the disorder, or a comorbid condition affected by similar mechanisms. Various studies have examined the impact of sleep deprivation on the presence of (or exacerbation of) depressive symptoms, and have examined longitudinal and concurrent associations between different sleep disturbances and unipolar depression. This review examines the evidence for sleep disturbances as a risk factor for the development and presence of depression, as well as examining common underlying mechanisms. Clinical implications pertaining to the comorbid nature of various sleep patterns and depression are considered. PMID:23620679

Prevalence and patterns of antidepressant switching amongst primary care patients in the UK.

PubMed

Mars, Becky; Heron, Jon; Gunnell, David; Martin, Richard M; Thomas, Kyla H; Kessler, David

2017-05-01

Non-response to antidepressant treatment is a substantial problem in primary care, and many patients with depression require additional second-line treatments. This study aimed to examine the prevalence and patterns of antidepressant switching in the UK, and identify associated demographic and clinical factors. Cohort analysis of antidepressant prescribing data from the Clinical Practice Research Datalink, a large, anonymised UK primary care database. The sample included 262,844 patients who initiated antidepressant therapy between 1 January 2005 and 31 June 2011. 9.3% of patients switched to a different antidepressant product, with most switches (60%) occurring within 8 weeks of the index date. The proportion switching was similar for selective serotonin reuptake inhibitors (SSRIs), tricyclic antidepressants and other antidepressants (9.3%, 9.8% and 9.2%, respectively). Most switches were to an SSRI (64.5%), and this was the preferred option regardless of initial antidepressant class. Factors predictive of switching included male gender, age, and history of self-harm and psychiatric illness. Over one in every 11 patients who initiates antidepressant therapy will switch medication, suggesting that initial antidepressant treatment has been unsatisfactory. Evidence to guide choice of second-line treatment for individual patients is currently limited. Additional research comparing different pharmacological and psychological second-line treatment strategies is required in order to inform guidelines and improve patient outcomes.

Comparison of urine specimen collection times and testing fractions for the detection of high-risk human papillomavirus and high-grade cervical precancer.

PubMed

Senkomago, V; Des Marais, A C; Rahangdale, L; Vibat, C R T; Erlander, M G; Smith, J S

2016-01-01

Urine testing for high-risk human papillomavirus (HR-HPV) detection could provide a non-invasive, simple method for cervical cancer screening. We examined whether HR-HPV detection is affected by urine collection time, portion of urine stream, or urine fraction tested, and assessed the performance of HR-HPV testing in urine for detection of cervical intraepithelial neoplasia grade II or worse (CIN2+). A total of 37 female colposcopy clinic attendees, ≥ 30 years, provided three urine samples: "first void" urine collected at home, and "initial stream" and "mid-stream" urine samples collected at the clinic later in the day. Self- and physician-collected brush specimens were obtained at the same clinic visit. Colposcopy was performed and directed biopsies obtained if clinically indicated. For each urine sample, HR-HPV DNA testing was conducted for unfractionated, pellet, and supernatant fractions using the Trovagene test. HR-HPV mRNA testing was performed on brush specimens using the Aptima HPV assay. HR-HPV prevalence was similar in unfractionated and pellet fractions of all urine samples. For supernatant urine fractions, HR-HPV prevalence appeared lower in mid-stream urine (56.8%[40.8-72.7%]) than in initial stream urine (75.7%[61.9-89.5%]). Sensitivity of CIN2+ detection was identical for initial stream urine and physician-collected cervical specimen (89.9%[95%CI=62.7-99.6%]), and similar to self-collected vaginal specimen (79.1%[48.1-96.6%]). This is among the first studies to compare methodologies for collection and processing of urine for HR-HPV detection. HR-HPV prevalence was similar in first void and initial stream urine, and was highly sensitive for CIN2+ detection. Additional research in a larger and general screening population is needed. Copyright © 2015 Elsevier B.V. All rights reserved.

The effect of acupressure on the initiation of labor: A randomized controlled trial.

PubMed

Torkzahrani, Shahnaz; Mahmoudikohani, Fatemeh; Saatchi, Kiarash; Sefidkar, Reyhaneh; Banaei, Mojdeh

2017-02-01

Induction of labor is a common obstetric procedure. Acupressure is a natural method that is used for inducing uterine contractions. Nevertheless, few studies have examined the impact of acupressure on the induction of labor. The aim of this study was to evaluate the effect of acupressure on the initiation of labor. In this randomized clinical trial, 162 nulliparous pregnant women were admitted to the hospital. They were categorized into 3 groups; acupressure, sham acupressure and control. Acupressure points SP6, BL 60 and BL 32 were pressured bilaterally. The intervention was done by the researcher every other day between 9 am and 11 am. The intervention was carried out on women in the afternoon and the following day. Subjects were examined to determine the initiation of labor symptoms48 and 96h after the start of intervention and at the time of hospitalization. Data were analyzed using the ANOVA, Kruskal-Wallis and Chi-square tests (p<0.05). There was no significant difference among the groups for spontaneous initiation of labor within 48h (P=0.464), and 49-96h after beginning the intervention (P=0.111) and 97h after beginning the intervention to the time of hospitalization for the spontaneous initiation of labor (P=0.897). There were no significant differences in the secondary outcomes between the groups. According to the finding of this study, it seems that acupressure treatment was not effective in initiating labor as compared with the sham acupressure and the routine care groups. Copyright © 2016 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Factors associated with long-term antiretroviral therapy attrition among adolescents in rural Uganda: a retrospective study.

PubMed

Okoboi, Stephen; Ssali, Livingstone; Yansaneh, Aisha I; Bakanda, Celestin; Birungi, Josephine; Nantume, Sophie; Okullu, Joanne Lyavala; Sharp, Alana R; Moore, David M; Kalibala, Samuel

2016-01-01

As access to antiretroviral therapy (ART) increases, the success of treatment programmes depends on ensuring high patient retention in HIV care. We examined retention and attrition among adolescents in ART programmes across clinics operated by The AIDS Support Organization (TASO) in Uganda, which has operated both facility- and community-based distribution models of ART delivery since 2004. Using a retrospective cohort analysis of patient-level clinical data, we examined attrition and retention in HIV care and factors associated with attrition among HIV-positive adolescents aged 10-19 years who initiated ART at 10 TASO clinics between January 2006 and December 2011. Retention in care was defined as the proportion of adolescents who had had at least one facility visit within the six months prior to 1 June 2013, and attrition was defined as the proportion of adolescents who died, were lost to follow-up, or stopped treatment. Descriptive statistics and Cox proportional hazards regression models were used to determine the levels of retention in HIV care and the factors associated with attrition following ART initiation. A total of 1228 adolescents began ART between 2006 and 2011, of whom 57% were female. The median duration in HIV care was four years (IQR=3-6 years). A total of 792 (65%) adolescents were retained in care over the five-year period; 36 (3%) had died or transferred out and 400 (32%) were classified as loss to follow-up. Factors associated with attrition included being older (adjusted hazard ratio (AHR)=1.38, 95% confidence interval (CI) 1.02-1.86), having a higher CD4 count (250+ cells/mm(3)) at treatment initiation (AHR=0.49, 95% CI 0.34-0.69) and HIV care site with a higher risk of attrition among adolescents in Gulu (AHR=2.26; 95% CI 1.27-4.02) and Masindi (AHR=3.30, 95% CI 1.87-5.84) and a lower risk of attrition in Jinja (AHR=0.24, 95% CI 0.08-0.70). Having an advanced WHO clinical stage at initiation was not associated with attrition. We found an overall retention rate of 65%, which is comparable to rates achieved by TASO's adult patients and adolescents in other studies in Africa. Variations in the risk of attrition by TASO treatment site and by clinical and demographic characteristics suggest the need for early diagnosis of HIV infection, use of innovative approaches to reach and retain adolescents living with HIV in treatment and identifying specific groups, such as older adolescents, that are at high risk of dropping out of treatment for targeted care and support.

Frequency of Evidence-Based Screening for Retinopathy in Type 1 Diabetes.

PubMed

Nathan, David M; Bebu, Ionut; Hainsworth, Dean; Klein, Ronald; Tamborlane, William; Lorenzi, Gayle; Gubitosi-Klug, Rose; Lachin, John M

2017-04-20

In patients who have had type 1 diabetes for 5 years, current recommendations regarding screening for diabetic retinopathy include annual dilated retinal examinations to detect proliferative retinopathy or clinically significant macular edema, both of which require timely intervention to preserve vision. During 30 years of the Diabetes Control and Complications Trial (DCCT) and its longitudinal follow-up Epidemiology of Diabetes Interventions and Complications (EDIC) study, retinal photography was performed at intervals of 6 months to 4 years. We used retinal photographs from the DCCT/EDIC study to develop a rational screening frequency for retinopathy. Markov modeling was used to determine the likelihood of progression to proliferative diabetic retinopathy or clinically significant macular edema in patients with various initial retinopathy levels (no retinopathy or mild, moderate, or severe nonproliferative diabetic retinopathy). The models included recognized risk factors for progression of retinopathy. Overall, the probability of progression to proliferative diabetic retinopathy or clinically significant macular edema was limited to approximately 5% between retinal screening examinations at 4 years among patients who had no retinopathy, 3 years among those with mild retinopathy, 6 months among those with moderate retinopathy, and 3 months among those with severe nonproliferative diabetic retinopathy. The risk of progression was also closely related to mean glycated hemoglobin levels. The risk of progression from no retinopathy to proliferative diabetic retinopathy or clinically significant macular edema was 1.0% over 5 years among patients with a glycated hemoglobin level of 6%, as compared with 4.3% over 3 years among patients with a glycated hemoglobin level of 10%. Over a 20-year period, the frequency of eye examinations was 58% lower with our practical, evidence-based schedule than with routine annual examinations, which resulted in substantial cost savings. Our model for establishing an individualized schedule for retinopathy screening on the basis of the patient's current state of retinopathy and glycated hemoglobin level reduced the frequency of eye examinations without delaying the diagnosis of clinically significant disease. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and others; DCCT/EDIC ClinicalTrials.gov numbers, NCT00360893 and NCT00360815 .).

Concurrent Oral Antipsychotic Drug Use Among Schizophrenia Patients Initiated on Long-Acting Injectable Antipsychotics Post-Hospital Discharge.

PubMed

Doshi, Jalpa A; Pettit, Amy R; Stoddard, Jeffrey J; Zummo, Jacqueline; Marcus, Steven C

2015-08-01

Pharmacological treatment is central to effective management of schizophrenia. Prescribing clinicians have an increasing array of options from which to choose, and oral antipsychotic polypharmacy is common in routine clinical practice. Practice guidelines recommend long-acting injectable (LAI) formulations, typically viewed as monotherapeutic alternatives, for patients with established nonadherence. Yet there are limited data on the prevalence and nature of concurrent oral antipsychotic prescriptions in patients receiving LAIs. Our observational, claims-based study examined the frequency and duration of concurrent oral prescriptions in 340 Medicaid patients receiving LAI therapy. Specifically, we examined patients with a recent history of nonadherence and hospitalization for schizophrenia and included both first-generation antipsychotic depot medications (fluphenazine decanoate, haloperidol decanoate) and more recently available second-generation injectables (LAI risperidone, paliperidone palmitate). Of all patients initiated on LAIs, 75.9% had a concurrent oral antipsychotic prescription in the 6 months post-hospital discharge. Patients receiving concurrent prescriptions were frequently prescribed an oral formulation of their LAI agent, but many first-generation LAI users received a concurrent second-generation oral medication. The lowest rate of concurrent prescribing (58.8%) was found with paliperidone palmitate, whereas the highest rate was with LAI risperidone (88.9%). Overlap in oral and LAI prescriptions typically occurred for a substantial period of time (ie, >30 days) and for a notable percentage of the days covered by LAIs (often 50% or more). Our findings highlight the need to further examine such prescribing patterns, to probe the reasons for them, and to clarify the optimal roles of different antipsychotic treatments in clinical practice.

Enrolling adolescents in asthma research: adolescent, parent, and physician influence in the decision-making process.

PubMed

Brody, Janet L; Annett, Robert D; Scherer, David G; Turner, Charles; Dalen, Jeanne

2009-06-01

The factors influencing family decisions to participate in adolescent asthma research are not well understood. Legal and ethical imperatives require adolescent research participation to be voluntary. While parents and adolescents often agree about research decisions, disagreements may also occur with relative frequency. Physician recommendations are also known to influence research participation decisions. Little attention has been given to how these dynamics may affect adolescents' involvement in decisions to participate in research. To examine the influence of family and physician-investigator relationships and recommendations on adolescent asthma clinical research participation decisions. A statewide community sample of 111 adolescents 11 to 17 years of age, with a diagnosis of asthma, and their parents participated in this study. Adolescents received a medical evaluation from an asthma specialist and then the family was offered participation in a hypothetical asthma clinical trial. By random assignment, the research study was presented by either the same or an unknown asthma specialist, and half the families in each group also received affirmative recommendations from the asthma specialist to participate in the hypothetical asthma clinical trial. Parents and adolescents made initial private decisions about participating in the trial. Then, following a family discussion of the clinical trial, a final research participation decision was made. Thirty-three percent of parents and adolescents initially disagreed about the research participation decision. When disagreements occurred, final decisions followed the parents' initial views except when the physician-investigator was known and a recommendation was made. Families with initial disagreement about participating were less likely to enroll when the investigator was unknown or when no recommendation was made. Adolescents who initially disagreed with parents' views were less likely to concur with the final research participation decision, felt less comfortable, and were less likely to feel they influenced the decision. Parents' views on research decisions take precedence over adolescents' views in most circumstances. Physician-investigator relationships may reduce parental resistance to participation and enhance adolescent decision-making autonomy when research participation is desired by the adolescent.

The role of serial free/total prostate-specific antigen ratios in a watchful observation protocol for men with localized prostate cancer.

PubMed

Do, V; Choo, R; De Boer, G; Klotz, L; Danjoux, C; Morton, G; Szumacher, E; Fleshner, N; Bunting, P

2002-05-01

To examine the change in the free/total prostate specific antigen ratio (f/tPSA) with time and to assess the potential value of serial measurements of f/tPSA as a determinant of disease progression in untreated, low-to-intermediate grade prostate cancer (T1b-T2b N0M0, Gleason score < or = 7 and PSA < or = 15 ng/mL). In a prospective single-arm cohort study from November 1995, patients were conservatively managed with watchful observation alone unless they met arbitrarily defined criteria (clinical, histological and biochemical) of disease progression. Patients were followed regularly and underwent blood tests including PSA and f/tPSA. The initial and mean f/tPSA and the rate of change of f/tPSA with time were evaluated against the rate constant for the PSA doubling time (PSATd). Correlation analyses were used to evaluate any association between baseline clinical variables and either the rate of change of f/tPSA or initial f/tPSA. As of December 2000, 161 of a total of 206 accrued patients had three or more f/tPSA measurements and formed the basis of the study (median age 70 years; median follow-up 2.7 years). The median initial f/tPSA was 0.16; there was a significant negative correlation between this value and the initial total PSA. The mean f/tPSA and rate of change of f/tPSA with time were significantly negatively correlated with the rate constant for PSATd. Also, the rate of change of f/tPSA correlated negatively with clinical T stage, but not with other baseline variables, including initial PSA, age and Gleason score. The f/tPSA in men with untreated, clinically localized prostate cancer varied widely. The negative correlation between the rate of change of f/tPSA with time and rate constant for PSATd suggests that both might provide valuable information to allow clinicians to develop a strategy for optimizing the timing of therapeutic intervention for those patients choosing watchful observation alone.

Enrolling adolescents in asthma research: Adolescent, parent, and physician influence in the decision-making process

PubMed Central

Brody, Janet L.; Annett, Robert D.; Scherer, David G.; Turner, Charles; Dalen, Jeanne

2009-01-01

Background The factors influencing family decisions to participate in adolescent asthma research are not well understood. Legal and ethical imperatives require adolescent research participation to be voluntary. While parents and adolescents often agree about research decisions, disagreements may also occur with relatively frequency. Physician recommendations are also known to influence research participation decisions. Little attention has been given to how these dynamics may affect adolescents’ involvement in decisions to participate in research. Objective To examine the influence of family and physician-investigator relationships and recommendations on adolescent asthma clinical research participation decisions. Methods A statewide community sample of 111 adolescents aged 11–17, with a diagnosis of asthma, and their parents participated in this study. Adolescents received a medical evaluation from an asthma specialist and then the family was offered participation in a hypothetical asthma clinical trial. By random assignment, the research study was presented by either the same or an unknown asthma specialist and half the families in each group also received affirmative recommendations from the asthma specialist to participate in the hypothetical asthma clinical trial. Parents and adolescent made initial private decisions about participating in the trial. Then, following a family discussion of the clinical trial, a final research participation decision was made. Results Thirty three percent of parents and adolescents initially disagreed about the research participation decision. When disagreements occurred, final decisions followed the parents’ initial views except when the physician-investigator was known and a recommendation was made. Families with initial disagreement about participating were less likely to enroll when the investigator was unknown or when no recommendation was made. Adolescents who initially disagreed with parents’ views were less likely to concur with the final research participation decision, felt less comfortable, and were less likely to feel they influenced the decision. Conclusions Parents’ views on research decisions take precedence over adolescents’ views in most circumstances. Physician-investigator relationships may reduce parental resistance to participation and enhance adolescent decision-making autonomy when research participation is desired by the adolescent. PMID:19544171

[Standard Cancer Therapy Are Established by the Investigator-Initiated Post-Marketing Clinical Trials, Not by the Indication-Directed Clinical Trials].

PubMed

Shimada, Yasuhiro

2016-04-01

The financial supports for investigator-initiated post-marketing clinical trial in clinical oncology are reduced after scandals related to the other fields of clinical trials in Japan. These clinical trials are the essential final steps of clinical development in newer cancer therapy, which should be conducted in the investigator-initiated clinical trial groups with well-organized infrastructure and continuous financial supports. The present problems are discussed and summarized. Future perspectives with the national viewpoints needed to be included the idea of "health technology assessment".

Prescribing Patterns of Metformin in High-risk Patients with Prediabetes.

PubMed

Stirling, Daniel L; Onor, Ifeanyi; Sarpong, Daniel; Rapp, Kristi Isaac; Crawford, Lori D

2015-01-01

The primary objective of this study is to examine the rates of metformin prescribing in patients with prediabetes who are either less than 60 years of age, have a BMI greater than 35 kg/m2, or women with a history of gestational diabetes mellitus (GDM). Secondary objectives include: 1) examination of the time from diagnosis of prediabetes to the initiation of metformin and 2) if metformin initiation status and length of time correlates to the patient having any other additional diabetes mellitus (DM) risk factors. This was a single center, retrospective cohort study. This study included all patients with prediabetes, defined as having hemoglobin A1c (HbA1c) of 39 through 46 mmol/mol (5.7-6.4 percent), who were patients at the Interim LSU Hospital and Clinics from January 2012-September 2013. There were a total of 13 patients out of 160 patients in the study population who were prescribed metformin for an overall metformin initiation rate of 8.1 percent. The metformin initiation rate for the three individual groups; history of GDM, aged less than 60 years, and BMI greater than 35 kg/m2 were 0 percent, 9.0 percent, and 17.5 percent respectively. Metformin initiation rates in patients with prediabetes are not in accordance with current recommendations, and provider education is necessary to increase rates to delay or prevent the progression of prediabetes to type 2 Diabetes Mellitus.

Digital photo documentation of forensically relevant injuries as part of the clinical first response protocol.

PubMed

Verhoff, Marcel A; Kettner, Mattias; Lászik, András; Ramsthaler, Frank

2012-09-01

A problem encountered by medical examiners is that they have to assess injuries that have already been medically treated. Thus, they have to base their reports on clinical forensic examinations performed hours or days after an injury was sustained, or even base their assessment solely on information gleaned from medical files. In both scenarios, the forensic examiner has to rely heavily on the first responder's documentation of the original injury pattern. Medical priority will be to immediately treat a patient's injuries, and the first responder may, in addition, initially be unaware of a possibly criminal origin of an injury. As a result, the documentation of injuries is frequently of limited value for forensic purposes. This situation could be improved if photographic records were briefly made of injuries before they were treated. German-language medicolegal, criminal, and photography journals and books were selectively searched with the help of PubMed and other databases. In addition, the authors' experiences in creating and evaluating photographic records for clinical forensic use were assessed. This paper is an aid to creating photographic records of sufficient quality for forensic purposes. The options provided by digital photography in particular make this endeavor feasible even in a clinical setting. In addition, our paper illuminates some technical aspects of creating and archiving photographic records for forensic use, and addresses possible error sources. With the requisite technical background knowledge, injuries can be photographically recorded to forensic standards during patient care.

The readiness and motivation interview for families (RMI-Family) managing pediatric obesity: study protocol.

