Individual treatment selection for patients with posttraumatic stress disorder.

PubMed

Deisenhofer, Anne-Katharina; Delgadillo, Jaime; Rubel, Julian A; Böhnke, Jan R; Zimmermann, Dirk; Schwartz, Brian; Lutz, Wolfgang

2018-04-16

Trauma-focused cognitive behavioral therapy (Tf-CBT) and eye movement desensitization and reprocessing (EMDR) are two highly effective treatment options for posttraumatic stress disorder (PTSD). Yet, on an individual level, PTSD patients vary substantially in treatment response. The aim of the paper is to test the application of a treatment selection method based on a personalized advantage index (PAI). The study used clinical data for patients accessing treatment for PTSD in a primary care mental health service in the north of England. PTSD patients received either EMDR (N = 75) or Tf-CBT (N = 242). The Patient Health Questionnaire (PHQ-9) was used as an outcome measure for depressive symptoms associated with PTSD. Variables predicting differential treatment response were identified using an automated variable selection approach (genetic algorithm) and afterwards included in regression models, allowing the calculation of each patient's PAI. Age, employment status, gender, and functional impairment were identified as relevant variables for Tf-CBT. For EMDR, baseline depressive symptoms as well as prescribed antidepressant medication were selected as predictor variables. Fifty-six percent of the patients (n = 125) had a PAI equal or higher than one standard deviation. From those patients, 62 (50%) did not receive their model-predicted treatment and could have benefited from a treatment assignment based on the PAI. Using a PAI-based algorithm has the potential to improve clinical decision making and to enhance individual patient outcomes, although further replication is necessary before such an approach can be implemented in prospective studies. © 2018 Wiley Periodicals, Inc.

Identification of precision treatment strategies for relapsed/refractory multiple myeloma by functional drug sensitivity testing.

PubMed

Majumder, Muntasir Mamun; Silvennoinen, Raija; Anttila, Pekka; Tamborero, David; Eldfors, Samuli; Yadav, Bhagwan; Karjalainen, Riikka; Kuusanmäki, Heikki; Lievonen, Juha; Parsons, Alun; Suvela, Minna; Jantunen, Esa; Porkka, Kimmo; Heckman, Caroline A

2017-08-22

Novel agents have increased survival of multiple myeloma (MM) patients, however high-risk and relapsed/refractory patients remain challenging to treat and their outcome is poor. To identify novel therapies and aid treatment selection for MM, we assessed the ex vivo sensitivity of 50 MM patient samples to 308 approved and investigational drugs. With the results we i) classified patients based on their ex vivo drug response profile; ii) identified and matched potential drug candidates to recurrent cytogenetic alterations; and iii) correlated ex vivo drug sensitivity to patient outcome. Based on their drug sensitivity profiles, MM patients were stratified into four distinct subgroups with varied survival outcomes. Patients with progressive disease and poor survival clustered in a drug response group exhibiting high sensitivity to signal transduction inhibitors. Del(17p) positive samples were resistant to most drugs tested with the exception of histone deacetylase and BCL2 inhibitors. Samples positive for t(4;14) were highly sensitive to immunomodulatory drugs, proteasome inhibitors and several targeted drugs. Three patients treated based on the ex vivo results showed good response to the selected treatments. Our results demonstrate that ex vivo drug testing may potentially be applied to optimize treatment selection and achieve therapeutic benefit for relapsed/refractory MM.

CT scans for pulmonary surveillance may be overused in lower-grade sarcoma.

PubMed

Miller, Benjamin J; Carmody Soni, Emily E; Reith, John D; Gibbs, C Parker; Scarborough, Mark T

2012-01-01

Chest CT scans are often used to monitor patients after excision of a sarcoma. Although sensitive, CT scans are more expensive than chest radiographs and are associated with possible health risks from a higher radiation dose. We hypothesized that a program based upon limited CT scans in lower-grade sarcoma could be efficacious and less expensive. We retrospectively assigned patients to a high-risk or low-risk hypothetical protocol. Eighty-three low- or intermediate-grade soft tissue sarcomas met our inclusion criteria. Eight patients had pulmonary metastasis. A protocol based on selective CT scans for high-risk patients would have identified seven out of eight lesions. The incremental cost-effectiveness ratio for routine CT scans was $731,400. A program based upon selective CT scans for higher-risk patients is accurate, spares unnecessary radiation to many patients, and is less expensive.