PubMed

Ball, Geoff D C; Spence, Nicholas D; Browne, Nadia E; O'Connor, Kathleen; Srikameswaran, Suja; Zelichowska, Joanna; Ho, Josephine; Gokiert, Rebecca; Mâsse, Louise C; Carson, Valerie; Morrison, Katherine M; Kuk, Jennifer L; Holt, Nicholas L; Kebbe, Maryam; Gehring, Nicole D; Cesar, Melody; Virtanen, Heidi; Geller, Josie

2017-04-11

Experts recommend that clinicians assess motivational factors before initiating care for pediatric obesity. Currently, there are no well-established clinical tools available for assessing motivation in youth with obesity or their families. This represents an important gap in knowledge since motivation-related information may shed light on which patients might fail to complete treatment programs. Our study was designed to evaluate the measurement properties and utility of the Readiness and Motivational Interview for Families (RMI-Family), a structured interview that utilizes a motivational interviewing approach to (i) assess motivational factors in youth and their parents, and (ii) examine the degree to which motivation and motivation-related concordance between youth and parents are related to making changes to lifestyle habits for managing obesity in youth. From 2016 to 2020, this prospective study will include youth with obesity (body mass index [BMI] ≥97th percentile; 13-17 years old; n = 250) and their parents (n = 250). The study will be conducted at two primary-level, multidisciplinary obesity management clinics based at children's hospitals in Alberta, Canada. Participants will be recruited and enrolled after referral to these clinics, but prior to initiating clinical care. Each youth and their parent will complete the RMI-Family (~1.5 h) at baseline, and 6- and 12-months post-baseline. Individual (i.e., youth or parent) and family-level (i.e., across youth and parent) responses to interview questions will be scored, as will aspects of interview administration (e.g., fidelity to motivational interviewing tenets). The RMI-Family will also be examined for test-retest reliability. Youth data collected at each time point will include demography, anthropometry, lifestyle habits, psychosocial functioning, and health services utilization. Cross-sectional and longitudinal associations between individual and family-level interview scores on the RMI-Family and these clinical measures will be examined. As a measurement tool drawing on family-centered care and motivational interviewing, the RMI-Family was designed to increase understanding of the role of motivational factors in pediatric obesity management, allowing healthcare providers and policymakers to manage pediatric obesity more effectively and efficiently. Findings will help to create an innovative, tailored model of health care delivery that uses resources judiciously and is designed to best meet families' needs.

Temporal Trends in the Use of Parenteral Nutrition in Critically Ill Patients

PubMed Central

Kahn, Jeremy M.; Wunsch, Hannah

2014-01-01

Background: Clinical practice guidelines recommend enteral over parenteral nutrition in critical illness and do not recommend early initiation. Few data are available on parenteral nutrition use or timing of initiation in the ICU or how this use may have changed over time. Methods: We used the Project IMPACT database to evaluate temporal trends in parenteral nutrition use (total and partial parenteral nutrition and lipid supplementation) and timing of initiation in adult ICU admissions from 2001 to 2008. We used χ2 tests and analysis of variance to examine characteristics of patients receiving parenteral nutrition and multilevel multivariate logistic regression models to assess parenteral nutrition use over time, in all patients and in specific subgroups. Results: Of 337,442 patients, 20,913 (6.2%) received parenteral nutrition. Adjusting for patient characteristics, the use of parenteral nutrition decreased modestly over time (adjusted probability, 7.2% in 2001-2002 vs 5.5% in 2007-2008, P < .001). Enteral nutrition use increased simultaneously (adjusted probability, 11.5% in 2001-2002 vs 15.3% in 2007-2008, P < .001). Use of parenteral nutrition declined most rapidly in emergent surgical patients, patients with moderate illness severity, patients in the surgical ICU, and patients admitted to an academic facility (P ≤ .01 for all interactions with year). When used, parenteral nutrition was initiated a median of 2 days (interquartile range, 1-3), after ICU admission and > 90% of patients had parenteral nutrition initiated within 7 days; timing of initiation of parenteral nutrition did not change from 2001 to 2008. Conclusions: Use of parenteral nutrition in US ICUs declined from 2001 through 2008 in all patients and in all examined subgroups, with the majority of parenteral nutrition initiated within the first 7 days in ICU; enteral nutrition use coincidently increased over the same time period. PMID:24233390

A National Cohort Study of U.S. Medical School Students Who Initially Failed Step 1 of the United States Medical Licensing Examination

PubMed Central

Andriole, Dorothy A.; Jeffe, Donna B.

2012-01-01

Purpose To describe educational outcomes for a national cohort of U.S. medical students who initially failed Step 1 of the United States Medical Licensing Examination Method The authors analyzed de-identified, individualized records for the 1993–2000 cohort of U.S. medical school matriculants who both initially failed Step l and were no longer in medical school as of March 2, 2009, using multivariable logistic regression to identify factors associated with attempting, and initially passing, Step 2 Clinical Knowledge (CK). Results Of 6,594 students who failed Step l, 5,985 (90.8%) took Step 2CK. Women and Asian/Pacific Islander students were more likely to attempt Step 2CK; more recent matriculants and students with lower failing Step 1 scores were less likely. Of the 5,985 students who attempted Step 2CK, 4,168 (69.6%) initially passed. Women, students with higher Medical College Admission Test scores, and more recent matriculants were more likely to pass Step 2CK; Asian/Pacific Islander students, underrepresented minority students, older students, and students with lower failing Step 1 scores were less likely. Ninety percent of students in the study sample (5,952/6,594) ultimately graduated from medical school, including 99.5% (4,148/4,168) of those who initially passed, 96.7% (1,757/1,817) of those who initially failed, and 7.7% (47/609) of those who never attempted Step 2CK. Conclusions The authors identified variables associated with educational outcomes among students who failed Step l. These findings can inform medical schools’ efforts to develop tailored interventions to maximize the likelihood that students will take Step 2CK and pass it on the first attempt. PMID:22361789

Review of systems, physical examination, and routine tests for case-finding in ambulatory patients.

PubMed

Boland, B J; Wollan, P C; Silverstein, M D

1995-04-01

The screening value of the comprehensive review of systems and the complete physical examination in detecting unsuspected diseases for which therapeutic interventions are initiated has not been formally studied in ambulatory patients. The medical records of 100 randomly selected adult patients who had an ambulatory general medical evaluation at the Mayo Clinic in 1990-1991 were surveyed to compare review of systems and physical examination with routine laboratory tests, chest radiography, and electrocardiography as case-finding maneuvers. The main outcome measure was the therapeutic yield of each case-finding maneuver, defined as the proportion of maneuvers leading to a new therapy for a new clinically important diagnosis. The utilization rate of routine tests in the 100 patients (mean age: 59 +/- 16 years; 58% women) was high, ranging from 77 to 98%. Overall, the case-finding maneuvers led to 36 unsuspected clinically important diagnoses and resulted in 25 new therapeutic interventions. Higher therapeutic yield was observed for review of systems (7%), physical examination (5%), and lipid screening (9.2%) than for chemistry group (2.2%), complete blood count (1.8%), thyroid tests (1.5%), urinalysis (1.1%), electrocardiography (0%), or chest radiography (0%). The number of therapeutic interventions was not associated with patient's age (P = 0.55), sex (P = 0.88), comorbidity (P = 0.30) or with the time interval since the last general medical evaluation (P = 0.12). Based on therapeutic yield, these data suggest that review of systems and physical examination are valuable case-finding maneuvers in the periodic medical evaluation of ambulatory patients.

Potential capacity of endoscopic screening for gastric cancer in Japan.

PubMed

Hamashima, Chisato; Goto, Rei

2017-01-01

In 2016, the Japanese government decided to introduce endoscopic screening for gastric cancer as a national program. To provide endoscopic screening nationwide, we estimated the proportion of increase in the number of endoscopic examinations with the introduction of endoscopic screening, based on a national survey. The total number of endoscopic examinations has increased, particularly in clinics. Based on the national survey, the total number of participants in gastric cancer screening was 3 784 967. If 30% of the participants are switched from radiographic screening to endoscopic screening, approximately 1 million additional endoscopic examinations are needed. In Japan, the participation rates in gastric cancer screening and the number of hospitals and clinics offering upper gastrointestinal endoscopy vary among the 47 prefectures. If the participation rates are high and the numbers of hospitals and clinics are small, the proportion of increase becomes larger. Based on the same assumption, 50% of big cities can provide endoscopic screening with a 5% increase in the total number of endoscopic examinations. However, 16.7% of the medical districts are available for endoscopic screening within a 5% increase in the total number of endoscopic examinations. Despite the Japanese government's decision to introduce endoscopic screening for gastric cancer nationwide, its immediate introduction remains difficult because of insufficient medical resources in rural areas. This implies that endoscopic screening will be initially introduced to big cities. To promote endoscopic screening for gastric cancer nationwide, the disparity of medical resources must first be resolved. © 2016 The Authors. Cancer Science published by John Wiley & Sons Australia, Ltd on behalf of Japanese Cancer Association.

Clinical response and safety of malathion shampoo for treatment of head lice in a primary school.

PubMed

Wananukul, Siriwan; Chatproedprai, Susheera; Tempark, Therdpong; Wananukul, Winai

2011-04-01

Help eradicate or at least alleviating head lice in a primary school with malathion shampoo and to study clinical response and safety of malathion shampoo. All students were examined by using a fine-toothed lice comb to help detect live lice. Direct visual examination and the collection of nits for microscopic examination were performed to differentiate viable nits from empty nits. Diagnosis of head lice was made by the presence of lice. All students that had lice and/or nits were treated with malathion shampoo. Malathion shampoo was also provided for all family members. Pediculocidal efficacy was by the presence or absence of live lice. Blood for red blood cell cholinesterase activity was drawn in 32 volunteers before treatment and after the second treatment. At the first visit, 629 students were examined and 48 students had live head lice. The infestation rate was 13% in girls and 1.3% in boys. The cure rate was 93% after the first treatment. The reported side effects were nausea, a burning sensation, and irritation that was found in five (4%), 10 (7%) and three (2%) students respectively. The mean of RBC cholinesterase activity before and after two applications showed significant changes (p = 0.03). It was -7.5 +/- 4.1% reduction from the initial, but all were in the normal range. There was no report of clinical manifestation of malathion toxicity. Malathion shampoo is safe and effective in the treatment of head lice. There is significant skin absorption so a scalp examination for head lice should be done before subsequent application to avoid unnecessary exposure.

Use of appropriate initial treatment among adolescents and young adults with cancer.

PubMed

Potosky, Arnold L; Harlan, Linda C; Albritton, Karen; Cress, Rosemary D; Friedman, Debra L; Hamilton, Ann S; Kato, Ikuko; Keegan, Theresa H M; Keel, Gretchen; Schwartz, Stephen M; Seibel, Nita L; Shnorhavorian, Margarett; West, Michele M; Wu, Xiao-Cheng

2014-11-01

There has been little improvement in the survival of adolescent and young adult (AYA) cancer patients aged 15 to 39 years relative to other age groups, raising the question of whether such patients receive appropriate initial treatment. We examined receipt of initial cancer treatment for a population-based sample of 504 AYAs diagnosed in 2007-2008 with acute lymphoblastic leukemia (ALL), Hodgkin's or non-Hodgkin's lymphoma, germ cell cancer, or sarcoma. Registry data, patient surveys, and detailed medical record reviews were used to evaluate the association of patient demographic, socioeconomic, and health care setting characteristics with receipt of appropriate initial treatment, which was defined by clinical specialists in AYA oncology based on adult guidelines and published literature available before 2009 and analyzed with multivariable logistic regression. All statistical tests were two-sided. Approximately 75% of AYA cancer patients in our sample received appropriate treatment, 68% after excluding stage I male germ cell patients who all received appropriate treatment. After this exclusion, appropriate treatment ranged from 79% of sarcoma patients to 56% of ALL patients. Cancer type (P < .01) and clinical trial participation (P = .04) were statistically significantly associated with appropriate treatment in multivariable analyses. Patients enrolled in clinical trials were more likely to receive appropriate therapy relative to those not enrolled (78% vs 67%, adjusted odds ratio = 2.6, 95% confidence interval = 1.1 to 6.4). Except for those with early stage male germ cell tumors, approximately 30% (or 3 in 10) AYA cancer patients did not receive appropriate therapy. Further investigation is required to understand the reasons for this potential shortfall in care delivery. © The Author 2014. Published by Oxford University Press. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Recurrence of Phaeochromocytoma and Abdominal Paraganglioma After Initial Surgical Intervention

PubMed Central

Mullan, Karen R; Atkinson, A Brew; Eatock, Fiona C; Wallace, Helen; Gray, Moyra; Hunter, Steven J

2015-01-01

Background Clinical and biochemical follow up after surgery for phaeochromocytoma is essential with long term studies demonstrating recurrence frequencies between 6% and 23%. Aim To examine the characteristics and frequency of tumour recurrence in a regional endocrine referral centre, in patients with surgical resection of phaeochromocytoma (P) and abdominal paraganglioma (AP). Methods We identified a cohort of 52 consecutive patients who attended our Regional Endocrinology & Diabetes Centre and retrospectively reviewed their clinical, biochemical and radiological data (between 2002 and 2013). After confirmation of early post-operative remission by negative biochemical testing, tumour recurrence was defined by demonstration of catecholamine excess with confirmatory imaging. Results Phaeochromocytoma was confirmed histologically in all cases (43:P, 9:AP, mean-age:53years). Open adrenalectomy was performed in 20 cases and laparoscopically in 32. Hereditary phaeochromocytoma was confirmed by genetic analysis in 12 (23%) patients. Median follow up time from initial surgery was 47 months, (range: 12 - 296 months), 49 patients had no evidence of tumour recurrence at latest follow-up. Three patients (6%) demonstrated tumour development, one in a patient with VHL which occurred in a contralateral adrenal gland, one sporadic case had local recurrence, and an adrenal tumour occurred in a patient with a SDHB gene mutation who had a previous bladder tumour. After initial surgery, the tumours occurred at 8.6, 12.0 and 17.7 years respectively. Conclusion In this study tumour development occurred in 6% of patients. Although tumour rates were low, careful and sustained clinical and biochemical follow up is advocated, as new tumour development or recurrence may occur long after the initial surgery is performed. PMID:26170485

Does universal active MRSA surveillance influence anti-MRSA antibiotic use? A retrospective analysis of the treatment of patients admitted with suspicion of infection at Veterans Affairs Medical Centers between 2005 and 2010

PubMed Central

Jones, Makoto; Huttner, Benedikt; Leecaster, Molly; Huttner, Angela; Damal, Kavitha; Tanner, Windy; Nielson, Christopher; Rubin, Michael A.; Goetz, Matthew Bidwell; Madaras-Kelly, Karl; Samore, Matthew H.

2014-01-01

Objectives After the implementation of an active surveillance programme for MRSA in US Veterans Affairs (VA) Medical Centers, there was an increase in vancomycin use. We investigated whether positive MRSA admission surveillance tests were associated with MRSA-positive clinical admission cultures and whether the availability of surveillance tests influenced prescribers' ability to match initial anti-MRSA antibiotic use with anticipated MRSA results from clinical admission cultures. Methods Analyses were based on barcode medication administration data, microbiology data and laboratory data from 129 hospitals between January 2005 and September 2010. Hospitalized patient admissions were included if clinical cultures were obtained and antibiotics started within 2 days of admission. Mixed-effects logistic regression was used to examine associations between positive MRSA admission cultures and (i) admission MRSA surveillance test results and (ii) initial anti-MRSA therapy. Results Among 569 815 included admissions, positive MRSA surveillance tests were strong predictors of MRSA-positive admission cultures (OR 8.5; 95% CI 8.2–8.8). The negative predictive value of MRSA surveillance tests was 97.6% (95% CI 97.5%–97.6%). The diagnostic OR between initial anti-MRSA antibiotics and MRSA-positive admission cultures was 3.2 (95% CI 3.1–3.4) for patients without surveillance tests and was not significantly different for admissions with surveillance tests. Conclusions The availability of nasal MRSA surveillance tests in VA hospitals did not seem to improve the ability of prescribers to predict the necessity of initial anti-MRSA treatment despite the high negative predictive value of MRSA surveillance tests. Prospective trials are needed to establish the safety and effectiveness of using MRSA surveillance tests to guide antibiotic therapy. PMID:25103488

Treatment patterns and outcomes in BRAF V600E-mutant melanoma patients with brain metastases receiving vemurafenib in the real-world setting.

PubMed

Gibney, Geoffrey T; Gauthier, Geneviève; Ayas, Charles; Galebach, Philip; Wu, Eric Q; Abhyankar, Sarang; Reyes, Carolina; Guérin, Annie; Yim, Yeun Mi

2015-08-01

Brain metastases are a common and serious complication among patients with metastatic melanoma. The selective BRAF inhibitor vemurafenib has demonstrated clinical efficacy in patients with BRAF V600E-mutant melanoma brain metastases (MBM). We examined the real-world application and clinical outcomes of vemurafenib in this patient population. Demographic, treatment patterns, response, and survival data were collected from medical charts. Clinical data on 283 patients with active BRAF V600E-mutant MBM treated with vemurafenib were provided by 70 US oncologists. Mean age was 57.2 years, 60.8% were male, 67.5% had ECOG performance status of 0-1, and 43.1% used corticosteroids at vemurafenib initiation. Median follow-up was 5.7 months. Following vemurafenib initiation, 48.1% of patients experienced intracranial response and 45.6% experienced extracranial response. The Kaplan-Meier estimate for overall survival was 59% at 12 months. Multivariate analyses showed associations between intracranial response and both corticosteroid use and vemurafenib as initial therapy after MBM diagnosis. Larger size (5-10 mm vs. < 5 mm) and number of brain metastases (≥ 5 vs. < 2) and progressive extracranial disease at treatment initiation were associated with decreased intracranial response and increased risk of disease progression. Multiple extracranial sites (2 vs. < 2) and the absence of local treatments were also associated with increased risk of progression. Increased risk of death was associated with ≥ 2 extracranial disease sites, progressive extracranial disease, and ≥ 5 brain metastases. Subgroups of MBM patients may derive more benefit with vemurafenib, warranting prospective investigation. © 2015 The Authors. Cancer Medicine published by John Wiley & Sons Ltd.

Improving Birth Control Service Utilization By Offering Services Prerelease Vs Postincarceration

PubMed Central

Clarke, Jennifer G.; Rosengard, Cynthia; Rose, Jennifer S.; Hebert, Megan R.; Peipert, Jeffrey; Stein, Michael D.

2006-01-01

Objectives. We examined whether incarcerated women would substantially increase birth control initiation if contraceptive services were available within the prison compared with after their release back into the community. Methods. During phase 1 of the study, a nurse educator met with women at the Rhode Island Adult Correctional Institute and offered them referrals for contraceptive services at a community health clinic after their release. During phase 2, contraceptive services were offered to women during their incarceration. Results. The majority of the participants (77.5%) reported a desire to initiate use of birth control methods. Within 4 weeks of their release, 4.4% of phase 1 participants initiated use of a contraceptive method, compared with 39.1% of phase 2 participants (odds ratio [OR]=14.6; 95% confidence interval [CI]=5.5, 38.8). Conclusions. Provision of contraceptive services to women during their incarceration is feasible and greatly increases birth control initiation compared to providing services only in the community. PMID:16571698

Postural adjustment errors during lateral step initiation in older and younger adults

PubMed Central

Sparto, Patrick J.; Fuhrman, Susan I.; Redfern, Mark S.; Perera, Subashan; Jennings, J. Richard; Furman, Joseph M.

2016-01-01

The purpose was to examine age differences and varying levels of step response inhibition on the performance of a voluntary lateral step initiation task. Seventy older adults (70 – 94 y) and twenty younger adults (21 – 58 y) performed visually-cued step initiation conditions based on direction and spatial location of arrows, ranging from a simple choice reaction time task to a perceptual inhibition task that included incongruous cues about which direction to step (e.g. a left pointing arrow appearing on the right side of a monitor). Evidence of postural adjustment errors and step latencies were recorded from vertical ground reaction forces exerted by the stepping leg. Compared with younger adults, older adults demonstrated greater variability in step behavior, generated more postural adjustment errors during conditions requiring inhibition, and had greater step initiation latencies that increased more than younger adults as the inhibition requirements of the condition became greater. Step task performance was related to clinical balance test performance more than executive function task performance. PMID:25595953

Postural adjustment errors during lateral step initiation in older and younger adults

PubMed Central

Sparto, Patrick J.; Fuhrman, Susan I.; Redfern, Mark S.; Perera, Subashan; Jennings, J. Richard; Furman, Joseph M.

2014-01-01

The purpose was to examine age differences and varying levels of step response inhibition on the performance of a voluntary lateral step initiation task. Seventy older adults (70 – 94 y) and twenty younger adults (21 – 58 y) performed visually-cued step initiation conditions based on direction and spatial location of arrows, ranging from a simple choice reaction time task to a perceptual inhibition task that included incongruous cues about which direction to step (e.g. a left pointing arrow appearing on the right side of a monitor). Evidence of postural adjustment errors and step latencies were recorded from vertical ground reaction forces exerted by the stepping leg. Compared with younger adults, older adults demonstrated greater variability in step behavior, generated more postural adjustment errors during conditions requiring inhibition, and had greater step initiation latencies that increased more than younger adults as the inhibition requirements of the condition became greater. Step task performance was related to clinical balance test performance more than executive function task performance. PMID:25183162

A single institution's 1-year experience with uterine fibroid embolization marketing.

PubMed

Ciacci, Joseph; Taussig, Jacob; Kouri, Brian; Bettmann, Michael

2011-09-01

To assess the impact of various marketing techniques on the referral pattern for uterine fibroid embolization (UFE) at an academic interventional radiology practice over a 1-year period. All referrals to the interventional radiology clinic for UFE from January 1, 2009, to December 31, 2009, were retrospectively reviewed. A standard intake sheet was completed by the interventional clinic secretary at the time of initial patient contact that included the source of the referral (radio, television, newspaper, mailing, Internet, physician, friend, other). All patients who proceeded to consultation were seen in the interventional radiology clinic by attending interventional radiologists in a university-based academic center. The referral pattern was analyzed with respect to the number of patients who contacted the clinic, the number of actual clinic visits, the number of magnetic resonance (MR) imaging examinations performed before and after the procedure, the total number of embolization cases performed, and the subsequent downstream revenue. During the 1-year period, 344 patients contacted the interventional radiology clinic regarding UFE resulting in 171 consultations and 100 pelvic MR imaging examinations performed before the procedure. Sixty-two patients proceeded to UFE, and 32 patients underwent follow-up pelvic MR imaging. These results show a significant increase from eight cases the previous year and are presumably attributable almost entirely to the directed marketing campaign. The marketing initiative consisted primarily of print and radio advertisements, with the latter being the most effective. The total advertising cost for the year was approximately $24,706, of which $20,520 was for radio advertisements. The radio advertisements generated 69% (237 of 344) of the referrals and 69% (43 of 62) of the UFE procedures. Using Medicare reimbursement rates, the radio advertisements generated $281,994 in UFE technical fees and $50,329 in MR imaging technical fees. Direct patient marketing techniques can promote significant growth for a fibroid embolization practice. In our market, radio advertisements proved to be the most cost-effective strategy. Copyright © 2011 SIR. Published by Elsevier Inc. All rights reserved.

Long-Term Effectiveness of Adalimumab in Patients with Rheumatoid Arthritis: An Observational Analysis from the Corrona Rheumatoid Arthritis Registry.

PubMed

Pappas, Dimitrios A; Kremer, Joel M; Griffith, Jenny; Reed, George; Salim, Bob; Karki, Chitra; Garg, Vishvas

2017-12-01

Current recommendations for the management of rheumatoid arthritis (RA) focus on a treat-to-target approach with the objective of maximizing long-term health-related quality-of-life in patients with RA. Published studies from randomized clinical trials have reported limited data regarding the long-term efficacy and safety of adalimumab in patients with RA. This study aims to evaluate the long-term (10+ years) persistency and effectiveness of adalimumab in patients with RA in a real-world setting. Included in this study were biologic-naïve adults with RA initiating adalimumab during follow-up enrolled in the Corrona RA registry. More than 10 years of data on persistency of adalimumab and rheumatologist-supplied reasons for discontinuation were examined. Among patients who persisted on adalimumab over the years, clinical [e.g., clinical disease activity index scores (CDAI), physician global assessment, tender joint count, and swollen joint count] and patient-reported outcomes (PRO), such as physical function, pain, fatigue, and morning stiffness, were examined. Of 1791 biologic-naive patients treated with adalimumab who had ≥1 follow-up registry visit, 64.1% were still on therapy at 1 year and 10.2% were still on therapy by the end of year 12. Among patients who persisted on adalimumab for at least 1 year (77.1% female, mean age 53.9 years), 67.0% were in low disease activity (LDA)/remission (CDAI ≤10) and had clinically meaningful improvements from baseline in all clinical assessments and PROs. Initial improvements in LDA/remission and in clinical and PRO assessments observed at year 1 were sustained in those patients who remained on adalimumab over 10 years of follow-up. Among patients who discontinued adalimumab, 61.6% were not in LDA/remission and 41.9% switched to another biologic within 12 months after discontinuing adalimumab. Real-world data demonstrate a sustained effectiveness of adalimumab in the treatment of RA for patients who remained on therapy for 10 years. Corrona, LLC and AbbVie.

Human Papillomavirus Vaccine Coverage and Prevalence of Missed Opportunities for Vaccination in an Integrated Healthcare System.

PubMed

Irving, Stephanie A; Groom, Holly C; Stokley, Shannon; McNeil, Michael M; Gee, Julianne; Smith, Ning; Naleway, Allison L

2018-03-01

Human papillomavirus (HPV) vaccination has been recommended in the United States for female and male adolescents since 2006 and 2011, respectively. Coverage rates are lower than those for other adolescent vaccines. The objective of this study was to evaluate an assessment and feedback intervention designed to increase HPV vaccination coverage and quantify missed opportunities for HPV vaccine initiation at preventive care visits. We examined changes in HPV vaccination coverage and missed opportunities within the adolescent (11-17 years) population at 9 Oregon-based Kaiser Permanente Northwest outpatient clinics after an assessment and feedback intervention. Quarterly coverage rates were calculated for the adolescent populations at the clinics, according to age group (11-12 and 13-17 years), sex, and department (Pediatrics and Family Medicine). Comparison coverage assessments were calculated at 3 nonintervention (control) clinics. Missed opportunities for HPV vaccine initiation, defined as preventive care visits in which a patient eligible for HPV dose 1 remained unvaccinated, were examined according to sex and age group. An average of 29,021 adolescents were included in coverage assessments. Before the intervention, 1-dose and 3-dose quarterly coverage rates were increasing at intervention as well as at control clinics in both age groups. Postimplementation quarterly trends in 1-dose or 3-dose coverage did not differ significantly between intervention and control clinics for either age group. One-dose coverage rates among adolescents with Pediatrics providers were significantly higher than those with Family Medicine providers (56% vs 41% for 11- to 12-year-old and 82% vs 69% for 13- to 17-year-old girls; 55% vs 40% for 11- to 12-year-old and 78% vs 62% for 13- to 17-year-old boys). No significant differences in HPV vaccine coverage were identified at intervention clinics. However, coverage rates were increasing before the start of the intervention and might have been influenced by ongoing health system best practices. HPV vaccine coverage rates varied significantly according to department, which could allow for targeted improvement opportunities. Copyright © 2017 Academic Pediatric Association. All rights reserved.

American Society of Clinical Oncology 2006 update of the breast cancer follow-up and management guidelines in the adjuvant setting.

PubMed

Khatcheressian, James L; Wolff, Antonio C; Smith, Thomas J; Grunfeld, Eva; Muss, Hyman B; Vogel, Victor G; Halberg, Francine; Somerfield, Mark R; Davidson, Nancy E

2006-11-01

To update the 1999 American Society of Clinical Oncology (ASCO) guideline on breast cancer follow-up and management in the adjuvant setting. An ASCO Expert Panel reviewed pertinent information from the literature through March 2006. More weight was given to studies that tested a hypothesis directly relating testing to one of the primary outcomes in a randomized design. The evidence supports regular history, physical examination, and mammography as the cornerstone of appropriate breast cancer follow-up. All patients should have a careful history and physical examination performed by a physician experienced in the surveillance of cancer patients and in breast examination. Examinations should be performed every 3 to 6 months for the first 3 years, every 6 to 12 months for years 4 and 5, and annually thereafter. For those who have undergone breast-conserving surgery, a post-treatment mammogram should be obtained 1 year after the initial mammogram and at least 6 months after completion of radiation therapy. Thereafter, unless otherwise indicated, a yearly mammographic evaluation should be performed. Patients at high risk for familial breast cancer syndromes should be referred for genetic counseling. The use of CBCs, chemistry panels, bone scans, chest radiographs, liver ultrasounds, computed tomography scans, [18F]fluorodeoxyglucose-positron emission tomography scanning, magnetic resonance imaging, or tumor markers (carcinoembryonic antigen, CA 15-3, and CA 27.29) is not recommended for routine breast cancer follow-up in an otherwise asymptomatic patient with no specific findings on clinical examination. Careful history taking, physical examination, and regular mammography are recommended for appropriate detection of breast cancer recurrence.

Guillain-Barré Syndrome presenting as unilateral hip pain in a child.

PubMed

Neocleous, Charalambos; Diakolios, Konstandinos; Adramerina, Alkistis; Varveris, Evangelos; Tsioni, Vasiliki; Machairidou, Konstandina

2015-01-01

The aim of this report is to highlight the importance of close observation and follow-up in children who present with an acutely irritable hip. This is because hip pain is a symptom of not only benign but also severe conditions. Thus, at the time of the initial presentation, hip pain can be misdiagnosed. This report serves as an example for a wide range of doctors such as orthopaedic surgeons, paediatricians, emergency room physicians or primary care physicians, because these are the first-line doctors who treat patients with a painful hip. We herein present a three-year-old child who was admitted to our hospital with pain in the right leg and initially diagnosed with transient synovitis of the hip. An additional examination two days later, after severe deterioration of the clinical picture, revealed that our patient was actually suffering from Guillain-Barré syndrome. Failure to diagnose Guillain-Barré syndrome and initiating prompt treatment is potentially life-threatening. Clinicians should be aware that hip pain could be the presenting complaint of Guillain-Barré syndrome, a syndrome that has many clinical features. Even when all the clinical and laboratory findings indicate a benign condition, Guillain- Barré syndrome should still be considered. Therefore, close observation and follow-up in children who present with an acutely irritable hip is highly recommended. In this way, the potentially catastrophic consequences of more severe conditions can be avoided. Copyright © 2015 by Academy of Sciences and Arts of Bosnia and Herzegovina.

Diagnosis and initial management of cerebellar infarction.

PubMed

Edlow, Jonathan A; Newman-Toker, David E; Savitz, Sean I

2008-10-01

Cerebellar infarction is an important cause of stroke that often presents with common and non-specific symptoms such as dizziness, nausea and vomiting, unsteady gait, and headache. Accurate diagnosis frequently relies on careful attention to patients' coordination, gait, and eye movements--components of the neurological physical examination that are sometimes omitted or abridged if cerebellar stroke is not specifically being considered. The differential diagnosis is broad, and includes many common and benign causes. Furthermore, early-stage posterior fossa ischaemia is rarely seen with brain CT--the most commonly available initial imaging test that is used for stroke. Insufficient examination and imaging can result in misdiagnosis. However, early correct diagnosis is crucial to help prevent treatable but potentially fatal complications, such as brainstem compression and obstructive hydrocephalus. The identification and treatment of the underlying vascular lesions at an early stage can also prevent subsequent occurrences of stroke and improve patients' outcomes. Here, we review the clinical presentation of cerebellar infarction, from diagnosis and misdiagnosis to patients' monitoring, treatment, and potential complications.

Primary pulmonary malignant melanoma: a clinicopathologic study of two cases.

PubMed

Gong, Li; Liu, Xiao-Yan; Zhang, Wen-Dong; Zhu, Shao-Jun; Yao, Li; Han, Xiu-Juan; Lan, Miao; Li, Yan-Hong; Zhang, Wei

2012-09-19

Malignant melanoma involving the respiratory tract is nearly always metastatic in origin, and primary tumors are very rare. To our knowledge, about 30 cases have been reported in the English literature, one of which involved multiple brain metastases. Here, we report two cases of primary pulmonary malignant melanoma. The first case, which occurred in a 52-year-old Chinese female patient who died 4 months after the initial diagnosis, involved rapid intrapulmonary and intracranial metastases. The second patient, a 65-year-old female, underwent surgical excision, and clinical examination, histopathological characteristics, and immunohistochemical features supported the diagnosis of pulmonary malignant melanoma. No evidence for recurrence and/or metastasis has been found more than one year after the initial surgery. To establish the diagnosis of primary pulmonary malignant melanoma, any extrapulmonary origin must be excluded by detailed examination. Moreover, the tumor should be removed surgically whether it occurs as a single lesion or multiple lesions. The virtual slide(s) for this article can be found here: http://www.diagnosticpathology.diagnomx.eu/vs/1480477335765055.

Embryonal rhabdomyosarcoma in an immature Baird's tapir (Tapirus bairdii).

PubMed

Bonar, Christopher J; Lewandowski, Albert H; Skowronek, Anthony J

2007-03-01

An immature Baird's tapir (Tapirus bairdii) with a history of seizure-like episodes developed signs of respiratory disease. The initial clinical diagnosis was pneumonia, and antibiotic therapy was started. The animal failed to improve after 14 days of therapy and developed unilateral, bloody nasal discharge. Endoscopic examination and radiography revealed a soft tissue mass in the nasopharynx depressing the soft palate. The tapir died 32 days after initial presentation. Histologic examination of the mass demonstrated a mesenchymal tumor composed of spindle cells with elongate nuclei forming densely packed fascicles. The neoplastic spindle cells showed prominent cross-striations. Immunohistochemistry revealed the cells to be positive for desmin and myoglobin, but negative for smooth muscle actin, confirming diagnosis of rhabdomyosarcoma. Embryonal rhabdomyosarcoma is the most common nasopharyngeal soft tissue tumor of humans, and it has been reported infrequently in dogs, horses, and pigs. Neoplasia should be a differential diagnosis in cases of unilateral nasal discharge and inspiratory stridor, even in young animals.

Clinical Outcomes after Conservative Management of Cervical Intraepithelial Neoplasia Grade 2 (CIN2) in Women Ages 21-39 Years.

PubMed

Silver, Michelle I; Gage, Julia C; Schiffman, Mark; Fetterman, Barbara; Poitras, Nancy E; Lorey, Thomas; Cheung, Li C; Katki, Hormuzd A; Locke, Alexander; Kinney, Walter K; Castle, Philip E

2018-03-01

Cervical intraepithelial neoplasia grade 2 (CIN2) frequently regresses, is typically slow-growing, and rarely progresses to cancer. Some women forgo immediate treatment, opting for conservative management (heightened surveillance with cytology and colposcopy), to minimize overtreatment and increased risk of obstetric complications; however, there are limited data examining clinical outcomes in these women. We performed a retrospective cohort analysis of younger women diagnosed with initially untreated CIN1/2, CIN2 and CIN2/3 lesions at Kaiser Permanente Northern California between 2003 and 2015. Clinical outcomes were categorized into five mutually exclusive hierarchical groups: cancer, treated, returned to routine screening, persistent high-grade lesion, or persistent low-grade lesion. Median follow-up for the 2,417 women was 48 months. Six women were diagnosed with cancer (0.2%), all with history of high-grade cytology, and none after a negative cotest. Thirty percent of women were treated, and only 20% returned to routine screening; 50% remained in continued intensive follow-up, of which 86% had either low-grade cytology/histology or high-risk human papillomavirus (HPV) positivity, but not necessarily persistence of a single HPV type. No cancers were detected after a single negative cotest in follow-up. Almost half of initially untreated women did not undergo treatment, but remained by protocol in colposcopy clinic for 2 or more years in the absence of persisting CIN2 + Their incomplete return to total negativity was possibly due to sequential new and unrelated low-grade abnormalities. The prolonged colposcopic surveillance currently required to return to routine screening in the absence of persisting CIN2 + might not be necessary after a negative cotest. Significance: Many younger women under conservative management following an initial CIN2 result remain in a clinical protocol of prolonged intensified surveillance without a subsequent diagnosis of CIN2 or more severe diagnoses. More research is needed to determine whether such prolonged management might be unnecessary following a negative cotest for those women with an initial CIN2 but otherwise only low-grade findings. Cancer Prev Res; 11(3); 165-70. ©2018 AACR . ©2018 American Association for Cancer Research.

Comparisons of stuttering frequency during and after speech initiation in unaltered feedback, altered auditory feedback and choral speech conditions.

PubMed

Saltuklaroglu, Tim; Kalinowski, Joseph; Robbins, Mary; Crawcour, Stephen; Bowers, Andrew

2009-01-01

Stuttering is prone to strike during speech initiation more so than at any other point in an utterance. The use of auditory feedback (AAF) has been found to produce robust decreases in the stuttering frequency by creating an electronic rendition of choral speech (i.e., speaking in unison). However, AAF requires users to self-initiate speech before it can go into effect and, therefore, it might not be as helpful as true choral speech during speech initiation. To examine how AAF and choral speech differentially enhance fluency during speech initiation and in subsequent portions of utterances. Ten participants who stuttered read passages without altered feedback (NAF), under four AAF conditions and under a true choral speech condition. Each condition was blocked into ten 10 s trials separated by 5 s intervals so each trial required 'cold' speech initiation. In the first analysis, comparisons of stuttering frequencies were made across conditions. A second, finer grain analysis involved examining stuttering frequencies on the initial syllable, the subsequent four syllables produced and the five syllables produced immediately after the midpoint of each trial. On average, AAF reduced stuttering by approximately 68% relative to the NAF condition. Stuttering frequencies on the initial syllables were considerably higher than on the other syllables analysed (0.45 and 0.34 for NAF and AAF conditions, respectively). After the first syllable was produced, stuttering frequencies dropped precipitously and remained stable. However, this drop in stuttering frequency was significantly greater (approximately 84%) in the AAF conditions than in the NAF condition (approximately 66%) with frequencies on the last nine syllables analysed averaging 0.15 and 0.05 for NAF and AAF conditions, respectively. In the true choral speech condition, stuttering was virtually (approximately 98%) eliminated across all utterances and all syllable positions. Altered auditory feedback effectively inhibits stuttering immediately after speech has been initiated. However, unlike a true choral signal, which is exogenously initiated and offers the most complete fluency enhancement, AAF requires speech to be initiated by the user and 'fed back' before it can directly inhibit stuttering. It is suggested that AAF can be a viable clinical option for those who stutter and should often be used in combination with therapeutic techniques, particularly those that aid speech initiation. The substantially higher rate of stuttering occurring on initiation supports a hypothesis that overt stuttering events help 'release' and 'inhibit' central stuttering blocks. This perspective is examined in the context of internal models and mirror neurons.

Medical Students as Health Educators at a Student-Run Free Clinic: Improving the Clinical Outcomes of Diabetic Patients

PubMed Central

Peltz, Alon; Ladner, Travis R.; Reddy, India; Miller, Bonnie M.; Miller, Robert F.; Fowler, Michael J.

2014-01-01

Purpose Student-run free clinics (SRFCs) provide service–learning opportunities for medical students and care to underserved patients. Few published studies, however, support that they provide high-quality care. In this study, the authors examined the clinical impact of a medical student health educator program for diabetic patients at an SRFC. Method In 2012, the authors retrospectively reviewed the electronic medical records of diabetic patients who established care at Shade Tree Clinic in Nashville, Tennessee, between 2008 and 2011. They compared clinical outcomes at initial presentation to the clinic and 12 months later. They analyzed the relationship between the number of patient–student interactions (touchpoints) and change in hemoglobin A1c values between these two time points and compared the quality of care provided to best-practice benchmarks (process and outcomes measures). Results The authors studied data from 45 patients. Mean hemoglobin A1c values improved significantly from 9.6 to 7.9, after a mean of 12.5 ± 1.5 months (P < .0001). A trend emerged between increased number of touchpoints and improvement in A1c values (r2 = 0.06, P = .10). A high percentage of patients were screened during clinic visits, whereas a low to moderate percentage met benchmarks for A1c, LDL, and blood pressure levels. Conclusions These findings demonstrate that a medical student health educator program at an SRFC can provide high-quality diabetes care and facilitate clinical improvement one year after enrollment, despite inherent difficulties in caring for underserved patients. Future studies should examine the educational and clinical value of care provided at SRFCs. PMID:24556762

A phase I trial of hypoxoside as an oral prodrug for cancer therapy--absence of toxicity.

PubMed

Smit, B J; Albrecht, C F; Liebenberg, R W; Kruger, P B; Freestone, M; Gouws, L; Theron, E; Bouic, P J; Etsebeth, S; van Jaarsveld, P P

1995-09-01

To assess the toxicity of hypoxoside taken orally by 24 patients with lung cancer. Open study with patients taking 1,200-3,200 mg standardised Hypoxis plant extract (200 mg capsules) per day divided in 3 doses in order to maintain metabolite blood levels near 100 micrograms/ml. Patients with histologically proven squamous, large-cell or adenocarcinoma were hospitalised initially at the radiation oncology ward, Karl Bremer Hospital, Bellville, W. Cape. Thereafter they returned every 2 weeks for full clinical examinations. Routine biochemical and haematological measurements were done. Patients underwent regular full clinical examinations including radiographs and computed tomography scanning according to the discretion of the principal investigator. Nineteen patients on hypoxoside therapy survived for an average of 4 months with progression of their primary tumours and metastases, while 5 survived for more than a year. One of them survived for 5 years and histological examination of the primary lesion showed absence of cancer. No toxic effects, in clinical examinations or biochemical or haematological measurements, were found that could be ascribed to the ingestion of hypoxoside. Only one occasion of possible drug intolerance, with anxiety, nausea, vomiting and diarrhoea, was noted. The absence of toxicity warrants further investigation of hypoxoside as an oral prodrug, especially in patients with slow-growing necrotising tumours that are inoperable and have high concentrations of beta-glucuronidase and sulphatase as well as a high sensitivity for rooperol.