Therapeutic considerations in special patients.

PubMed

Little, J W; Falace, D A

1984-07-01

Careful attention to patients' histories and their medical problems and consultation with their physicians should provide sound bases for selection of drugs. Antibiotic prophylaxis for patients with cardiovascular disorders is described for American Heart Association standards, but for other indications sound judgment based on the principles of antibiotic prophylaxis must be the rule. Patients with end-stage renal disease and severe liver impairment may be at risk with certain drugs. The most critical time for consideration of use of drugs during pregnancy is the first trimester. However, careful selection of drugs for use during the balance of the term can reduce the risk of harm to the mother and fetus.

Verification of Pharmacogenetics-Based Warfarin Dosing Algorithms in Han-Chinese Patients Undertaking Mechanic Heart Valve Replacement

PubMed Central

Zhao, Li; Chen, Chunxia; Li, Bei; Dong, Li; Guo, Yingqiang; Xiao, Xijun; Zhang, Eryong; Qin, Li

2014-01-01

Objective To study the performance of pharmacogenetics-based warfarin dosing algorithms in the initial and the stable warfarin treatment phases in a cohort of Han-Chinese patients undertaking mechanic heart valve replacement. Methods We searched PubMed, Chinese National Knowledge Infrastructure and Wanfang databases for selecting pharmacogenetics-based warfarin dosing models. Patients with mechanic heart valve replacement were consecutively recruited between March 2012 and July 2012. The predicted warfarin dose of each patient was calculated and compared with the observed initial and stable warfarin doses. The percentage of patients whose predicted dose fell within 20% of their actual therapeutic dose (percentage within 20%), and the mean absolute error (MAE) were utilized to evaluate the predictive accuracy of all the selected algorithms. Results A total of 8 algorithms including Du, Huang, Miao, Wei, Zhang, Lou, Gage, and International Warfarin Pharmacogenetics Consortium (IWPC) model, were tested in 181 patients. The MAE of the Gage, IWPC and 6 Han-Chinese pharmacogenetics-based warfarin dosing algorithms was less than 0.6 mg/day in accuracy and the percentage within 20% exceeded 45% in all of the selected models in both the initial and the stable treatment stages. When patients were stratified according to the warfarin dose range, all of the equations demonstrated better performance in the ideal-dose range (1.88–4.38 mg/day) than the low-dose range (<1.88 mg/day). Among the 8 algorithms compared, the algorithms of Wei, Huang, and Miao showed a lower MAE and higher percentage within 20% in both the initial and the stable warfarin dose prediction and in the low-dose and the ideal-dose ranges. Conclusions All of the selected pharmacogenetics-based warfarin dosing regimens performed similarly in our cohort. However, the algorithms of Wei, Huang, and Miao showed a better potential for warfarin prediction in the initial and the stable treatment phases in Han-Chinese patients undertaking mechanic heart valve replacement. PMID:24728385

Verification of pharmacogenetics-based warfarin dosing algorithms in Han-Chinese patients undertaking mechanic heart valve replacement.

PubMed

Zhao, Li; Chen, Chunxia; Li, Bei; Dong, Li; Guo, Yingqiang; Xiao, Xijun; Zhang, Eryong; Qin, Li

2014-01-01

To study the performance of pharmacogenetics-based warfarin dosing algorithms in the initial and the stable warfarin treatment phases in a cohort of Han-Chinese patients undertaking mechanic heart valve replacement. We searched PubMed, Chinese National Knowledge Infrastructure and Wanfang databases for selecting pharmacogenetics-based warfarin dosing models. Patients with mechanic heart valve replacement were consecutively recruited between March 2012 and July 2012. The predicted warfarin dose of each patient was calculated and compared with the observed initial and stable warfarin doses. The percentage of patients whose predicted dose fell within 20% of their actual therapeutic dose (percentage within 20%), and the mean absolute error (MAE) were utilized to evaluate the predictive accuracy of all the selected algorithms. A total of 8 algorithms including Du, Huang, Miao, Wei, Zhang, Lou, Gage, and International Warfarin Pharmacogenetics Consortium (IWPC) model, were tested in 181 patients. The MAE of the Gage, IWPC and 6 Han-Chinese pharmacogenetics-based warfarin dosing algorithms was less than 0.6 mg/day in accuracy and the percentage within 20% exceeded 45% in all of the selected models in both the initial and the stable treatment stages. When patients were stratified according to the warfarin dose range, all of the equations demonstrated better performance in the ideal-dose range (1.88-4.38 mg/day) than the low-dose range (<1.88 mg/day). Among the 8 algorithms compared, the algorithms of Wei, Huang, and Miao showed a lower MAE and higher percentage within 20% in both the initial and the stable warfarin dose prediction and in the low-dose and the ideal-dose ranges. All of the selected pharmacogenetics-based warfarin dosing regimens performed similarly in our cohort. However, the algorithms of Wei, Huang, and Miao showed a better potential for warfarin prediction in the initial and the stable treatment phases in Han-Chinese patients undertaking mechanic heart valve replacement.

A universal deep learning approach for modeling the flow of patients under different severities.

PubMed

Jiang, Shancheng; Chin, Kwai-Sang; Tsui, Kwok L

2018-02-01

The Accident and Emergency Department (A&ED) is the frontline for providing emergency care in hospitals. Unfortunately, relative A&ED resources have failed to keep up with continuously increasing demand in recent years, which leads to overcrowding in A&ED. Knowing the fluctuation of patient arrival volume in advance is a significant premise to relieve this pressure. Based on this motivation, the objective of this study is to explore an integrated framework with high accuracy for predicting A&ED patient flow under different triage levels, by combining a novel feature selection process with deep neural networks. Administrative data is collected from an actual A&ED and categorized into five groups based on different triage levels. A genetic algorithm (GA)-based feature selection algorithm is improved and implemented as a pre-processing step for this time-series prediction problem, in order to explore key features affecting patient flow. In our improved GA, a fitness-based crossover is proposed to maintain the joint information of multiple features during iterative process, instead of traditional point-based crossover. Deep neural networks (DNN) is employed as the prediction model to utilize their universal adaptability and high flexibility. In the model-training process, the learning algorithm is well-configured based on a parallel stochastic gradient descent algorithm. Two effective regularization strategies are integrated in one DNN framework to avoid overfitting. All introduced hyper-parameters are optimized efficiently by grid-search in one pass. As for feature selection, our improved GA-based feature selection algorithm has outperformed a typical GA and four state-of-the-art feature selection algorithms (mRMR, SAFS, VIFR, and CFR). As for the prediction accuracy of proposed integrated framework, compared with other frequently used statistical models (GLM, seasonal-ARIMA, ARIMAX, and ANN) and modern machine models (SVM-RBF, SVM-linear, RF, and R-LASSO), the proposed integrated "DNN-I-GA" framework achieves higher prediction accuracy on both MAPE and RMSE metrics in pairwise comparisons. The contribution of our study is two-fold. Theoretically, the traditional GA-based feature selection process is improved to have less hyper-parameters and higher efficiency, and the joint information of multiple features is maintained by fitness-based crossover operator. The universal property of DNN is further enhanced by merging different regularization strategies. Practically, features selected by our improved GA can be used to acquire an underlying relationship between patient flows and input features. Predictive values are significant indicators of patients' demand and can be used by A&ED managers to make resource planning and allocation. High accuracy achieved by the present framework in different cases enhances the reliability of downstream decision makings. Copyright © 2017 Elsevier B.V. All rights reserved.