Comprehensive molecular diagnosis of 179 Leber congenital amaurosis and juvenile retinitis pigmentosa patients by targeted next generation sequencing

PubMed Central

Wang, Xia; Wang, Hui; Sun, Vincent; Tuan, Han-Fang; Keser, Vafa; Wang, Keqing; Ren, Huanan; Lopez, Irma; Zaneveld, Jacques E; Siddiqui, Sorath; Bowles, Stephanie; Khan, Ayesha; Salvo, Jason; Jacobson, Samuel G; Iannaccone, Alessandro; Wang, Feng; Birch, David; Heckenlively, John R; Fishman, Gerald A; Traboulsi, Elias I; Li, Yumei; Wheaton, Dianna; Koenekoop, Robert K; Chen, Rui

2014-01-01

Background Leber congenital amaurosis (LCA) and juvenile retinitis pigmentosa (RP) are inherited retinal diseases that cause early onset severe visual impairment. An accurate molecular diagnosis can refine the clinical diagnosis and allow gene specific treatments. Methods We developed a capture panel that enriches the exonic DNA of 163 known retinal disease genes. Using this panel, we performed targeted next generation sequencing (NGS) for a large cohort of 179 unrelated and prescreened patients with the clinical diagnosis of LCA or juvenile RP. Systematic NGS data analysis, Sanger sequencing validation, and segregation analysis were utilised to identify the pathogenic mutations. Patients were revisited to examine the potential phenotypic ambiguity at the time of initial diagnosis. Results Pathogenic mutations for 72 patients (40%) were identified, including 45 novel mutations. Of these 72 patients, 58 carried mutations in known LCA or juvenile RP genes and exhibited corresponding phenotypes, while 14 carried mutations in retinal disease genes that were not consistent with their initial clinical diagnosis. We revisited patients in the latter case and found that homozygous mutations in PRPH2 can cause LCA/juvenile RP. Guided by the molecular diagnosis, we reclassified the clinical diagnosis in two patients. Conclusions We have identified a novel gene and a large number of novel mutations that are associated with LCA/juvenile RP. Our results highlight the importance of molecular diagnosis as an integral part of clinical diagnosis. PMID:23847139

Glu-Ureido-Based Inhibitors of Prostate-Specific Membrane Antigen: Lessons Learned During the Development of a Novel Class of Low-Molecular-Weight Theranostic Radiotracers.

PubMed

Kopka, Klaus; Benešová, Martina; Bařinka, Cyril; Haberkorn, Uwe; Babich, John

2017-09-01

In recent years, several radioligands targeting prostate-specific membrane antigen (PSMA) have been clinically introduced as a new class of theranostic radiopharmaceuticals for the treatment of prostate cancer (PC). In the second decade of the 21 st century, a new era in nuclear medicine was initiated by the clinical introduction of small-molecule PSMA inhibitor radioligands, 40 y after the clinical introduction of 18 F-FDG. Because of the high incidence and mortality of PC, the new PSMA radioligands have already had a remarkable impact on the clinical management of PC. For the continuing clinical development and long-term success of theranostic agents, designing modern prospective clinical trials in theranostic nuclear medicine is essential. First-in-human studies with PSMA radioligands derived from small-molecule PSMA inhibitors showed highly sensitive imaging of PSMA-positive PC by means of PET and SPECT as well as a dramatic response of metastatic castration-resistant PC after PSMA radioligand therapy. This tremendous success logically led to the initiation of prospective clinical trials with several PSMA radioligands. Meanwhile, MIP-1404, PSMA-11, 2-(3-{1-carboxy-5-[(6-fluoro-pyridine-3-carbonyl)-amino]-pentyl}-ureido)-pentanedioic acid (DCFPyL), PSMA-617, PSMA-1007, and others have entered or will enter prospective clinical trials soon in several countries. The significance becomes apparent by, for example, the considerable increase in the number of publications about PSMA-targeted PET imaging from 2013 to 2016 (e.g., a search of the Web of Science for "PSMA" AND "PET" found only 19 publications in 2013 but 218 in 2016). Closer examination of the initial success of PC treatment with PSMA inhibitor radiotracers leads to several questions from the basic research perspective as well as from the perspective of clinical demands: What lessons have been learned regarding the design of PSMA radioligands that have already been developed? Has an acceptable compromise between optimal PSMA radioligand design and a broad range of clinical demands been reached? Can the lessons learned from multiple successes within the PSMA experience be transferred to further theranostic approaches? © 2017 by the Society of Nuclear Medicine and Molecular Imaging.

Methotrexate Dosage Reduction Upon Adalimumab Initiation: Clinical and Ultrasonographic Outcomes from the Randomized Noninferiority MUSICA Trial.

PubMed

Kaeley, Gurjit S; Evangelisto, Amy M; Nishio, Midori J; Goss, Sandra L; Liu, Shufang; Kalabic, Jasmina; Kupper, Hartmut

2016-08-01

To examine the clinical and ultrasonographic (US) outcomes of reducing methotrexate (MTX) dosage upon initiating adalimumab (ADA) in MTX-inadequate responders with moderately to severely active rheumatoid arthritis (RA). MUSICA (NCT01185288) was a double-blind, randomized, parallel-arm study of 309 patients with RA receiving MTX ≥ 15 mg/week for ≥ 12 weeks before screening. Patients were randomized to high dosage (20 mg/week) or low dosage (7.5 mg/week) MTX; all patients received 40 mg open-label ADA every other week for 24 weeks. The primary endpoint was Week 24 mean 28-joint Disease Activity Score based on C-reactive protein (DAS28-CRP) to test for noninferiority of low-dosage MTX using a 15% margin. US images were scored using a 10-joint semiquantitative system incorporating OMERACT definitions for pathology, assessing synovial hypertrophy, vascularity, and bony erosions. Rapid improvement in clinical indices was observed in both groups after addition of ADA. The difference in mean DAS28-CRP (0.37, 95% CI 0.07-0.66) comparing low-dosage (4.12, 95% CI 3.88-4.34) versus high-dosage MTX (3.75, 95% CI 3.52-3.97) was statistically significant and non-inferiority was not met. Statistically significant differences were not detected for most clinical, functional, and US outcomes. Pharmacokinetic and safety profiles were similar. In MUSICA, Week 24 mean DAS28-CRP, the primary endpoint, did not meet non-inferiority for the low-dosage MTX group. Although the differences between the 2 MTX dosage groups were small, our study findings did not support routine MTX reduction in MTX inadequate responders initiating ADA.

Computed Tomography Angiography in Patients Evaluated for Acute Pulmonary Embolism with Low Serum D-dimer Levels: A Prospective Study.

PubMed

Gimber, Lana Hirai; Travis, R Ing; Takahashi, Jayme M; Goodman, Torrey L; Yoon, Hyo-Chun

2009-01-01

Pulmonary computed tomography angiography (CTA) and the Wells criteria both have interobserver variability in the assessment of pulmonary embolism (PE). Quantitative D-dimer assay findings have been shown to have a high negative predictive value in patients with low pretest probability of PE. Evaluate roles for clinical probability and CTA in Emergency Department (ED) patients suspected of acute PE but having a low serum D-dimer level. Prospective observational study of ED patients with possible PE who underwent pulmonary CTA and had D-dimer levels

Use of 2-octyl cyanoacrylate for wound closure in a modified Roberts-Bistner procedure for eyelid agenesis in five cats (nine eyes).

PubMed

Reed, Zoe; Doering, Clinton J; Barrett, Paul M

2018-01-15

CASE DESCRIPTION 5 cats (9 eyes) were evaluated for surgical correction of bilateral eyelid agenesis. CLINICAL FINDINGS All eyes lacked > 25% of the temporal upper eyelid, and all cats had clinical signs attributable to chronic ocular exposure. Abnormalities were limited to the ocular surface in the 4 female cats, whereas the sole male cat had additional abnormalities consistent with anterior segment dysgenesis. TREATMENT AND OUTCOME A modified Roberts-Bistner procedure involving 2-octyl cyanoacrylate (2OCA) was performed on 9 eyes; 1 eye was enucleated. Surgical wounds in the initial 3 eyes were closed with 2OCA plus sutures, and flaps were lined with conjunctiva. The technique was optimized for remaining eyes by use of a single suture for flap apposition, no conjunctival lining of flaps, and 2OCA alone for wound closure. Median duration of surgery was 35 minutes/eye for the initial 3 eyes versus 16 minutes/eye for the subsequent 6 eyes treated with the optimized procedure. After surgery, all cats had complete palpebral reflexes and resolution of clinical signs of ocular irritation. Minor complications in the early postoperative period included eyelid swelling (n = 9), poor cosmesis (7), and persistent epiphora (3). By the second recheck examination, swelling had resolved and cosmesis was considered excellent. Two eyes with epiphora had been treated with the initial modified procedure and required cryoepilation for resolution of epiphora. CLINICAL RELEVANCE The modified Roberts-Bistner procedure for eyelid agenesis involving 2OCA for wound closure provided functional, cosmetic eyelids that improved comfort and provided protection of the ocular surface in affected cats.

Poor cognitive outcome in shunt-responsive idiopathic normal pressure hydrocephalus.

PubMed

Koivisto, Anne M; Alafuzoff, Irina; Savolainen, Sakari; Sutela, Anna; Rummukainen, Jaana; Kurki, Mitja; Jääskeläinen, Juha E; Soininen, Hilkka; Rinne, Jaakko; Leinonen, Ville

2013-01-01

Idiopathic normal pressure hydrocephalus (iNPH) causes cognitive decline that can be alleviated by shunting, but long-term outcome studies are scarce. To elucidate the long-term cognitive condition of shunt-responsive iNPH patients. The follow-up data (Kuopio University Hospital NPH Registry) of 146 patients diagnosed with iNPH by clinical and radiological examination, 24-hour intraventricular pressure monitoring, frontal cortical biopsy, and response to the shunt were analyzed for signs of dementia. The Diagnostic and Statistical Manual for Mental Disorders, Fourth Edition, and specified memory disorder criteria were used. Median follow-up was 4.8 years. At the end of follow-up, 117 (80%) of the 146 iNPH patients had cognitive decline and 67 (46%) had clinical dementia. The most common clinical diagnoses were Alzheimer disease and vascular dementia. In multivariate analysis of the 146 iNPH patients, memory deficit as a first symptom before shunt (odds ratio [OR] 18.3; 95% confidence interval [CI] 1.9-175), male sex (OR 3.29; 95% CI 1.11-9.73), age (OR 1.17 year; 95% CI 1.07-1.28), and follow-up time (OR 1.20 year; 95% CI 1.02-1.40) predicted dementia. Interestingly, 8 (5%) iNPH patients had dementia without any signs of other neurodegenerative diseases in clinical, neuroradiological, or brain biopsy evaluation. These patients initially presented a full triad of symptoms, with gait disturbance being the most frequent initial symptom followed by deterioration in cognition. The novel findings were (a) a significant risk of dementia in iNPH initially responsive to cerebrospinal fluid shunt, (b) cognitive impairment most commonly due to iNPH-related dementia followed by concurrent degenerative brain disease, and (c) a subgroup with dementia related to iNPH without comorbidities.

Prolonged fever in peritoneal tuberculosis: A case report

NASA Astrophysics Data System (ADS)

Zein, U.; Irwandi, S.; Habib, H.; Lim, H.; Pasha, M.; Janis, I.; Saragih, R. H.; Ginting, Y.; Effendy-Y S, R.

2018-03-01

Peritoneal tuberculosis may lead to delayed diagnosis because of the nonspecific features such as fever, abdominal distension, abdominal tenderness, ascites, and weight loss. Here, wereported a case of prolonged fever and abdominal pain which was due to peritoneal tuberculosis. Initial examinations including acomplete blood test and serologic tests did not lead to the diagnosis. A final diagnosis was made by abdominal CT-scan and laparoscopy combined with histopathological studies. Antituberculous medications provided a good clinical response in this patient.

Controlling inpatient psychiatric utilization through managed care.

PubMed

Wickizer, T M; Lessler, D; Travis, K M

1996-03-01

There is little current understanding of how managed care strategies affect hospital inpatient psychiatric care for mentally ill patients. This study examined one prominent form of managed care, utilization management, which reviews requests for psychiatric care and authorizes provision of care deemed appropriate and clinically necessary. The authors analyzed data on 2,265 utilization management reviews conducted during 1989-1992 for patients insured by a single large commercial insurance company. Three utilization management procedures were examined: preadmission review, continued-stay review, and case management. The performance indicators analyzed included percent of admission requests granted, number of days requested and approved, and number of treatment extensions granted. Utilization management initially approved inpatient psychiatric treatment for nearly all (98.8%) of the patients but authorized, on average, only one-third of the days requested (6.9 versus 19.0). On average, 23.5 (total) days of care were requested and 16.8 days were approved. Care for patients with alcohol or drug dependence diagnoses was more restricted than was care for other patients. These data suggest that managed care does restrict inpatient psychiatric care, primarily by managing length of stay. The fact that almost all patients were approved for the same initial length of stay implies adherence to strict treatment protocols that do not distinguish among different clinical or patient factors. There is a need for careful study of the effects of managed care on outcomes and quality of psychiatric care.

Treatment of Pediatric Graves' Disease Is Associated with Excessive Weight Gain

PubMed Central

van Veenendaal, Nicole R.

2011-01-01

Context: Little information is available about changes in body weight and body mass index in children before, during, and after treatment for Graves' disease (GD). Objective: Our objective was to examine changes in body weight after treatment for GD in children as related to clinical features. Design: The medical records of 43 pediatric patients with GD [35 girls and eight boys, aged 4.0–18.5 (mean 10.9) yr] were examined. Patients were included if clinical data were available for 1 yr before and after the diagnosis of GD. Main Outcome Measures: Weight, height, body mass index (BMI) z-scores, and thyroid hormone levels were assessed. Results: Overall, patients presented with an average BMI z-score of −0.02 ± 1.05 that was not different from the normal population (P = 0.921) or their premorbid values (P = 0.07). However, in the subset of patients who were initially overweight or obese in the premorbid state, the BMI decreased significantly during the development of hyperthyroidism (P < 0.05). After initiation of treatment, patients gained significant amounts of weight over the first 6 months leading to elevated BMI z-scores (P < 0.0001), and elevations in BMI persisted in about 25% of the patients. Conclusion: Excessive weight gain within 6 months of treatment is seen in children treated for GD, and the gain in weight can persist. PMID:21849528

Overgeneral autobiographical memory as a predictor of the course of depression: a meta-analysis.

PubMed

Sumner, Jennifer A; Griffith, James W; Mineka, Susan

2010-07-01

Overgeneral autobiographical memory (OGM) is a robust phenomenon in depression, but the extent to which OGM predicts the course of depression is not well-established. This meta-analysis synthesized data from 15 studies to examine the degree to which OGM 1) correlates with depressive symptoms at follow-up, and 2) predicts depressive symptoms at follow-up over and above initial depressive symptoms. Although the effects are small, specific and categoric/overgeneral memories generated during the Autobiographical Memory Test significantly predicted the course of depression. Fewer specific memories and more categoric/overgeneral memories were associated with higher follow-up depressive symptoms, and predicted higher follow-up symptoms over and above initial symptoms. Potential moderators were also examined. The age and clinical depression status of participants, as well as the length of follow-up between the two depressive symptom assessments, significantly moderated the predictive relationship between OGM and the course of depression. The predictive relationship between specific memories and follow-up depressive symptoms became greater with increasing age and a shorter length of follow-up, and the predictive relationship was stronger for participants with clinical depression diagnoses than for nonclinical participants. These findings highlight OGM as a predictor of the course of depression, and future studies should investigate the mechanisms underlying this relationship. Copyright 2010 Elsevier Ltd. All rights reserved.

Biodosimetry of Persons Chronically Exposed to Low and Therapeutic Doses of Ionizing Radiation

PubMed Central

Zedginidze, Alla; Namchevadze, Ema; Ormocadze, George; Kapanadze, Archil; Nikuradze, Tamara; Lomidze, Darejan

2016-01-01

Dynamic changes of the chromosomal aberrations and the DNA damage were analyzed in individuals exposed to low and therapeutic doses of radiation. The investigation included 37 persons living in areas where the radioactive sources were discovered 10–12 years ago. It was established by biodosimetry methods that the examined persons had absorbed dose of 0.2–0.7 Gy or had increased number of chromosomal aberrations, though insufficient to determine a dose. Clinical examination, chromosomal analysis, and assay of DNA damage by the comet (single-cell gel electrophoresis) assay were carried out. There was no correlation between the doses received 10 years ago and the cytogenetic changes with clinical outcome. The effect of the local fractionated gamma-irradiation with doses of 40–70 Gy was studied in cancer patients with localized head and neck tumors. The study of chromosomal abnormalities, the DNA damages by the comet assay, and the micronuclei detection of the buccal cells revealed a statistically significant correlation between the initial cytogenetic indices in cancer patients and their dynamic changes during and after the radiation exposure. In addition, the correlation was detected between the initial cytogenetic parameters and the functional stage of red blood system. Our results allow us to conclude that there is a need for further research to estimate the individual radiation risk to optimize and individualize the subsequent medical management of radiotherapy. PMID:28217288

Biodosimetry of Persons Chronically Exposed to Low and Therapeutic Doses of Ionizing Radiation.

PubMed

Zedginidze, Alla; Namchevadze, Ema; Ormocadze, George; Kapanadze, Archil; Nikuradze, Tamara; Lomidze, Darejan

2016-01-01

Dynamic changes of the chromosomal aberrations and the DNA damage were analyzed in individuals exposed to low and therapeutic doses of radiation. The investigation included 37 persons living in areas where the radioactive sources were discovered 10-12 years ago. It was established by biodosimetry methods that the examined persons had absorbed dose of 0.2-0.7 Gy or had increased number of chromosomal aberrations, though insufficient to determine a dose. Clinical examination, chromosomal analysis, and assay of DNA damage by the comet (single-cell gel electrophoresis) assay were carried out. There was no correlation between the doses received 10 years ago and the cytogenetic changes with clinical outcome. The effect of the local fractionated gamma-irradiation with doses of 40-70 Gy was studied in cancer patients with localized head and neck tumors. The study of chromosomal abnormalities, the DNA damages by the comet assay, and the micronuclei detection of the buccal cells revealed a statistically significant correlation between the initial cytogenetic indices in cancer patients and their dynamic changes during and after the radiation exposure. In addition, the correlation was detected between the initial cytogenetic parameters and the functional stage of red blood system. Our results allow us to conclude that there is a need for further research to estimate the individual radiation risk to optimize and individualize the subsequent medical management of radiotherapy.

Classification of adults with problematic internet experiences: linking internet and conventional problems from a clinical perspective.

PubMed

Mitchell, Kimberly J; Finkelhor, David; Becker-Blease, Kathryn A

2007-06-01

This article utilizes data from clinical reports of 929 adults to examine whether various problematic Internet experiences are distinctly different from or extensions of conventional problems. A TwoStep Cluster Analysis identified three mutually exclusive groups of adults, those with (1) online relationship problems and victimization; (2) online and offline problems; and (3) marital discord. Results suggest some initial support for the idea that problematic Internet experiences are often extensions of experiences and behaviors that pre-date the Internet. However, the Internet may be introducing some qualitatively new dimensions-such as an increased severity, an increased frequency, or unique dynamics-that require new responses or interventions.

Refractory sciatica could be a sign of malignancy: A unique case presentation.

PubMed

Arunachalam, Karuppiah

2016-01-04

t Renal cell carcinoma is one of the highly aggressive tumors and notorious for late presentations. It is associated with high morbidity and mortality. Renal cell carcinoma is known for rare metastatic sites. In clinical practice, it is often important not to anchor to a particular diagnosis but rather revisit and revaluate entire history and clinical examination. We describe a case of metastatic renal cell carcinoma that was initially treated as sciatica and later found to have advanced debilitating malignancy. Internal medicine physicians should be able to recognize one of the rare metastatic sites of renal cell carcinoma and understand the importance of imaging studies if patient has persisting sciatica symptoms without improvement.

Surfer’s Myelopathy: A Radiologic Study of 23 Cases

PubMed Central

Nakamoto, B.K.; Siu, A.M.; Hashiba, K.A.; Sinclair, B.T.; Baker, B.J.; Gerber, M.S.; McMurtray, A.M.; Pearce, A.M.; Pearce, J.W.

2015-01-01

BACKGROUND AND PURPOSE Surfing is an uncommon cause of an acute nontraumatic myelopathy. This study describes the MR imaging characteristics and clinical correlates in 23 subjects with surfer’s myelopathy. MATERIALS AND METHODS This was a retrospective review of 23 cases of surfer’s myelopathy from 2003–2012. Spinal cord MR imaging characteristics and neurologic examinations with the use of the American Spinal Injury Association scale were reviewed. Logistic regression was used to determine associations between MR imaging characteristics, American Spinal Injury Association scale, and clinical improvement. RESULTS All subjects (19 male, 4 female; mean age, 26.3 ± 7.4 years) demonstrated “pencil-like,” central T2-hyperintense signal abnormalities in the spinal cord extending from the midthoracic region to the conus with associated cord expansion and varying degrees of conus enlargement on spinal cord MR imaging within 24 hours of symptom onset. T1 signal was normal. Faint gadolinium enhancement was present in a minority. Although there was a strong correlation between initial American Spinal Injury Association score and clinical improvement (P = .0032), MR imaging characteristics were not associated with American Spinal Injury Association score or clinical improvement. CONCLUSIONS Surfer’s myelopathy should be considered in the radiographic differential diagnosis of a longitudinally extensive T2-hyperintense spinal cord lesion. MR imaging characteristics do not appear to be associated with severity on examination or clinical improvement. PMID:23828111

Ecological Validity and Clinical Utility of Patient-Reported Outcomes Measurement Information System (PROMIS®) instruments for detecting premenstrual symptoms of depression, anger, and fatigue

PubMed Central

Junghaenel, Doerte U.; Schneider, Stefan; Stone, Arthur A.; Christodoulou, Christopher; Broderick, Joan E.