Use of tailored loading-dose clopidogrel in patients undergoing selected percutaneous coronary intervention based on adenosine diphosphate-mediated platelet aggregation.

PubMed

Meng, Kang; Lü, Shu-Zheng; Zhu, Hua-Gang; Chen, Xin; Ge, Chang-Jiang; Song, Xian-Tao

2010-12-01

Adenosine phosphate-mediated platelet aggregation is a prognostic factor for major adverse cardiac events in patients who have undergone selective percutaneous coronary interventions. This study aimed to assess whether an adjusted loading dose of clopidogrel could more effectively inhibit platelet aggregation in patients undergoing selected percutaneous coronary intervention. A total of 205 patients undergoing selected percutaneous coronary intervention were enrolled in this multicenter, prospective, randomized study. Patients receiving domestic clopidogrel (n = 104) served as the Talcom (Taijia) group; others (n = 101) received Plavix, the Plavix group. Patients received up to 3 additional 300-mg loading doses of clopidogrel to decrease the adenosine phosphate-mediated platelet aggregation index by more than 50% (the primary endpoint) compared with the baseline. The secondary endpoint was major adverse cardiovascular events at 12 months. Compared with the rational loading dosage, the tailored loading dosage better inhibited platelet aggregation based on a > 50% decrease in adenosine phosphate-mediated platelet aggregation (rational loading dosage vs. tailored loading dosage, 48% vs. 73%, P = 0.028). There was no significant difference in the eligible index between the Talcom and Plavix groups (47% vs. 49% at 300 mg; 62% vs. 59% at 600 mg; 74% vs. 72% at 900 mg; P > 0.05) based on a standard adenosine diphosphate-mediated platelet aggregation decrease of > 50%. After 12 months of follow-up, there were no significant differences in major adverse cardiac events (2.5% vs. 2.9%, P = 5.43). No acute or subacute stent thrombosis events occurred. An adjusted loading dose of clopidogrel could have significant effects on antiplatelet aggregation compared with a rational dose, decreasing 1-year major adverse cardiac events in patients undergoing percutaneous coronary interventions based on adenosine phosphate-mediated platelet aggregation with no increase in bleeding.

Improving health care proxy documentation using a web-based interview through a patient portal

PubMed Central

Crotty, Bradley H; Kowaloff, Hollis B; Safran, Charles; Slack, Warner V

2016-01-01

Objective Health care proxy (HCP) documentation is suboptimal. To improve rates of proxy selection and documentation, we sought to develop and evaluate a web-based interview to guide patients in their selection, and to capture their choices in their electronic health record (EHR). Methods We developed and implemented a HCP interview within the patient portal of a large academic health system. We analyzed the experience, together with demographic and clinical factors, of the first 200 patients who used the portal to complete the interview. We invited users to comment about their experience and analyzed their comments using established qualitative methods. Results From January 20, 2015 to March 13, 2015, 139 of the 200 patients who completed the interview submitted their HCP information for their clinician to review in the EHR. These patients had a median age of 57 years (Inter Quartile Range (IQR) 45–67) and most were healthy. The 99 patients who did not previously have HCP information in their EHR were more likely to complete and then submit their information than the 101 patients who previously had a proxy in their health record (odds ratio 2.4, P = .005). Qualitative analysis identified several ways in which the portal-based interview reminded, encouraged, and facilitated patients to complete their HCP. Conclusions Patients found our online interview convenient and helpful in facilitating selection and documentation of an HCP. Our study demonstrates that a web-based interview to collect and share a patient’s HCP information is both feasible and useful. PMID:26568608

[Surgery in portal hypertension. Which patient and which operation?].

PubMed

Mercado, M A; Takahashi, T; Rojas, G; Prado, E; Hernández, J; Tielve, M; Orozco, H

1993-01-01

A prospective trial of a cohort of patients (N = 94) with portal hypertension and history of bleeding was selected for surgery based on strict clinical and laboratory criteria. All of them were treated with portal blood flow preserving procedures. The following selection criteria were used: good cardiopulmonary function without pulmonary hypertension and good liver function (Child-Pugh A). All patients were operated in an elective fashion and the operations performed were: selective shunts (N = 38) (distal splenorenal and splenocaval), low diameter mesocaval shunts (N = 13) and the esophagogastric devascularization with esophageal transection (Sugiura-Futagawa) (N = 43). Patients were selected for each operation according to their anatomical conditions. Sixty-one of the patients were cirrhotics. Operative mortality was 8% and rebleeding was observed in 5% of the cases. Postoperative encephalopathy was seen in seven patients (three selective shunts, two low diameter mesocaval shunts and two devascularizations). In 13 of 62 patients postoperatively evaluated by means of angiography, portal vein thrombosis was shown (seven selective shunts, two low diameter shunts and four devascularizations). Twenty-two patients with preoperative portal vein thrombosis (and treated with a Sugiura-Futagawa operation) were excluded from postoperative angiographic evaluation. Survival (Kaplan-Meier) was 85% at 60 months. Portal blood flow preserving procedures are the treatment of choice for patients with hemorrhagic portal hypertension and good liver function. The kind of operation is selected according to the individual anatomical status of the patient.

Pharmacist's Role in Improving Medication Adherence in Transplant Recipients With Comorbid Psychiatric Disorders.

PubMed

Khorassani, Farah; Tellier, Shannon; Tsapepas, Demetra

2018-01-01

Medication nonadherence rates are high in both the transplant and psychiatric populations. The consequence of medication nonadherence posttransplant is graft rejection and psychiatric decompensation, highlighting the importance of optimizing adherence to medication regimens. Pharmacists may work with transplant patients with psychiatric comorbidity to improve medication adherence through identifying patient-specific barriers and recommending an appropriate intervention. Multiple evidence-based practices for improving nonadherence have been detailed in the transplant and psychiatric population. Medication adherence aids, medication management, patient education, and motivational interviewing are all strategies that may be used to improve adherence. Selecting which interventions to make will be based on the reasons for a patient's nonadherence. Most patients benefit from medication management, patient education, and medication adherence aids. Selection of medication adherence aids may be based on patient demographics, technology literacy, and preference. Motivational interviewing may be considered in patients with intentional nonadherence relating to a lack of insight into their illness or the importance of taking medication. Pharmacists may promote adherence and potentially improve patient outcomes in transplant recipients with comorbid psychiatric disorders through assisting patients with designing a tailored medication adherence plan.

On the feasibility of automatically selecting similar patients in highly individualized radiotherapy dose reconstruction for historic data of pediatric cancer survivors.

PubMed

Virgolin, Marco; van Dijk, Irma W E M; Wiersma, Jan; Ronckers, Cécile M; Witteveen, Cees; Bel, Arjan; Alderliesten, Tanja; Bosman, Peter A N