2014-01-01

Objective This study examined the ecological validity and clinical utility of NIH Patient Reported-Outcomes Measurement Information System (PROMIS®) instruments for anger, depression, and fatigue in women with premenstrual symptoms. Methods One-hundred women completed daily diaries and weekly PROMIS assessments over 4 weeks. Weekly assessments were administered through Computerized Adaptive Testing (CAT). Weekly CATs and corresponding daily scores were compared to evaluate ecological validity. To test clinical utility, we examined if CATs could detect changes in symptom levels, if these changes mirrored those obtained from daily scores, and if CATs could identify clinically meaningful premenstrual symptom change. Results PROMIS CAT scores were higher in the pre-menstrual than the baseline (ps < .0001) and post-menstrual (ps < .0001) weeks. The correlations between CATs and aggregated daily scores ranged from .73 to .88 supporting ecological validity. Mean CAT scores showed systematic changes in accordance with the menstrual cycle and the magnitudes of the changes were similar to those obtained from the daily scores. Finally, Receiver Operating Characteristic (ROC) analyses demonstrated the ability of the CATs to discriminate between women with and without clinically meaningful premenstrual symptom change. Conclusions PROMIS CAT instruments for anger, depression, and fatigue demonstrated validity and utility in premenstrual symptom assessment. The results provide encouraging initial evidence of the utility of PROMIS instruments for the measurement of affective premenstrual symptoms. PMID:24630180

Whole-flock, metaphylactic tilmicosin failed to eliminate contagious ovine digital dermatitis and footrot in sheep: a cluster randomised trial.

PubMed

Angell, J W; Grove-White, D H; Williams, H J; Duncan, J S

2016-09-24

The aim of this study was to evaluate the clinical success of whole-flock systemic tilmicosin and enhanced biosecurity in eliminating active contagious ovine digital dermatitis (CODD) from sheep flocks. Thirty flocks in the UK were randomly allocated to receive either treatment as usual (as per the farmer's normal routine) or whole-flock treatment with tilmicosin, together with isolation and extended treatment of clinically affected individuals and isolation and treatment of purchased sheep during the study period. All flocks were visited once at onset of the trial to examine all sheep. One year later, all sheep were re-examined to determine the presence/absence of clinical lesions. The primary outcome was the clinical elimination of CODD from flocks. Secondary outcomes were reduction in prevalence of CODD, clinical elimination of footrot and reduction in prevalence of footrot. The analysis included 11 control flocks and 13 intervention flocks, with initially 3460 and 4686 sheep, respectively. For CODD: at follow-up, in the intervention group, 6/13 (46 per cent) flocks had a prevalence of zero compared with 1/11 (9 per cent) in the control group (P=0.12). For footrot: at follow-up, no flocks had a prevalence of zero. Therefore, the intervention is not recommended for the elimination of CODD or footrot in the UK. British Veterinary Association.

Whole-flock, metaphylactic tilmicosin failed to eliminate contagious ovine digital dermatitis and footrot in sheep: a cluster randomised trial

PubMed Central

Angell, J. W.; Grove-White, D. H.; Williams, H. J.; Duncan, J. S.

2016-01-01

The aim of this study was to evaluate the clinical success of whole-flock systemic tilmicosin and enhanced biosecurity in eliminating active contagious ovine digital dermatitis (CODD) from sheep flocks. Thirty flocks in the UK were randomly allocated to receive either treatment as usual (as per the farmer's normal routine) or whole-flock treatment with tilmicosin, together with isolation and extended treatment of clinically affected individuals and isolation and treatment of purchased sheep during the study period. All flocks were visited once at onset of the trial to examine all sheep. One year later, all sheep were re-examined to determine the presence/absence of clinical lesions. The primary outcome was the clinical elimination of CODD from flocks. Secondary outcomes were reduction in prevalence of CODD, clinical elimination of footrot and reduction in prevalence of footrot. The analysis included 11 control flocks and 13 intervention flocks, with initially 3460 and 4686 sheep, respectively. For CODD: at follow-up, in the intervention group, 6/13 (46 per cent) flocks had a prevalence of zero compared with 1/11 (9 per cent) in the control group (P=0.12). For footrot: at follow-up, no flocks had a prevalence of zero. Therefore, the intervention is not recommended for the elimination of CODD or footrot in the UK. PMID:27450091

Can objective measurements of the nasal form and function represent the clinical picture in unilateral cleft lip and palate?

PubMed

Peroz, Roshan; Holmström, Mats; Mani, Maria

2017-05-01

The present study aimed to evaluate the potential correlations between objective measurements of nasal function and self-assessed nasal symptoms or clinical findings at nasal examination among adults treated for unilateral cleft lip and palate (UCLP), respectively. All UCLP patients born between 1960 and 1987 (n = 109) treated at a tertiary referring center were invited. Participation rate was 76% (n = 83) at a mean of 37 years after the initial surgery. All participants completed the same study protocol including acoustic rhinometry (AR), rhinomanometry (RM), anterior rhinoscopy, and questionnaires regarding self-experienced nasal symptoms. A reduced volume of the anterior nasal cavity on the operated side (measured by AR) correlated to an expressed wish by the patient to change the function of the nose. A similar correlation was seen for the minimal cross-sectional area of anterior nasal cavity on the operated side. Furthermore, correlations were found between smaller volume and area of nasal cavity and a greater frequency of nasal obstruction. No further correlations were found. Objective measurements partly correlate to the clinical picture among adults treated for UCLP. However, these need to be combined with findings at clinical examination and patient self-assessment to represent the complete clinical picture. Copyright © 2017 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.

Bridging basic and clinical science with policy studies: The Partners with Transdisciplinary Tobacco Use Research Centers experience.

PubMed

Kobus, Kimberly; Mermelstein, Robin

2009-05-01

The Partners with Transdisciplinary Tobacco Use Research Centers (TTURCs) initiative was a transdisciplinary team-building program, funded by the Robert Wood Johnson Foundation, to expand the policy research capacity of the TTURCs. EXPANSION INTO POLICY RESEARCh: Policy research activities at the TTURCs fell into four broad domains: (a) health services research, (b) examination of the business case for cessation treatment and funding, (c) collaborative teams with key stakeholders, and (d) direct assessment of smoking-related policies. Examples of each domain are presented. Goals of the initiative included efforts to foster collaborative, transdisciplinary research, to bring new investigators into the field, to develop programs of policy research, to answer next-step translational questions, and to enhance awareness of policy relevance. Success at meeting each of these goals is discussed. We offer recommendations for incorporating programs of policy research into full-spectrum transdisciplinary research initiatives, including the roles of research teams, senior researchers, infrastructure, stakeholders, and communications activities. The TTURC Partners initiative represented a first-generation effort to fill the gap between scientific discovery and research translation through expansion into policy studies. While all aspects of the effort were not equally successful, the effort demonstrated that it is possible to develop successful collaborations that extend more basic and applied research into studies that examine their policy and practice implications.

The current state of funded NIH grants in implementation science in genomic medicine: a portfolio analysis.

PubMed

Roberts, Megan C; Clyne, Mindy; Kennedy, Amy E; Chambers, David A; Khoury, Muin J

2017-10-26

PurposeImplementation science offers methods to evaluate the translation of genomic medicine research into practice. The extent to which the National Institutes of Health (NIH) human genomics grant portfolio includes implementation science is unknown. This brief report's objective is to describe recently funded implementation science studies in genomic medicine in the NIH grant portfolio, and identify remaining gaps.MethodsWe identified investigator-initiated NIH research grants on implementation science in genomic medicine (funding initiated 2012-2016). A codebook was adapted from the literature, three authors coded grants, and descriptive statistics were calculated for each code.ResultsForty-two grants fit the inclusion criteria (~1.75% of investigator-initiated genomics grants). The majority of included grants proposed qualitative and/or quantitative methods with cross-sectional study designs, and described clinical settings and primarily white, non-Hispanic study populations. Most grants were in oncology and examined genetic testing for risk assessment. Finally, grants lacked the use of implementation science frameworks, and most examined uptake of genomic medicine and/or assessed patient-centeredness.ConclusionWe identified large gaps in implementation science studies in genomic medicine in the funded NIH portfolio over the past 5 years. To move the genomics field forward, investigator-initiated research grants should employ rigorous implementation science methods within diverse settings and populations.Genetics in Medicine advance online publication, 26 October 2017; doi:10.1038/gim.2017.180.

Clinical assessment is an accurate predictor of which patients will need septoplasty.

PubMed

Sedaghat, Ahmad R; Busaba, Nicolas Y; Cunningham, Michael J; Kieff, David A

2013-01-01

Septoplasty is a frequently performed surgical procedure with the most common indication being nasal airway obstruction. Almost universally, health insurance companies mandate a trial of medical therapy consisting of intranasal corticosteroids prior to performance of septoplasty regardless of clinical assessment. Evidence for this requirement is lacking. We sought to evaluate the initial clinical assessment as a predictor of response to this mandated trial of medical treatment. Retrospective review of prospectively collected data on 137 consecutive patients who presented with symptoms of nasal obstruction and a deviated nasal septum on physical examination. Patients were placed into one of three cohorts based on prediction of 1) failure of medical therapy with subsequent septoplasty, 2) success of medical therapy without subsequent septoplasty, or 3) unable to make a prediction. Patients from each cohort were assessed for subsequent response to medical therapy and ultimate need for septoplasty. Overall clinical assessment had a sensitivity of 86.9%, specificity of 91.8%, positive predictive value of 93.6%, and negative predictive value of 96.4% for detecting/predicting need for septoplasty. The accuracy of the overall clinical assessment is considerably better than severe deviation at any one septal anatomical site. Of patients whose response to medical therapy could not be predicted, 61.3% failed medical therapy and needed surgery; this is statistically equivalent to a 50/50 distribution between either needing septoplasty or not. Clinical assessment at initial presentation of patients with nasal obstruction and deviated septum is highly accurate in predicting which patients will need septoplasty. Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.

Accessing specialty behavioral health treatment in private health plans.

PubMed

Merrick, Elizabeth L; Horgan, Constance M; Garnick, Deborah W; Reif, Sharon; Stewart, Maureen T

2009-10-01

Connecting people to mental health and substance abuse services is critical, given the extent of unmet need. The way health plans structure access to care can play a role. This study examined treatment entry procedures for specialty behavioral health care in private health plans and their relationship with behavioral health contracting arrangements, focusing primarily on initial entry into outpatient treatment. The data source was a nationally representative health plan survey on behavioral health services in 2003 (N = 368 plans with 767 managed care products; 83% response rate). Most health plan products initially authorized six or more outpatient visits if authorization was required, did not routinely conduct telephonic clinical assessment, had standards for timely access, and monitored wait time. Products with carve-outs differed on several treatment entry dimensions. Findings suggest that health plans focus on timely access and typically do not heavily manage initial entry into outpatient treatment.

The impact of a new universal postpartum program on breastfeeding outcomes.

PubMed

Sheehan, Debbie; Watt, Susan; Krueger, Paul; Sword, Wendy

2006-11-01

The Ontario Mother and Infant Study II examined changes in postpartum health outcomes, including breastfeeding initiation and discontinuation, for mothers and their infants and compared these results to data collected prior to the initiation of the Universal Hospital Stay and Postpartum Home Visiting Program policy change in 1998. Data were collected using cross-sectional surveys before discharge and at 4 weeks postdischarge. Ninety percent of the women surveyed at 4 weeks postpartum initiated breastfeeding. Of these, 84% were still breastfeeding at 4 weeks postpartum. None of the 3 major program components-extended length of stay, a postpartum phone call from a public health worker, or a postpartum in-home visit-were associated with breastfeeding continuation to 4 weeks. Discontinuation before 4 weeks postdischarge was associated with maternal attitudes toward breastfeeding, formula feeding or supplementation in hospital, infant readmission, and use of walk-in clinics for infant care.

Plasma Deactivation of Oral Bacteria Seeded on Hydroxyapatite Disks as Tooth Enamel Analogue

PubMed Central

Blumhagen, Adam; Singh, Prashant; Mustapha, Azlin; Chen, Meng; Wang, Yong; Yu, Qingsong

2014-01-01

Purpose To study the plasma treatment effects on deactivation of oral bacteria seeded on a tooth enamel analogue. Methods A non-thermal atmospheric pressure argon plasma brush was used to treat two different Gram-positive oral bacteria including Lactobacillus acidophilus (L. acidophilus) and Streptococcus mutans (S. mutans). The bacteria were seeded on hydroxyapatite (HA) disks used as tooth enamel analogue with three initial bacterial seeding concentrations: a low inoculum concentration between 2.1×108 and 2.4×108 cfu/mL, a medium inoculum concentration between 9.8×108 and 2.4×109 cfu/mL, and a high inoculum concentration between 1.7×1010 and 3.5×1010 cfu/mL. The bacterial survivability upon plasma exposure was examined in terms of plasma exposure time and oxygen addition into the plasmas. SEM was performed to examine bacterial morphological changes after plasma exposure. Results The experimental data indicated that 13 second plasma exposure time completely killed all the bacteria when initial bacterial seeding density on HA surfaces were less than 6.9×106 cfu/cm2 for L. acidophilus and 1.7×107 cfu/cm2 for S. mutans, which were resulted from low initial seeding inoculum concentration between 2.1×108 and 2.4×108 cfu/mL. Plasma exposure of the bacteria at higher initial bacterial seeding density obtained with high initial seeding inoculum concentration, however, only resulted in ~ 1.5 to 2 log reduction and ~ 2 to 2.5 log reduction for L. acidophilus and S. mutans, respectively. It was also noted that oxygen addition into the argon plasma brush did not affect the plasma deactivation effectiveness. SEM images showed that plasma deactivation mainly occurred with the top layer bacteria, while shadowing effects from the resulting bacterial debris reduced the plasma deactivation of the underlying bacteria. Clinical Significance The experimental results indicate that, with direct contact, nonthermal atmospheric pressure argon plasmas could rapidly and effectively deactivate oral bacteria seeded on HA surfaces and thus could be a promising technique in various dental clinical applications. PMID:25000666

The Correlation between the Scores of Written Examination, the Clinical Clerkship Examination, the Clinical Skill Assessment, and the Graduation Examination of the Medical Students.

PubMed

Koh, Suk Bong; Park, Hye Jin

2009-12-01

The aim of this study was to investigate correlations between medical student scores on 4 examinations: the written examination, clinical clerkship examination, clinical skill assessment, and graduation examination. Scores for 51 students who entered Daegu Catholic Medical School in 2005 on the written examination, clinical clerkship examination, clinical skill assessment, and graduation examination were included. Correlations between the scores were analyzed statistically. The scores on the written examination showed a strong correlation with those of the clinical clerkship assessment (0.833) and graduation examination (0.821). The clinical clerkship assessment scores correlated significantly with graduation examination scores (0.907). In addition, clinical skill assessment scores correlated with the written examination (0.579), clinical clerkship examination (0.570), and graduation examination (0.465) scores. Overall, the correlation between the scores on the clinical clerkship examination and the written examination was more significant than the correlation between scores on the clinical clerkship examination and clinical skill assessment. Therefore, we need to improve the evaluation method for the clinical clerkship examination and clinical skill assessment.

A Case Series of the Probability Density and Cumulative Distribution of Laryngeal Disease in a Tertiary Care Voice Center.

PubMed

de la Fuente, Jaime; Garrett, C Gaelyn; Ossoff, Robert; Vinson, Kim; Francis, David O; Gelbard, Alexander

2017-11-01

To examine the distribution of clinic and operative pathology in a tertiary care laryngology practice. Probability density and cumulative distribution analyses (Pareto analysis) was used to rank order laryngeal conditions seen in an outpatient tertiary care laryngology practice and those requiring surgical intervention during a 3-year period. Among 3783 new clinic consultations and 1380 operative procedures, voice disorders were the most common primary diagnostic category seen in clinic (n = 3223), followed by airway (n = 374) and swallowing (n = 186) disorders. Within the voice strata, the most common primary ICD-9 code used was dysphonia (41%), followed by unilateral vocal fold paralysis (UVFP) (9%) and cough (7%). Among new voice patients, 45% were found to have a structural abnormality. The most common surgical indications were laryngotracheal stenosis (37%), followed by recurrent respiratory papillomatosis (18%) and UVFP (17%). Nearly 55% of patients presenting to a tertiary referral laryngology practice did not have an identifiable structural abnormality in the larynx on direct or indirect examination. The distribution of ICD-9 codes requiring surgical intervention was disparate from that seen in clinic. Application of the Pareto principle may improve resource allocation in laryngology, but these initial results require confirmation across multiple institutions.

Web-based objective structured clinical examination with remote standardized patients and Skype: resident experience.

PubMed

Langenau, Erik; Kachur, Elizabeth; Horber, Dot

2014-07-01

Using Skype and remote standardized patients (RSPs), investigators sought to evaluate user acceptance of a web-based objective structured clinical examination (OSCE) among resident physicians. After participating in four web-based clinical encounters addressing pain with RSPs, 59 residents from different training programs, disciplines and geographic locations completed a 52-item questionnaire regarding their experience with Skype and RSPs. Open-ended responses were solicited as well. The majority of participants (97%) agreed or strongly agreed the web-based format was convenient and a practical learning exercise, and 90% agreed or strongly agreed the format was effective in teaching communication skills. Although 93% agreed or strongly agreed they could communicate easily with RSPs using Skype, 80% preferred traditional face-to-face clinical encounters, and 58% reported technical difficulties during the encounters. Open-ended written responses supported survey results. Findings from this study expose challenges with technology and human factors, but positive experiences support the continued investigation of web-based OSCEs as a synchronous e-learning initiative for teaching and assessing doctor-patient communication. Such educational programs are valuable but unlikely to replace face-to-face encounters with patients. This web-based OSCE program provides physician learners with additional opportunity to improve doctor-patient communication. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Streptococcus equi subsp zooepidemicus pleuropneumonia and peritonitis in a dromedary camel (Camelus dromedarius) calf in North America.

PubMed

Stoughton, William B; Gold, Jenifer

2015-08-01

A 12-week-old female dromedary camel (Camelus dromedarius) calf was evaluated because of acute (< 24 hours) inappetence and lethargy. The calf was being bottle-fed because of maternal rejection. Physical examination revealed decreased bronchovesicular sounds and absent borborygmi. The rectal temperature was 38.9°C (102.0°F). A CBC indicated leukopenia with a degenerative left shift suggestive of a systemic infection. Results of abdominal and thoracic ultrasonography showed severe bicavitary effusion, peripheral lung consolidation, and intestinal hypomotility. Pleural and peritoneal fluid analysis confirmed a diagnosis of septic pleuritis and peritonitis. Results of aerobic bacterial culture of venous blood, peritoneal fluid, and pleural fluid samples indicated Streptococcus equi subsp zooepidemicus septicemia as the etiology for the polyserositis (ie, alpaca fever). Treatment with IV broad-spectrum antimicrobials, an NSAID, and pleural drainage was initiated. Clinical signs of pleuropneumonia, peritonitis, and systemic infection improved rapidly 24 hours after initiation of medical treatment. The calf was discharged from the hospital after 11 days, and antimicrobial treatment continued for 2 weeks after discharge. At follow-up approximately 4 weeks after hospital discharge (6 weeks after the initial examination), there were no clinical signs suggestive of relapse or any reported complications. S equi subsp zooepidemicus may cause polyserositis in Old World camelids (eg, dromedary camels) with signs similar to those seen in New World camelids (eg, alpaca and llama). The rapid response to medical treatment for the patient described suggested that S equi subsp zooepidemicus-induced polyserositis (alpaca fever) in dromedary camels may respond favorably to appropriate treatment. Reducing stress, reducing overcrowding, and separate housing of equids and camelids are suggested. Further studies are needed to better assess the epidemiology of alpaca fever in dromedary camels in North America.

Toxic keratopathy associated with abuse of topical anesthetics and amniotic membrane transplantation for treatment

PubMed Central

Tok, Ozlem Yalcin; Tok, Levent; Atay, Inci Meltem; Argun, Tugba Cakmak; Demirci, Nazire; Gunes, Alime

2015-01-01

AIM To evaluate the clinical findings of toxic keratopathy associated with abuse of topical anesthetics and the treatment efficacy of amniotic membrane transplantation (AMT). METHODS Fifteen eyes of 10 patients with abuse of topical anesthetics were included in this study. The data collected included patients' demographic information, initial best corrected visual acuity (BCVA), clinical findings, time to AMT, duration of epithelization, additional treatments, posttreatment BCVA, and the results of psychiatric examination. RESULTS All patients were male, with the mean age of 37.9±5.4y. The patients had received 0.5% proparacaine hydrochloride due to pain resulting from foreign bodies, such as welding flash burns and car battery explosions, for a mean of 18.2±12.4d. The mean initial BCVA of the patients was 0.069±0.100. All patients had persistent epithelial defects, stromal infiltration, ring ulcer, and corneal edema. Initially, medical treatment was attempted in all cases. Because of severe pain, persistent epithelial defects and progressing stromal thinning did not improve with medical treatment, thus, the patients underwent AMT. The mean posttreatment BCVA of the patients was 0.33±0.27. All of them, except for two patients, showed improved visual acuity. One patient underwent evisceration for corneal melting and endophthalmitis in another center, and one patient underwent evisceration for severe pain of unknown origin. All 5 patients who consented to a psychiatric examination had depression, had personality disorder, and used tobacco. CONCLUSION AMT appears to be an effective method for pain relief, rapid epithelial and stromal healing; however, visual prognosis is still poor despite medical and surgical interventions. PMID:26558205

Contrast-enhanced spectral mammography versus MRI: Initial results in the detection of breast cancer and assessment of tumour size.

PubMed

Fallenberg, E M; Dromain, C; Diekmann, F; Engelken, F; Krohn, M; Singh, J M; Ingold-Heppner, B; Winzer, K J; Bick, U; Renz, D M

2014-01-01

To compare mammography (MG), contrast-enhanced spectral mammography (CESM), and magnetic resonance imaging (MRI) in the detection and size estimation of histologically proven breast cancers using postoperative histology as the gold standard. After ethical approval, 80 women with newly diagnosed breast cancer underwent MG, CESM, and MRI examinations. CESM was reviewed by an independent experienced radiologist, and the maximum dimension of suspicious lesions was measured. For MG and MRI, routine clinical reports of breast specialists, with judgment based on the BI-RADS lexicon, were used. Results of each imaging technique were correlated to define the index cancer. Fifty-nine cases could be compared to postoperative histology for size estimation. Breast cancer was visible in 66/80 MG, 80/80 CESM, and 77/79 MRI examinations. Average lesion largest dimension was 27.31 mm (SD 22.18) in MG, 31.62 mm (SD 24.41) in CESM, and 27.72 mm (SD 21.51) in MRI versus 32.51 mm (SD 29.03) in postoperative histology. No significant difference was found between lesion size measurement on MRI and CESM compared with histopathology. Our initial results show a better sensitivity of CESM and MRI in breast cancer detection than MG and a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography (CESM) is slowly being introduced into clinical practice. • Access to breast MRI is limited by availability and lack of reimbursement. • Initial results show a better sensitivity of CESM and MRI than conventional mammography. • CESM showed a good correlation with postoperative histology in size assessment. • Contrast-enhanced spectral mammography offers promise, seemingly providing information comparable to MRI.

A Pilot Study Using a Web Survey to Identify Characteristics That Influence Hypogonadal Men to Initiate Testosterone Replacement Therapy.

PubMed

Rosen, Raymond C; Seftel, Allen D; Ruff, Dustin D; Muram, David

2018-05-01

Men with hypogonadism (HG) who choose testosterone replacement therapy (TRT) may have distinct characteristics that provide insight as to why they may/may not initiate therapy. The aim of the current study was to identify trends in patient characteristics and attitudes in men diagnosed with HG who initiated TRT (TRT+) compared with men who were diagnosed with HG but did not initiate TRT (TRT-). The market research-based online survey conducted between 2012 and 2013 included patients from a Federated Sample, a commercially available panel of patients with diverse medical conditions. The current analysis was composed of two groups: TRT+ ( n = 155) and TRT- ( n = 157). Patient demographics, clinical characteristics, and attitudes toward HG and TRT were examined as potential predictors of primary adherence in men with HG; cohorts were compared by using Fisher's exact test. Significant associations among sexual orientation, relationship status, educational level, presence of comorbid erectile dysfunction, area of residence, and TRT initiation were present ( p ≤ .05). College-educated, heterosexual, married men with comorbid erectile dysfunction living in suburban and urban areas were more likely to initiate treatment. The most bothersome symptoms reported were lack of energy (90% vs. 81%, p = .075), decreased strength and endurance (86% vs. 76%, p = .077), and deterioration in work performance (52% vs. 31%, p = .004); lack of energy prompted men to seek help. Patients (48%) in the TRT+ group were more knowledgeable regarding HG as compared with TRT- respondents (14%, p < .001), and most men obtained their information from a health care professional (89% vs. 82%, p = .074). The current analysis identified distinct demographic and clinical characteristics and attitudes among TRT users compared with men who were diagnosed with HG yet remained untreated.

The use of renal replacement therapy in acute decompensated heart failure.

PubMed

Udani, Suneel M; Murray, Patrick T

2009-01-01

The worsening of renal function in the context of decompensated heart failure is an increasingly common clinical scenario, dubbed the cardiorenal syndrome. Its development is not completely understood; however, it results from the hemodynamic and neurohumoral alterations that occur in the setting of left ventricular pressure and volume overload with poor cardiac output. Diuretics have been the mainstay of treatment; however, they are often unsuccessful in reversing the vicious cycle of volume overload, worsening cardiac function, and azotemia. Renal replacement therapy (RRT) in the form of isolated or continuous ultrafiltration (UF) with or without a component of solute clearance (hemofiltration or hemodialysis) has been increasingly utilized as a therapeutic tool in this setting. Initial clinical trial data on the use of UF have demonstrated promising cardiac outcomes with regard to fluid removal and symptom relief without worsening renal function. The addition of a component of solute clearance may provide additional benefits in these patients with varying degrees of renal impairment. The exact clinical setting in which the various forms of RRT should be applied as initial or early therapy for acute decompensated heart failure (ADHF) remains unknown. More research examining the use of RRT in ADHF is necessary; however, it appears that the patients with the most severe clinical presentations have the best chance of benefiting from the early application of RRT.

Histologic changes in thyroid nodules after percutaneous ethanol injection in patients subsequently operated on due to new focal thyroid lesions.

PubMed

Pomorski, Lech; Bartos, Magdalena

2002-02-01

This paper reports macro- and microscopic changes in hyperfunctioning thyroid nodules (HTN), initially diagnosed as solitary, in patients treated with percutaneous ethanol injection (PEI). In 78 patients, benign solitary HTN were diagnosed by clinical and hormonal examination. High resolution ultrasonography confirmed the solitary nodule. The results of fine needle aspiration biopsy (FNAB), performed twice, ruled out malignancy of the nodule. The patients were referred for PEI treatment. At 1-year follow-up, newly formed thyroid nodules, whose volumes increased, were detected in five patients (6.4%) with HTN, initially diagnosed as solitary. Therefore, these patients were operated on. Subtotal thyroidectomy was performed. At the intraoperative macroscopic evaluation, a hard fibrous solid mass was found in place of three nodules (n1, n2, n3) following PEI treatment. The middle area of the cut surface of PEI-treated nodules (n4 and n5) in the other two patients was firm and haemorrhagic, surrounded by a fibrous mass. Histolopathologic examination of n1, n2 and n3 revealed fibrosis and hyalinosis. Examination of n4 and n5 showed haemorrhagic necrosis in the middle of the nodules surrounded by fibrous tissue.

Research Areas - Clinical Trials

Cancer.gov

Information about NCI programs and initiatives that sponsor, conduct, develop, or support clinical trials, including NCI’s Clinical Trial Network (NCTN) and NCI Community Oncology Research Program (NCORP) initiatives.

The development and psychometric properties of the selective mutism questionnaire.

PubMed

Bergman, R Lindsey; Keller, Melody L; Piacentini, John; Bergman, Andrea J

2008-04-01

Research on selective mutism (SM) has been limited by the absence of standardized, psychometrically sound assessment measures. The purpose of our investigation was to present two studies that examined the factor structure and initial reliability and validity of the Selective Mutism Questionnaire (SMQ), a 17-item parent report measure of failure to speak related to SM. Study 1 (N = 589) utilized an Internet sample of parents of children ages 3 to 11 to demonstrate that the SMQ has a theoretically and clinically meaningful factor structure accounting for a significant portion of variance in responses with good internal consistency. Study 2 (N = 66) supported the validity of the SMQ in that scores discriminated clinic-referred children with SM from children with other anxiety disorders. Scores on the SMQ were correlated with measures of several theoretically and clinically important dimensions.

An outbreak of Candida albicans folliculitis masquerading as Malassezia folliculitis in a prison population.

PubMed

Jalalat, Sheila; Hunter, Lindsey; Yamazaki, Mika; Head, Elizabeth; Kelly, Brent

2014-04-01

Several inmates from a non-air-conditioned prison were sent to the University of Texas Medical Branch dermatology clinic for unexplained eruptions not responding to various treatments. They were initially diagnosed with Malassezia folliculitis based on clinical examination and histological findings. The patients' cultures from skin scrapings, however, revealed Candida albicans confirmed by growth on Mycosel agar and further by the germ tube production method. Five cases were brought to the clinic, but at least 30 other inmates were reported to have similar cutaneous eruptions. Given that these patients were generally immunocompetent, this is a rare finding. Factors favoring pseudohyphal growth for these patients included use of topical steroids and/or systemic antibiotics and hot and humid climate. All patients' folliculitis resolved with fluconazole and/or antifungal cream with no further complications.

Efficacy of vitamin D3 supplementation in reducing incidence of pulmonary tuberculosis and mortality among HIV-infected Tanzanian adults initiating antiretroviral therapy: study protocol for a randomized controlled trial.

PubMed

Sudfeld, Christopher R; Mugusi, Ferdinand; Aboud, Said; Nagu, Tumaini J; Wang, Molin; Fawzi, Wafaie W

2017-02-10

HIV-infected adults initiating antiretroviral therapy (ART) in sub-Saharan Africa continue to experience high rates of morbidity and mortality during the initial months of treatment. Observational studies in high-income and resource-limited settings indicate that HIV-infected adults with low vitamin D levels may be at increased risk of mortality, HIV disease progression, and incidence of pulmonary tuberculosis (TB). As a result, vitamin D 3 supplementation may improve survival and treatment outcomes for HIV-infected adults initiating ART. The Trial of Vitamins-4 (ToV4) is an individually randomized, double-blind, placebo-controlled trial of vitamin D 3 (cholecalciferol) supplementation conducted among 4000 HIV-infected adults with low vitamin D levels [25-hydroxyvitamin D (25(OH)D) <30 ng/mL] initiating ART in Dar es Salaam, Tanzania. The two primary aims of the trial are to determine the effect of a vitamin D 3 supplementation regimen on incidence of (1) mortality and (2) pulmonary TB as compared to a matching placebo regimen. The primary safety outcome of the study is incident hypercalcemia. The investigational vitamin D 3 regimen consists of oral supplements containing 50,000 IU vitamin D 3 taken under direct observation at randomization and once a week for 3 weeks (four doses) followed by daily oral supplements containing 2000 IU vitamin D 3 taken at home from the fourth week until trial discharge at 1 year post ART initiation. Trial participants are followed up at weekly clinic visits during the first month of ART and at monthly clinic visits thereafter until trial discharge at 1 year post ART initiation. Secondary aims of the trial are to examine the effect of the vitamin D 3 regimen on CD4 T cell reconstitution, incidence of non-TB comorbidities, body mass index (BMI), depression and anxiety, physical activity, bone health, and immunologic biomarkers. The ToV4 will provide causal evidence on the effect of vitamin D 3 supplementation on incidence of pulmonary TB and mortality among HIV-infected Tanzanian adults initiating ART. The trial will also give insight to whether vitamin D 3 supplementation trials for the prevention of pulmonary TB should be pursued in HIV-uninfected populations. ClinicalTrials.gov, NCT01798680 . Registered on 21 February 2013.

Tinea atypica: report of nine cases.

PubMed

Zisova, Liliya Georgieva; Dobrev, Hristo Petrov; Tchernev, Georgi; Semkova, Kristina; Aliman, Anastasia Atanasova; Chorleva, Kristina Ivanova; Chapanova, Antonina Teneva; Vutova, Nina Ivanova; Wollina, Uwe

2013-12-01

Fungal infections of the skin are a common condition, usually easy to diagnose and treat. When the infection is clinically mimicking another cutaneous disorder or when the clinical presentation is modified by the use of inappropriate treatment, it is referred to as tinea atypica or tinea incognito.We report a series of nine cases of patients with tinea atypica, imitating and diagnosed initially as different skin diseases. Two patients were defined as pyoderma in the facial and pubic regions (caused respectively by Trichophyton mentagrophytes var. mentagrophytes and Microsporum canis) and one as herpes zoster ophthalmicus (caused by Trichophyton rubrum). Six additional patients were initially misdiagnosed: (1) Plaque-like formation of the skin misdiagnosed as an impetiginized eczema (with isolated agent Trichophyton verrucosum). (2) A rare form of skin infection of the hand caused by T. rubrum, imitating clinically cutaneous infection with tuberculum mulgentium. (3) Rosacea-like dermatitis with an isolated agent Fusarium. (4) A patient with the typical clinical symptoms of seborrheic dermatitis of the face (and with isolated T. rubrum as a causative agent). (5) Another patient presented with a widespread folliculitis by Trichophyton mentagrophytes. (6) In a patient with bullous pemphigoid and immunosuppression pemphigoid-like eruptions were caused by Malassezia pachydermatis and T. rubrum. The diagnosis in the presented cases was based on direct microscopic examination with KOH and a culture on Sabouraud agar.After the diagnosis of tinea, treatment with topical and systemic antifungal agents was administrated, followed by complete clinical remissions in all cases.The clinical manifestations of tinea atypica can mimic a large number of other dermatoses, which often leads to misdiagnosing, and as a consequence--to serious difficulties in the management of clinical symptoms and in offering appropriate therapy.

Epilepsy Characteristics and Clinical Outcome in Patients With Mitochondrial Encephalomyopathy, Lactic Acidosis, and Stroke-Like Episodes (MELAS).

PubMed

Lee, Ha Neul; Eom, Soyong; Kim, Se Hoon; Kang, Hoon-Chul; Lee, Joon Soo; Kim, Heung Dong; Lee, Young-Mock

2016-11-01

Epileptic seizures in patients with mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes (MELAS) are heterogeneous with no pathognomonic features. We reviewed epilepsy characteristics and clinical outcome exclusively in a pediatric population. Twenty-two children and adolescents (13 males) with confirmed mitochondrial encephalomyopathy, lactic acidosis, and stroke-like episodes due to mitochondrial DNA A3243G mutation and epilepsy were recruited. Clinical data including seizure semiology, treatment response, neuroimaging findings, and electroencephalography were analyzed. We also examined the effect of the age at seizure onset and initial symptoms on the clinical variables. Seizure semiology and electroencephalography abnormalities showed no syndrome-specific findings. Focal seizures occurred in 21 of 22 subjects (95.5%), whereas generalized seizures developed in seven of 22 subjects (31.8%). Twenty of 22 subjects (90.9%) achieved partial to complete reduction of clinical seizures for more than one year with a combination of more than two antiepileptic drugs. The subgroup with earlier seizure onset presented significantly earlier and showed significantly higher rates of drug-resistant epilepsy compared with the late onset group, although there were no significant differences in the initial symptoms. The subjects with severe epileptic conditions tended to have more severe clinical dysfunction and more severe organ involvement. Both focal and generalized seizures occurred in patients with MELAS. Epilepsy in this population is drug resistant, but a certain degree of clinical seizure reduction was achievable with antiepileptic drugs, with more favorable outcomes than historically expected. Close observation and active epilepsy treatment of individuals with MELAS episodes and earlier seizure onset might improve the prognosis. Copyright © 2016 Elsevier Inc. All rights reserved.

Longitudinal changes in white matter disease and cognition in the first year of the Alzheimer disease neuroimaging initiative.

PubMed

Carmichael, Owen; Schwarz, Christopher; Drucker, David; Fletcher, Evan; Harvey, Danielle; Beckett, Laurel; Jack, Clifford R; Weiner, Michael; DeCarli, Charles

2010-11-01

To evaluate relationships between magnetic resonance imaging (MRI)-based measures of white matter hyperintensities (WMHs), measured at baseline and longitudinally, and 1-year cognitive decline using a large convenience sample in a clinical trial design with a relatively mild profile of cardiovascular risk factors. Convenience sample in a clinical trial design. A total of 804 participants in the Alzheimer Disease Neuroimaging Initiative who received MRI scans, cognitive testing, and clinical evaluations at baseline, 6-month follow-up, and 12-month follow-up visits. For each scan, WMHs were detected automatically on coregistered sets of T1, proton density, and T2 MRI images using a validated method. Mixed-effects regression models evaluated relationships between risk factors for WMHs, WMH volume, and change in outcome measures including Mini-Mental State Examination (MMSE), Alzheimer Disease Assessment Scale-Cognitive Subscale (ADAS-Cog), and Clinical Dementia Rating Scale sum of boxes scores. Covariates in these models included race, sex, years of education, age, apolipoprotein E genotype, baseline clinical diagnosis (cognitively normal, mild cognitive impairment, or Alzheimer disease), cardiovascular risk score, and MRI-based hippocampal and brain volumes. Higher baseline WMH volume was associated with greater subsequent 1-year increase in ADAS-Cog and decrease in MMSE scores. Greater WMH volume at follow-up was associated with greater ADAS-Cog and lower MMSE scores at follow-up. Higher baseline age and cardiovascular risk score and more impaired baseline clinical diagnosis were associated with higher baseline WMH volume. White matter hyperintensity volume predicts 1-year cognitive decline in a relatively healthy convenience sample that was similar to clinical trial samples, and therefore should be considered as a covariate of interest at baseline and longitudinally in future AD treatment trials.

Pleural effusion as the initial clinical presentation in disseminated cryptococcosis and fungaemia: an unusual manifestation and a literature review.

PubMed

Chen, Mayun; Wang, Xiaomi; Yu, Xianjuan; Dai, Caijun; Chen, Dunshun; Yu, Chang; Xu, Xiaomei; Yao, Dan; Yang, Li; Li, Yuping; Wang, Liangxing; Huang, Xiaoying

2015-09-22

Cryptococcus neoformans infection usually presents as chronic meningitis and is increasingly being recognized in immunocompromised patients. Presentation with pleural effusion is rare in cryptococcal disease; in fact, only 4 cases of pleural effusion as the initial clinical presentation in cryptococcosis have been reported in English-language literature to date. We report the first case of pleural effusion as the initial clinical presentation in a renal transplant recipient who was initially misdiagnosed with tuberculous pleuritis but who then developed fungaemia and disseminated cryptococcosis. The examination of this rare manifestation and the accompanying literature review will contribute to increased recognition of the disease and a reduction in misdiagnoses. We describe a 63-year-old male renal transplant recipient on an immunosuppressive regimen who was admitted for left pleural effusion and fever. Cytological examinations and pleural fluid culture were nonspecific and negative. Thoracoscopy only found chronic, nonspecific inflammation with fibrosis in the pleura. After empirical anti-tuberculous therapy, the patient developed an elevated temperature, a severe headache and vomiting and fainted in the ward. Cryptococci were specifically found in the cerebrospinal fluid following lumbar puncture. Blood cultures were twice positive for C. neoformans one week later. He was transferred to the respiratory intensive care unit (RICU) immediately and was placed on non-invasive ventilation for respiratory failure for 2 days. He developed meningoencephalitis and fungaemia with C. neoformans during hospitalization. He was given amphotericin B liposome combined with 5-flucytosine and voriconazole for first 11 days, then amphotericin B liposome combined with 5-flucytosine sustained to 8 weeks, after that changed to fluconazole for maintenance. His condition improved after antifungal treatment, non-invasive ventilation and other support. Further pathological consultation and periodic acid-Schiff staining revealed Cryptococcus organisms in pleural sections, providing reliable evidence for cryptococcal pleuritis. Pleural effusion is an unusual manifestation of cryptococcosis. Cryptococcal infection must be considered in the case of patients on immunosuppressives, especially solid-organ transplant recipients, who present with pleural effusion, even if pleural fluid culture is negative. Close communication between the pathologist and the clinician, multiple special biopsy section stains and careful review are important and may contribute to decreasing misdiagnosis.

Factors associated with obstructive sleep apnea among commercial motor vehicle drivers.

PubMed

Xie, Wen; Chakrabarty, Sangita; Levine, Robert; Johnson, Roy; Talmage, James B

2011-02-01

Identify factors associated with obstructive sleep apnea (OSA) risk during commercial driver medical examinations. A case-control study was conducted at an occupational health clinic by reviewing the commercial driver medical examinations medical records performed from January 2007 to December 2008. The magnitude of association with OSA was estimated with logistic regression. Among 1890 commercial motor vehicle drivers, 51 were confirmed positive for OSA by polysomnography after initial screening by Joint Task Force guidelines, yielding estimated positive predictive values of 78.5% for the screening criteria. Multivariable logistic regression showed that body mass index ≥ 30 (odds ratio: 26.86), hypertension (odds ratio: 2.57), and diabetes (odds ratio: 2.03) were independently associated with OSA. Medical examiners' use of objectively measurable risk factors, such as obesity, history of hypertension, and/or diabetes, rather than symptoms, may be more effective in identifying undiagnosed OSA in commercial drivers during the commercial driver medical examinations.

Transmission risk of Borrelia burgdorferi sensu lato from Ixodes ricinus ticks to humans in southwest Germany.

PubMed Central

Maiwald, M.; Oehme, R.; March, O.; Petney, T. N.; Kimmig, P.; Naser, K.; Zappe, H. A.; Hassler, D.; von Knebel Doeberitz, M.

1998-01-01

The risk of Borrelia burgdorferi infection and the value of antibiotic prophylaxis after tick bite are controversial. In this study, performed in two areas of southwestern Germany, ticks were collected from 730 patients and examined by the polymerase chain reaction (PCR) for B. burgdorferi. To assess whether transmission of B. burgdorferi occurred, the patients were clinically and serologically examined after tick removal and during follow-up examinations. Data from all tick bites gave a total transmission rate of 2.6% (19 patients). Eighty-four ticks (11.3%) were PCR positive. Transmission occurred to 16 (26.7%) of 60 patients who were initially seronegative and could be followed up after the bite of an infected tick. These results indicate that the transmission rate from infected ticks in Europe is higher than previously assumed. Examination of ticks and antibiotic prophylaxis in the case of positivity appears to be indicated. PMID:9747761

A critical review of clinical trials in systemic lupus erythematosus

PubMed Central

Mahieu, Mary A.; Strand, Vibeke; Simon, Lee S.; Lipsky, Peter E.; Ramsey-Goldman, Rosalind

2016-01-01

One challenge in caring for patients with systemic lupus erythematosus (SLE) is a paucity of approved therapeutics for treatment of the diverse disease manifestations. In the last 60 years, only one drug, belimumab, has been approved for SLE treatment. Critical evaluation of investigator initiated and pharma-sponsored randomized controlled trials (RCTs) highlights barriers to successful drug development in SLE, including disease heterogeneity, inadequate trial size or duration, insufficient dose finding before initiation of large trials, handling of background medications, and choice of primary endpoint. Herein we examine lessons learned from landmark SLE RCTs and subsequent advances in trial design, as well as discuss efforts to address limitations in current SLE outcome measures that will improve detection of true therapeutic responses in future RCTs. PMID:27497257

Treatment attrition: Associations with negative affect smoking motives and barriers to quitting among treatment-seeking smokers.

PubMed

Garey, Lorra; Kauffman, Brooke Y; Neighbors, Clayton; Schmidt, Norman B; Zvolensky, Michael J

2016-12-01

Pre-treatment attrition and perceived barriers for quitting are clinically important processes involved in early phases of quitting smoking. However, less is known about the constructs that may contribute to these processes such as negative affect reduction smoking motives. The current study sought to evaluate the relation between negative affect reduction smoking motives and pre-treatment attrition and perceived barriers for quitting in a sample of 425 treatment-seeking smokers (48.5% female; Mage=37.69 years; SD=13.61) enrolled in a smoking cessation study examining the efficacy of a transdiagnostic panic-smoking cessation treatment relative to a standard smoking cessation treatment. Results indicated that greater negative affect reduction smoking motives was associated with an increased likelihood of treatment initiation (odds ratio=1.49, CI: 1.09, 2.04). Additionally, negative affect reduction smoking motives was associated with greater perceived barriers for cessation among pre-treatment drop-outs and treatment initiators. This initial investigation provides evidence for the possible clinical utility in addressing negative affect reduction smoking motives during early stages of quitting. Additionally, such findings could potentially inform the development of personalized, early stages of quitting interventions for smoking cessation. Copyright © 2016 Elsevier Ltd. All rights reserved.

STORC safety initiative: a multicentre survey on preparedness & confidence in obstetric emergencies.

PubMed

Guise, Jeanne-Marie; Segel, Sally Y; Larison, Kristine; M Jump, Sarah; Constable, Marion; Li, Hong; Osterweil, Patricia; Dieter Zimmer

2010-12-01

Patient safety is a national and international priority. The purpose of this study was to understand clinicians' perceptions of teamwork during obstetric emergencies in clinical practice, to examine factors associated with confidence in responding to obstetric emergencies and to evaluate perceptions about the value of team training to improve preparedness. An anonymous survey was administered to all clinical staff members who respond to obstetric emergencies in seven Oregon hospitals from June 2006 to August 2006. 614 clinical staff (74.5%) responded. While over 90% felt confident that the appropriate clinical staff would respond to emergencies, more than half reported that other clinical staff members were confused about their role during emergencies. Over 84% were confident that emergency drills or simulation-based team training would improve performance. Clinical staff who respond to obstetric emergencies in their practice reported feeling confident that the qualified personnel would respond to an emergency; however, they were less confident that the responders would perform well as a team. They reported that simulation and team training may improve their preparedness and confidence in responding to emergencies.

How clients "change emotion with emotion": A programme of research on emotional processing.

PubMed

Pascual-Leone, Antonio

2018-03-01

This paper reviews a body of research that has examined Pascual-Leone and Greenberg's sequential model of emotional processing or used its accompanying measure (the Classification of Affective Meaning States). Research from 24 studies using a plurality of methods examined process-outcome relationships from micro to macro levels of observation and builds support for emotional transformation as a possible causal mechanism of change in psychotherapy. A pooled sample of 310 clinical and 130 sub-clinical cases have been studied, reflecting the process of 7 different treatment approaches in addressing over 5 different presenting clinical problems (including depression, anxiety, relational trauma, and personality disorders). The initial findings on this model support the hypothesis that emotional transformation occurs in specific canonical sequences and these show large effects in the prediction of positive treatment outcomes. This model is the first in the field of psychotherapy to show how non-linear temporal patterns of moment-by-moment process relate to the unfolding of increasingly larger changes to create good psychotherapy treatment outcomes. Finally, clinical application of the model is also considered as a template for case formulations focused on emotion. Clinical or methodological significance of this article: This review article examines research on a specific model of emotional processing. (i) Experiencing certain key emotions during psychotherapy seems to predict good treatment outcomes, at both the session and treatment levels. (ii) There is also evidence to suggest that these productive emotional experiences unfold in an ordered pattern. Moreover, (iii) support for this way of understanding emotional processing comes from a number of very different treatment approaches and for several kinds of major disorders.

Evaluation of a Topical Anti-inflammatory/Antifungal Combination Cream in Mild-to-moderate Facial Seborrheic Dermatitis: An Intra-subject Controlled Trial Examining Treated vs. Untreated Skin Utilizing Clinical Features and Erythema-directed Digital Photography.

PubMed

Dall'Oglio, Federica; Tedeschi, Aurora; Guardabasso, Vincenzo; Micali, Giuseppe

2015-09-01

To evaluate if nonprescription topical agents may provide positive outcomes in the management of mild-to-moderate facial seborrheic dermatitis by reducing inflammation and scale production through clinical evaluation and erythema-directed digital photography. Open-label, prospective, not-blinded, intra-patient, controlled, clinical trial (target area). Twenty adult subjects affected by mild-to-moderate facial seborrheic dermatitis were enrolled and instructed to apply the study cream two times daily, initially on a selected target area only for seven days. If the subject developed visible improvement, it was advised to extend the application to all facial affected area for 21 additional days. Efficacy was evaluated by measuring the grade of erythema (by clinical examination and by erythema-directed digital photography), desquamation (by clinical examination), and pruritus (by subject-completed visual analog scale). Additionally, at the end of the protocol, a Physician Global Assessment was carried out. Eighteen subjects completed the study, whereas two subjects were lost to follow-up for nonadherence and personal reasons, respectively. Day 7 data from target areas showed a significant reduction in erythema. At the end of study, a significant improvement was recorded for erythema, desquamation, and pruritus compared to baseline. Physician Global Assessment showed improvement in 89 percent of patients, with a complete response in 56 percent of cases. These preliminary results indicate that the study cream may be a viable nonprescription therapeutic option for patients affected by facial seborrheic dermatitis able to determine early and significant improvement. This study also emphasizes the advantages of using an erythema-directed digital photography system for assisting in a simple, more accurate erythema severity grading and therapeutic monitoring in patients affected by seborrheic dermatitis.

Medical humanitarianism in the United States: alternative healthcare, spirituality and political advocacy in the case of Our Lady Guadalupe Free Clinic.

PubMed

Tiedje, Kristina; Plevak, David J

2014-11-01

Exclusionary practices in dominant market-based systems are recognized as contributing to global health inequities. Undocumented immigrants are particularly vulnerable to unequal access to healthcare. Humanitarian NGOs strive to respond meaningfully to these health inequities among migrants and undocumented immigrants. Few studies describe the work of humanitarian NGOs that advocate for the right to health of undocumented immigrants in high-income countries. This paper discusses immigration, health, and human rights while examining solidarity, spirituality, and advocacy using a U.S.-based example of medical humanitarianism: the 'Our Lady of Guadalupe Free Clinic.' In 2011, the Free Clinic began in the basement of a Catholic parish in Minnesota in response to the lack of access to medical services for undocumented immigrants. Run by a local grassroots organization, it is held every six weeks and offers free primary healthcare to Latino immigrants and the uninsured. In this article, we examine the tricky relationship between humanitarianism and human rights in the U.S. Using ethnography, we draw on participant observation and interviews with 30 clinic volunteers, including health professionals, administrators, language interpreters, and spiritual leaders. The study was conducted September 2012-December 2013 in southern Minnesota. We examine how notions of solidarity, spirituality, and advocacy structure faith-based medical humanitarianism in the U.S. and explore the underlying tensions between the humanitarian mandate, spiritual teachings (social justice, solidarity), and political advocacy. Examining a moment of "crisis" in the Clinic, our study shows that volunteers experience the alliance between spirituality and advocacy with uneasiness. While a spiritual calling may initially motivate volunteers to serve, an embrace of human rights advocacy is important in a sustained effort to provide humanitarian medical care to individuals who fall outside of the political and moral community in the U.S. Copyright © 2014 Elsevier Ltd. All rights reserved.

A Prospective Comparative Study of the Toxicity Profile of 5-Flurouracil, Adriamycin, Cyclophosphamide Regime VS Adriamycin, Paclitaxel Regime in Patients with Locally Advanced Breast Carcinoma

PubMed Central

Pillai, Pradeep Sadasivan; Jayakumar, Krishnan Nair Lalithamma

2015-01-01

Introduction A 5-flurouracil, Adriamycin, Cyclophosphamide (FAC) and Adriamycin, Paclitaxel (AT) are two popular chemotherapeutic regimens for treatment of breast carcinoma. The most time tested and popular regimen is FAC. It is extensively studied for efficacy and toxicity. But data regarding toxicity profile and efficacy of AT regimen is sparse. Aim To study the toxicity profile, severity of toxicities and clinical response rate of FAC and AT regimens in patients with locally advanced breast carcinoma. Materials and Methods A prospective observational study with 50 patients in each treatment arm. Study duration was 12 months from November 2012 to October 2013. Consecutive patients with locally advanced breast carcinoma receiving treatment with either FAC or AT regimen, satisfying inclusion criteria were enrolled into the study after getting informed written consent. Prior to initiation of treatment detailed medical history was taken from all patients. General clinical examination, examination of organ systems and local examination of breast lump were done. After each cycle of chemotherapy and after completion of treatment patients were interviewed and examined for clinical response and toxicities. Toxicities were graded with WHO toxicity grading criteria. All data were entered in a structured proforma. At least 50% reduction in tumour size was taken as adequate clinical response. Statistical Analysis Data was analysed using Chi-square test with help of Excel 2007 and SPSS-16 statistical software. Results Different pattern of toxicities were seen with FAC and AT regimens. Anaemia, thrombocytopenia, stomatitis, hyperpigmentation, photosensitivity and diarrhoea were more common with patients receiving FAC regimen. Leucopenia, peripheral neuropathy, myalgia, arthralgia, vomiting and injection site reactions were more common in AT regimen. Both FAC and AT regimens gave 100% clinical response. Conclusion FAC and AT regimens are equally efficacious but have different toxicity profiles. Patient’s predisposition to toxicities may govern the selection of a particular regime. PMID:26870703

A dimensional approach to measuring anxiety for DSM-5.

PubMed

Lebeau, Richard T; Glenn, Daniel E; Hanover, Lauren N; Beesdo-Baum, Katja; Wittchen, Hans-Ulrich; Craske, Michelle G

2012-12-01

In preparation for DSM-5's planned inclusion of dimensional assessments of psychopathology as a complement to traditional categorical diagnoses, we developed brief self-rated scales for anxiety disorders that are consistent in content and structure. In the present paper, we discuss the creation of the scales and examine their psychometric properties and clinical sensitivity. Phase One assessed psychometric properties of the initial versions of the scales in a large non-clinical sample (n = 702). Phase Two assessed the psychometric properties of revised versions of the scales, including test-retest reliability, in a non-clinical sample (n = 57). Phase Three examined the scales' psychometric properties and relationship with clinician ratings of disorder severity in a clinical sample (n = 48). The scales demonstrated internal consistency (α = 0.85-0.92), convergent validity (r(s)  = 0.39-0.69), and test-retest reliability in the non-clinical samples (ICC = 0.51-0.81). In the clinical sample, the scales demonstrated significantly higher total scores than in the non-clinical sample (Cohen's d = 0.72-1.50) and moderate to high correlations with clinician ratings of disorder severity (r = 0.43-0.82) Although further evaluation and refinement of the scales (particularly the specific phobia and agoraphobia scales) is needed, the results provide preliminary support for the use of these scales in DSM-5 and thus take an important step toward the integration of standardized dimensional measurement into the diagnosis of anxiety disorders. Copyright © 2012 American Psychiatric Association. All rights reserved.

The Value of Electronic Medical Record Implementation in Mental Health Care: A Case Study

PubMed Central

Fischler, Ilan; Stuckey, Melanie I; Klassen, Philip E; Chen, John

2017-01-01

Background Electronic medical records (EMR) have been implemented in many organizations to improve the quality of care. Evidence supporting the value added to a recovery-oriented mental health facility is lacking. Objective The goal of this project was to implement and customize a fully integrated EMR system in a specialized, recovery-oriented mental health care facility. This evaluation examined the outcomes of quality improvement initiatives driven by the EMR to determine the value that the EMR brought to the organization. Methods The setting was a tertiary-level mental health facility in Ontario, Canada. Clinical informatics and decision support worked closely with point-of-care staff to develop workflows and documentation tools in the EMR. The primary initiatives were implementation of modules for closed loop medication administration, collaborative plan of care, clinical practice guidelines for schizophrenia, restraint minimization, the infection prevention and control surveillance status board, drug of abuse screening, and business intelligence. Results Medication and patient scan rates have been greater than 95% since April 2014, mitigating the adverse effects of medication errors. Specifically, between April 2014 and March 2015, only 1 moderately severe and 0 severe adverse drug events occurred. The number of restraint incidents decreased 19.7%, which resulted in cost savings of more than Can $1.4 million (US $1.0 million) over 2 years. Implementation of clinical practice guidelines for schizophrenia increased adherence to evidence-based practices, standardizing care across the facility. Improved infection prevention and control surveillance reduced the number of outbreak days from 47 in the year preceding implementation of the status board to 7 days in the year following. Decision support to encourage preferential use of the cost-effective drug of abuse screen when clinically indicated resulted in organizational cost savings. Conclusions EMR implementation allowed Ontario Shores Centre for Mental Health Sciences to use data analytics to identify and select appropriate quality improvement initiatives, supporting patient-centered, recovery-oriented practices and providing value at the clinical, organizational, and societal levels. PMID:28057607

Cost-Effectiveness of HIV Screening in STD Clinics, Emergency Departments, and Inpatient Units: A Model-Based Analysis

PubMed Central

Prabhu, Vimalanand S.; Farnham, Paul G.; Hutchinson, Angela B.; Soorapanth, Sada; Heffelfinger, James D.; Golden, Matthew R.; Brooks, John T.; Rimland, David; Sansom, Stephanie L.

2011-01-01

Background Identifying and treating persons with human immunodeficiency virus (HIV) infection early in their disease stage is considered an effective means of reducing the impact of the disease. We compared the cost-effectiveness of HIV screening in three settings, sexually transmitted disease (STD) clinics serving men who have sex with men, hospital emergency departments (EDs), settings where patients are likely to be diagnosed early, and inpatient diagnosis based on clinical manifestations. Methods and Findings We developed the Progression and Transmission of HIV/AIDS model, a health state transition model that tracks index patients and their infected partners from HIV infection to death. We used program characteristics for each setting to compare the incremental cost per quality-adjusted life year gained from early versus late diagnosis and treatment. We ran the model for 10,000 index patients for each setting, examining alternative scenarios, excluding and including transmission to partners, and assuming HAART was initiated at a CD4 count of either 350 or 500 cells/µL. Screening in STD clinics and EDs was cost-effective compared with diagnosing inpatients, even when including only the benefits to the index patients. Screening patients in STD clinics, who have less-advanced disease, was cost-effective compared with ED screening when treatment with HAART was initiated at a CD4 count of 500 cells/µL. When the benefits of reduced transmission to partners from early diagnosis were included, screening in settings with less-advanced disease stages was cost-saving compared with screening later in the course of infection. The study was limited by a small number of observations on CD4 count at diagnosis and by including transmission only to first generation partners of the index patients. Conclusions HIV prevention efforts can be advanced by screening in settings where patients present with less-advanced stages of HIV infection and by initiating treatment with HAART earlier in the course of infection. PMID:21625489

Misdiagnosis of cerebellar hemorrhage - features of 'pseudo-gastroenteritis' clinical presentations to the ED and primary care.

PubMed

Lee, Seung-Han; Stanton, Victoria; Rothman, Richard E; Crain, Barbara; Wityk, Robert; Wang, Zheyu; Newman-Toker, David E

2017-03-01

Early-stage cerebellar hemorrhage can present with nausea or vomiting absent other neurological symptoms or signs, potentially leading to an incorrect diagnosis of gastroenteritis. We sought to determine the frequency of gastroenteritis-like presentations and delayed or missed diagnoses among patients with spontaneous cerebellar hemorrhage. This is a retrospective, case-control analysis of atraumatic, primary cerebellar hemorrhages derived from a systematic search of surgical pathology and autopsy databases at two large urban, academic medical centers from 1984 to 2006. Hospital visit and clinical symptom data were abstracted from electronic and paper medical records for included patients. Delayed or missed diagnoses were defined as those at least one previous visit for relevant clinical symptoms in the 7 days prior to the correct diagnosis being confirmed. Among 254 records captured by our search filter, we identified 35 cases of pathologically proven primary cerebellar hemorrhage. Four patients (11%) were misdiagnosed initially - three with "gastroenteritis" and one with "hypertension". In this small sample, misdiagnosed patients presented more often with normal mental state (100% vs. 35%, p=0.07) and nausea/vomiting (100% vs. 58%, p=0.22). Although patients deteriorated clinically after the initial misdiagnosis, and potentially dangerous diagnostic tests and treatment strategies were instituted as a result of misdiagnosis, none of the misdiagnosed patients died or suffered major permanent harms due to diagnostic delay. Our study is limited by the small number of identified cases. Nevertheless, it appears that patients with cerebellar hemorrhages can present with relatively unimpressive clinical findings without obvious neurological manifestations. Such individuals are sometimes misdiagnosed with gastroenteritis or other benign disorders initially, possibly when neurologic examination, particularly gait testing, is omitted or abridged. A careful search for subtle cerebellar signs, including dysarthria, limb ataxia, nystagmus or tandem gait instability, absent in true gastroenteritis cases, could potentially reduce misdiagnosis.

The effect of a chlorhexidine-based surgical lubricant during pelvic examination on the detection of group B Streptococcus.

PubMed

Schwope, Ora I; Chen, Katherine T; Mehta, Isha; Re, Margaret; Rand, Larry

2010-03-01

The objective of the study was to estimate whether surgical lubricant used during pelvic examination alters the detection of group B Streptococcus (GBS). We conducted a prospective cohort study of patients undergoing GBS screening at the prenatal clinics of a New York City public hospital. Two specimens were collected from each patient, before and after a pelvic examination with Surgilube (Fougera and Co, Melville, NY), a bacteriostatic surgical lubricant. Test performance indices using GBS status pre-pelvic examination as the reference were calculated. Over 10 months, 168 patients were enrolled in the study. Twenty of 168 patients (11.9%; 95% confidence interval, 7.4-17.8%) tested GBS positive before the pelvic examination. Of the initial 20 GBS-positive patients, 10 tested GBS positive after the pelvic examination with surgical lubricant. The sensitivity of detecting GBS after the examination with surgical lubricant was 50%. Because pelvic examination with surgical lubricant may decrease the detection of GBS, obstetric practitioners should collect GBS screening cultures before the use of surgical lubricant. Copyright 2010 Mosby, Inc. All rights reserved.

Local oxygen therapy for treating acute necrotizing periodontal disease in smokers.

PubMed

Gaggl, Alexander J; Rainer, Heribert; Grund, Eveline; Chiari, Friedrich M

2006-01-01

The main aim of treatment for acute necrotizing periodontal disease is fast and effective reduction of anaerobic destructive microorganisms to avoid periodontal damage. The effect of adjunctive local oxygen therapy in the treatment of necrotizing periodontal disease was examined in this study. Thirty patients with acute necrotizing periodontal disease were treated with the systemic antibiotics amoxicillin, clavulanic acid, and metronidazole. In 15 out of 30 patients, adjunctive local oxygen therapy was administered. The patients were followed from the first to 10th day of treatment with clinical and bacteriological examinations. The clinical examination registered gingival bleeding, periodontal probing depth, and attachment loss; to follow up microbiological colonization of the periodontal sulcus, five representative bacteria were registered by a semiquantitative DNA polymerase chain reaction test. In both groups of patients, colonization with Prevotella intermedia, Tannerella forsythensis, and Treponema denticola was initially positive. None of these three microorganisms were completely eradicated in any of the patients in the group without oxygen therapy within the first 10 days of treatment. In the group with adjunctive oxygen therapy, all patients either showed a reduction in or complete eradication of the microorganisms, resulting in more rapid clinical restitution with less periodontal destruction. Adjunctive oxygen therapy results in early eradication of pathogenic anaerobic microorganisms in cases of acute necrotizing periodontal disease. The damage to periodontal tissue is reduced.

PET scanning in head and neck oncology: a review.

PubMed

McGuirt, W F; Greven, K; Williams, D; Keyes, J W; Watson, N; Cappellari, J O; Geisinger, K R

1998-05-01

The objective of this study was to review and describe the usage of fluorine-labeled deoxyglucose (FDG) and positron emission tomography (PET) in the diagnosis and management of head and neck cancer. Several prospective series,-including 159 newly diagnosed and previously untreated and 23 previously irradiated head and neck squamous cell carcinoma patients initially seen at the Wake Forest University Medical Center and evaluated by clinical examination, conventional computed tomography/ magnetic resonance imaging (CT/MRI) scans, PET scans, and histopathologic studies,-were reviewed and the findings summarized for comparison of the correct differentiation of primary and metastatic cancers and for postirradiation tumor clearance in a subsegment of those cases. Positron emission tomography scanning using a fluorine-labeled deoxyglucose (FDG) radiotracer proved as reliable as conventional scanning for primary and metastatic tumor identification. Compared with clinical examination, PET was better for identification of nodal metastatic tumors but poorer for small primary tumors. For previously irradiated patients treated at least 4 months before the test, PET scanning was clearly superior to clinical examination and conventional imaging in differentiating tumor recurrence from soft-tissue irradiation effects. Fluorine-labeled deoxyglucose-PET scanning is comparable to conventional imaging of head and neck cancers in detecting primary and metastatic carcinoma. Lack of anatomic detail remains its major drawback. Currently, its greatest role is in the evaluation of the postradiotherapy patient.

[Support Team for Investigator-Initiated Clinical Research].

PubMed

Fujii, Hisako

2017-07-01

Investigator-initiated clinical research is that in which investigators plan and carry out their own clinical research in academia. For large-scale clinical research, a team should be organized and implemented. This team should include investigators and supporting staff, who will promote smooth research performance by fulfilling their respective roles. The supporting staff should include project managers, administrative personnel, billing personnel, data managers, and clinical research coordinators. In this article, I will present the current status of clinical research support and introduce the research organization of the Dominantly Inherited Alzheimer Network (DIAN) study, an investigator-initiated international clinical research study, with particular emphasis on the role of the project management staff and clinical research coordinators.

Relevance of adjacent joint imaging in the evaluation of ankle fractures.

PubMed

Antoci, Valentin; Patel, Shaun P; Weaver, Michael J; Kwon, John Y

2016-10-01

Routinely obtaining adjacent joint radiographs when evaluating patients with ankle fractures may be of limited clinical utility and an unnecessary burden, particularly in the absence of clinical suspicion for concomitant injuries. One thousand, three hundred and seventy patients who sustained ankle fractures over a 5-year period presenting to two level 1 trauma centers were identified. Medical records were retrospectively reviewed for demographics, physical examination findings, and radiographic information. Analyses included descriptive statistics along with sensitivity and predictive value calculations for the presence of adjacent joint fracture. Adjacent joint imaging (n=1045 radiographs) of either the knee or foot was obtained in 873 patients (63.7%). Of those, 75/761 patients (9.9%) demonstrated additional fractures proximal to the ankle joint, most commonly of the proximal fibula. Twenty-two of 284 (7.7%) demonstrated additional fractures distal to the ankle joint, most commonly of the metatarsals. Tenderness to palpation demonstrated sensitivities of 0.92 and 0.77 and positive predictive values of 0.94 and 0.89 for the presence of proximal and distal fractures, respectively. Additionally, 19/22 (86.4%) of patients sustaining foot fractures had their injury detectable on initial ankle X-rays. Overall, only 5.5% (75/1370) of patients sustained fractures proximal to the ankle and only 0.2% (3/1370) of patients had additional foot fractures not evident on initial ankle X-rays. The addition of adjacent joint imaging for the evaluation of patients sustaining ankle fractures is low yield. As such, patient history, physical examination, and clinical suspicion should direct the need for additional X-rays. Level IV. Copyright © 2016 Elsevier Ltd. All rights reserved.

Diagnosis of Metastasis to the Thyroid Gland: Comparison of Core-Needle Biopsy and Fine-Needle Aspiration.

PubMed

Choi, Sang Hyun; Baek, Jung Hwan; Ha, Eun Ju; Choi, Young Jun; Song, Dong Eun; Kim, Jae Kyun; Chung, Ki-Wook; Kim, Tae Yong; Lee, Jeong Hyun

2016-04-01

Early detection and diagnosis of metastasis to the thyroid gland is important. This study aims to evaluate the clinical value of core-needle biopsy (CNB) by comparing the results of CNB and fine-needle aspiration (FNA) in patients with clinically suspected metastasis to the thyroid gland. Case series with chart review. Tertiary referral practice. Fifty-two thyroid nodules from 52 patients with clinically suspected metastasis to the thyroid gland (mean age, 62.8 years). Of these 52 patients, FNA was initially used in 41 patients and CNB in 20 patients (11 patients as the initial approach and 9 patients after inconclusive FNA results). Ultrasound features of metastasis to the thyroid gland were evaluated. The diagnostic performance, repeated diagnostic examination rate, and diagnostic surgery rate were evaluated for FNA and CNB. Among these 52 patients, 46 were diagnosed with thyroid metastases and 6 were diagnosed with primary thyroid cancer. Common ultrasound features were an ovoid to round shape (58.7%), ill-defined margin (56.5%), hypoechogenicity (65.2%), and no calcifications (87.0%). Core-needle biopsy achieved a significantly higher sensitivity than FNA (100.0% vs 58.6%, P = .008) without any false-negative results. Both the repeated diagnostic examination rate and the diagnostic surgery rate were significantly lower in CNB than in FNA (5.0% vs 46.3%, P = .001, and 5.0% vs 34.1%, P = .013, respectively). In cases of known rare primary malignancy, nontypical ultrasound features of primary thyroid malignancy, and need for an additional immunohistochemical analysis, CNB may be primarily considered. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2016.

Clinical and MRI outcome of cervical spine lesions in children with juvenile idiopathic arthritis treated with anti-TNFα drugs early in disease course.

PubMed

Ključevšek, Damjana; Emeršič, Nina; Toplak, Nataša; Avčin, Tadej

2017-05-15

The purpose of the study was to evaluate the clinical and magnetic resonance imaging (MRI) outcome of cervical spine arthritis in children with juvenile idiopathic arthritis (JIA), who received anti-TNFα early in the course of cervical spine arthritis. Medical charts and imaging of JIA patients with cervical spine involvement were reviewed in this retrospective study. Data, including age at disease onset, JIA type, disease activity, treatment and clinical outcome were collected. Initial and followup MRI examinations of cervical spine were performed according to the hospital protocol to evaluate the presence of inflammation and potential chronic/late changes. Fifteen JIA patients with MRI proved cervical spine inflammation (11 girls, 4 boys, median age 6.3y) were included in the study: 9 had polyarthritis, 3 extended oligoarthritis, 2 persistent oligoarthritis and 1 juvenile psoriatic arthritis. All children were initially treated with high-dose steroids and methotrexate. In addition, 11 patients were treated with anti-TNFα drug within 3 months, and 3 patients within 7 months of cervical spine involvement confirmed by MRI. Mean observation time was 2.9y, mean duration of anti-TNFα treatment was 2.2y. Last MRI showed no active inflammation in 12/15 children, allowing to stop biological treatment in 3 patients, and in 3/15 significant reduction of inflammation. Mild chronic changes were found on MRI in 3 children. Early treatment with anti-TNFα drugs resulted in significantly reduced inflammation or complete remission of cervical spine arthritis proved by MRI, and prevented the development of serious chronic/late changes. Repeated MRI examinations are suggested in the follow-up of JIA patients with cervical spine arthritis.

The dialysis orders objective structured clinical examination (OSCE): a formative assessment for nephrology fellows

PubMed Central

Prince, Lisa K; Campbell, Ruth C; Gao, Sam W; Kendrick, Jessica; Lebrun, Christopher J; Little, Dustin J; Mahoney, David L; Maursetter, Laura A; Nee, Robert; Saddler, Mark; Watson, Maura A

2018-01-01

Abstract Background Few quantitative nephrology-specific simulations assess fellow competency. We describe the development and initial validation of a formative objective structured clinical examination (OSCE) assessing fellow competence in ordering acute dialysis. Methods The three test scenarios were acute continuous renal replacement therapy, chronic dialysis initiation in moderate uremia and acute dialysis in end-stage renal disease-associated hyperkalemia. The test committee included five academic nephrologists and four clinically practicing nephrologists outside of academia. There were 49 test items (58 points). A passing score was 46/58 points. No item had median relevance less than ‘important’. The content validity index was 0.91. Ninety-five percent of positive-point items were easy–medium difficulty. Preliminary validation was by 10 board-certified volunteers, not test committee members, a median of 3.5 years from graduation. The mean score was 49 [95% confidence interval (CI) 46–51], κ = 0.68 (95% CI 0.59–0.77), Cronbach’s α = 0.84. Results We subsequently administered the test to 25 fellows. The mean score was 44 (95% CI 43–45); 36% passed the test. Fellows scored significantly less than validators (P < 0.001). Of evidence-based questions, 72% were answered correctly by validators and 54% by fellows (P = 0.018). Fellows and validators scored least well on the acute hyperkalemia question. In self-assessing proficiency, 71% of fellows surveyed agreed or strongly agreed that the OSCE was useful. Conclusions The OSCE may be used to formatively assess fellow proficiency in three common areas of acute dialysis practice. Further validation studies are in progress. PMID:29644053

Predictors of a variceal source among patients presenting with upper gastrointestinal bleeding.

PubMed

Alharbi, Ahmad; Almadi, Majid; Barkun, Alan; Martel, Myriam

2012-04-01

Patients with upper gastrointestinal bleeding (UGIB) require an early, tailored approach best guided by knowledge of the bleeding lesion, especially a variceal versus a nonvariceal source. To identify, by investigating a large national registry, variables that would be predictive of a variceal origin of UGIB using clinical parameters before endoscopic evaluation. A retrospective study was conducted in 21 Canadian hospitals during the period from January 2004 until the end of May 2005. Consecutive charts for hospitalized patients with a primary or secondary discharge diagnosis of UGIB were reviewed. Data regarding demographics, including historical, physical examination, initial laboratory investigations, endoscopic and pharmacological therapies administered, as well as clinical outcomes, were collected. Multivariable logistic regression modelling was performed to identify clinical predictors of a variceal source of bleeding. The patient population included 2020 patients (mean [± SD] age 66.3±16.4 years; 38.4% female). Overall, 215 (10.6%) were found to be bleeding from upper gastrointestinal varices. Among 26 patient characteristics, variables predicting a variceal source of bleeding included history of liver disease (OR 6.36 [95% CI 3.59 to 11.3]), excessive alcohol use (OR 2.28 [95% CI 1.37 to 3.77]), hematemesis (OR 2.65 [95% CI 1.61 to 4.36]), hematochezia (OR 3.02 [95% CI 1.46 to 6.22]) and stigmata of chronic liver disease (OR 2.49 [95% CI 1.46 to 4.25]). Patients treated with antithrombotic therapy were more likely to experience other causes of hemorrhage (OR 0.44 [95% CI 0.35 to 0.78]). Presenting historical and physical examination data, and initial laboratory tests carry significant predictive ability in discriminating variceal versus nonvariceal sources of bleeding.

Predictors of Seizure Threshold in Right Unilateral Ultrabrief Electroconvulsive Therapy: Role of Concomitant Medications and Anaesthesia Used.

PubMed

Gálvez, Verònica; Hadzi-Pavlovic, Dusan; Smith, Deidre; Loo, Colleen K

2015-01-01

An individualized approach to maximize electroconvulsive therapy (ECT) efficacy and minimize cognitive side effects is to treat patients relative to their seizure threshold (ST). However, although Right Unilateral-Ultrabrief (0.3 ms) (RUL-UB) ECT is increasingly used in clinical settings as an effective form of ECT with minimal cognitive effects, there is sparse data regarding predictors of ST. To analyze the relationship between ST and clinical and demographic factors in a sample of patients treated with RUL-UB ECT. Clinical, demographic and ECT data from 179 patients in ECT research studies were examined. Seizure threshold was titrated at the first ECT session. ECT was performed with a Thymatron(®) or Mecta(®) device, with thiopentone (2.5-5 mg/kg) or propofol (1-2 mg/kg) anaesthesia. Medications taken at the time of ST titration were documented. The association between ST and candidate predictor variables was examined with regression analysis. Multiple regression analyses showed that 34% of the variance in ST (P < 0.001) could be predicted. Older age (R(2) = 0.194, P < 0.001), propofol (vs thiopentone) (R(2) = 0.029, P ≤ 0.01) and higher anaesthetic dose (mg in propofol equivalents) (R(2) = 0.029, P < 0.05) were found to be predictors of higher initial ST. Treatment with lithium (R(2) = 0.043, P < 0.01) and study site (R(2) = 0.019, P < 0.05) significantly predicted lower initial ST. Empirical titration is recommended for accurate determination of ST in patients receiving RUL-UB ECT. Novel findings of this study are that propofol anaesthesia resulted in higher ST than thiopentone and concomitant treatment with lithium treatment lowered ST. Copyright © 2015 Elsevier Inc. All rights reserved.

Diagnostic choices and clinical outcomes in octogenarians and nonagenarians with iron-deficiency anemia in the Netherlands.

PubMed

Hamaker, Marije E; Acampo, Tessa; Remijn, Jasper A; van Tuyl, Sebastiaan A C; Pronk, Apollo; van der Zaag, Edwin S; Paling, Heleen A; Smorenburg, Carolien H; de Rooij, Sophia E; van Munster, Barbara C

2013-04-01

To evaluate current clinical practice for octogenarians with iron-deficiency anemia (IDA) by assessing referral patterns, diagnostic choices, clinical consequences of omission of endoscopy, and risks and benefits of IDA-related surgery. Chart review. A regional hospital-based laboratory in the Netherlands between January 2008 and December 2010. All individuals aged 80 and older with newly ascertained IDA. IDA was defined as a hemoglobin level of 11.1 g/dL or less and a ferritin level of 25 μg/L or less. Four hundred seventy-one participants were newly diagnosed with IDA during the study period (median age 85.4), 276 of whom (59%) did not undergo any diagnostic procedures for IDA. A cause of anemia was identified during the initial examination in 50% of the 205 investigated participants, including nine (4%) upper and 37 (18%) lower gastrointestinal malignancies. Another 24 malignancies were identified during follow-up, of which 16 were in the gastrointestinal tract, primarily in participants for whom the initial diagnostic examination was limited or omitted. Perioperative mortality was 15% in individuals with colon cancer. Median survival for participants with colon cancer was 2.2 years, and the survival benefit of surgery over supportive care was not apparent until 1.3 years after ascertainment of IDA. The omission of endoscopy for IDA and the omission of surgery for colon cancer occur frequently in octogenarians and seem appropriate in the presence of significant comorbidity and in cases in which there is limited life expectancy. Further research is needed to determine which baseline factors should guide decision-making to optimize treatment outcomes and quality of life. © 2013, Copyright the Authors Journal compilation © 2013, The American Geriatrics Society.

Brief Report: Developmental Trajectories of Adaptive Behavior in Children and Adolescents with ASD.

PubMed

Meyer, Allison T; Powell, Patrick S; Butera, Nicole; Klinger, Mark R; Klinger, Laura G

2018-03-17

Research suggests that individuals with autism spectrum disorder (ASD) have significant difficulties with adaptive behavior skills including daily living and functional communication skills. Few studies have examined the developmental trajectory of adaptive behavior across childhood and adolescence. The present study examined longitudinal trajectories of adaptive behavior in a community-based clinic sample of 186 individuals with ASD. The overall pattern indicated an initial increase in adaptive behavior during early childhood followed by a plateau in skills during adolescence for individuals of all IQ groups. Given the importance of adaptive behavior for employment and quality of life, this study emphasizes the importance of targeting adaptive behavior during adolescence to insure continued gains.

Alberta CancerBridges development of a care plan evaluation measure

PubMed Central

Giese-Davis, J.; Sisler, J.; Zhong, L.; Brandelli, Y.; McCormick, J.L.; Railton, C.; Shirt, L.; Lau, H.; Hao, D.; Chobanuk, J.; Walley, B.; Joy, A.A.; Taylor, A.; Carlson, L.

2018-01-01

Background No standardized measures specifically assess cancer survivors’ and healthcare providers’ experience of Survivor Care Plans (scps). We sought to develop two care plan evaluation (cpe) measures, one for survivors (cpe-s) and one for healthcare providers (cpe-p), examine initial psychometric qualities in Alberta, and assess generalizability in Manitoba, Canada. Methods We developed the initial measures using convenience samples of breast (n = 35) and head and neck (n = 18) survivors who received scps at the end of active cancer-centre treatment. After assessing Alberta’s scp concordance with Institute of Medicine (iom) recommendations using a published coding scheme, we examined psychometric qualities for the cpe-s and cpe-p. We examined generalizability in Manitoba, Canada, with colorectal survivors discharged to primary care providers for follow-up (n = 75). Results We demonstrated acceptable internal consistency for the cpe-s and cpe-p subscales and total score after eliminating one item per subscale for cpe-s, two for cpe-p, resulting in revised scales with four 7-item and 6-item subscales, respectively. Subscale scores correlated highly indicating that for each measure the total score may be the most reliable and valid. We provide initial cpe-s discriminant, convergent, and predictive validity using the total score. Using the Manitoba sample, initial psychometrics similarly indicated good generalizability across differences in tumour groups, scp, and location. Conclusions We recommend the revised cpe-s and cpe-p for further use and development. Studies documenting the creation and standardization of scp evaluations are few, and we recommend further development of patient experience measures to improve both clinical practice and the specificity of research questions. PMID:29507497

Coincidental diagnosis of tuberculous lymphadenitis: a case report.

PubMed

Garg, A K; Chaudhary, A; Tewari, R K; Bariar, L M; Agrawal, N

2014-06-01

The aim of this case report was to present a case of multiple calcified tuberculous lymph nodes found on a panoramic radiograph coincidently diagnosed in an endodontic clinic. A detailed discussion on the differential diagnosis of similar such calcification found in the same region is also presented. A 14-year-old girl was referred to our department with the complaint of painless swelling in the left side of the lower jaw. Clinical and radiographical examinations were performed, leading to the initial diagnosis of chronic periapical abscess. The patient's medical history was re-evaluated. Advanced imaging and excisional biopsy were performed in order to confirm the final diagnosis. Regarding the presenting signs and symptoms of bilateral carious mandibular molars, a periapical inflammatory process was considered in the provisional diagnosis. A thorough examination and investigations were suggestive of cervical tuberculous lymphadenitis (scrofula), and the patient underwent excision of the same. The clinician should consider the possibility of chronic granulomatous inflammatory lesions in the differential diagnosis of radiopaque lesions. © 2014 Australian Dental Association.

In vivo Raman spectral pathology of human atherosclerosis and vulnerable plaque

NASA Astrophysics Data System (ADS)

Motz, Jason T.; Fitzmaurice, Maryann; Miller, Arnold; Gandhi, Saumil J.; Haka, Abigail S.; Galindo, Luis; Dasari, Ramachandra R.; Kramer, John R., Jr.; Feld, Michael S.

2006-03-01

The rupture of vulnerable atherosclerotic plaque accounts for the majority of clinically significant acute cardiovascular events. Because stability of these culprit lesions is directly related to chemical and morphological composition, Raman spectroscopy may be a useful technique for their study. Recent developments in optical fiber probe technology have allowed for the real-time in vivo Raman spectroscopic characterization of human atherosclerotic plaque demonstrated in this work. We spectroscopically examine 74 sites during carotid endarterectomy and femoral artery bypass surgeries. Of these, 34 are surgically biopsied and examined histologically. Excellent signal-to-noise ratio spectra are obtained in only 1 s and fit with an established model, demonstrating accurate tissue characterization. We also report the first evidence that Raman spectroscopy has the potential to identify vulnerable plaque, achieving a sensitivity and specificity of 79 and 85%, respectively. These initial findings indicate that Raman spectroscopy has the potential to be a clinically relevant diagnostic tool for studying cardiovascular disease.

Spinal stenosis presenting as "the postpolio syndrome". Review of four cases.

PubMed

LaBan, M M; Sanitate, S S; Taylor, R S

1993-12-01

The diagnosis of postpolio syndrome is based primarily on a thorough history supported by both clinical and laboratory examination. Similarly, the presence of an occult spinal stenosis may be suspected initially by a history of progressive lumbar or cervical radicular pain, as well as concomitant extremity weakness and/or myelopathic signs. Appropriate electrodiagnostic examinations, including somatosensory spinal-evoked potentials and electroneuromyography, as well as imaging studies, computer-assisted tomography scan, magnetic resonance imaging and/or myelography are all useful in confirming the clinical diagnosis of either cervical spinal stenosis or lumbar spinal stenosis in patients who also may have had a history of poliomyelitis. Four patients (three men and one woman) previously diagnosed as having postpolio syndrome were referred with predominate complaints of spinal and extremity pain as well as associated motor weakness. It was subsequently recognized that these patients, ranging in age from 45-65 yr, were actually presenting with symptomatic spinal stenosis. It was discovered that two patients had cervical spinal stenosis; the other two had lumbar spinal stenosis.