2018-04-01

The aim of this study is to establish the first step toward a novel and highly individualized three-dimensional (3D) dose distribution reconstruction method, based on CT scans and organ delineations of recently treated patients. Specifically, the feasibility of automatically selecting the CT scan of a recently treated childhood cancer patient who is similar to a given historically treated child who suffered from Wilms' tumor is assessed. A cohort of 37 recently treated children between 2- and 6-yr old are considered. Five potential notions of ground-truth similarity are proposed, each focusing on different anatomical aspects. These notions are automatically computed from CT scans of the abdomen and 3D organ delineations (liver, spleen, spinal cord, external body contour). The first is based on deformable image registration, the second on the Dice similarity coefficient, the third on the Hausdorff distance, the fourth on pairwise organ distances, and the last is computed by means of the overlap volume histogram. The relationship between typically available features of historically treated patients and the proposed ground-truth notions of similarity is studied by adopting state-of-the-art machine learning techniques, including random forest. Also, the feasibility of automatically selecting the most similar patient is assessed by comparing ground-truth rankings of similarity with predicted rankings. Similarities (mainly) based on the external abdomen shape and on the pairwise organ distances are highly correlated (Pearson r p ≥ 0.70) and are successfully modeled with random forests based on historically recorded features (pseudo-R 2 ≥ 0.69). In contrast, similarities based on the shape of internal organs cannot be modeled. For the similarities that random forest can reliably model, an estimation of feature relevance indicates that abdominal diameters and weight are the most important. Experiments on automatically selecting similar patients lead to coarse, yet quite robust results: the most similar patient is retrieved only 22% of the times, however, the error in worst-case scenarios is limited, with the fourth most similar patient being retrieved. Results demonstrate that automatically selecting similar patients is feasible when focusing on the shape of the external abdomen and on the position of internal organs. Moreover, whereas the common practice in phantom-based dose reconstruction is to select a representative phantom using age, height, and weight as discriminant factors for any treatment scenario, our analysis on abdominal tumor treatment for children shows that the most relevant features are weight and the anterior-posterior and left-right abdominal diameters. © 2018 American Association of Physicists in Medicine.

Comparative cardiovascular safety of nonsteroidal anti-inflammatory drugs in patients with hypertension: a population-based cohort study.

PubMed

Dong, Yaa-Hui; Chang, Chia-Hsuin; Wu, Li-Chiu; Hwang, Jing-Shiang; Toh, Sengwee

2018-05-01

Previous studies have suggested that nonsteroidal anti-inflammatory drugs (NSAIDs) may be associated with higher cardiovascular risks. However, few have been active comparison studies that directly assessed the potential differential cardiovascular risk between NSAID classes or across individual NSAIDs. We compared the risk of major cardiovascular events between cyclooxygenase 2 (COX-2)-selective and nonselective NSAIDs in patients with hypertension. We conducted a cohort study of patients with hypertension who initiated COX-2-selective or nonselective NSAIDs in a population-based Taiwanese database. The outcomes included hospitalization for the following major cardiovascular events: ischaemic stroke, acute myocardial infarction, congestive heart failure, transient ischaemic attack, unstable angina or coronary revascularization. We followed patients for up to 4 weeks, based on the as-treated principle. We used inverse probability weighting to control for baseline and time-varying covariates, and estimated the on-treatment hazard ratios (HRs) and 95% conservative confidence interval (CIs). We identified 2749 eligible COX-2-selective NSAID users and 52 880 eligible nonselective NSAID users. The HR of major cardiovascular events comparing COX-2-selective with nonselective NSAIDs after adjusting for baseline and time-varying covariates was 1.07 (95% CI 0.65, 1.74). We did not observe a differential risk when comparing celecoxib to diclofenac (HR 1.17; 95% CI 0.61, 2.25), ibuprofen (HR 1.36; 95% CI 0.58, 3.18) or naproxen (HR 0.75; 95% CI 0.23, 2.44). There was an increased risk with COX-2-selective NSAIDs, however, when comparing COX-2-selective NSAIDs with mefenamic acid (HR 2.11; 95% CI 1.09, 4.09). Our results provide important information about the comparative cardiovascular safety of NSAIDs in patients with hypertension. © 2018 The British Pharmacological Society.

Molecular image-directed biopsies: improving clinical biopsy selection in patients with multiple tumors

NASA Astrophysics Data System (ADS)

Harmon, Stephanie A.; Tuite, Michael J.; Jeraj, Robert

2016-10-01

Site selection for image-guided biopsies in patients with multiple lesions is typically based on clinical feasibility and physician preference. This study outlines the development of a selection algorithm that, in addition to clinical requirements, incorporates quantitative imaging data for automatic identification of candidate lesions for biopsy. The algorithm is designed to rank potential targets by maximizing a lesion-specific score, incorporating various criteria separated into two categories: (1) physician-feasibility category including physician-preferred lesion location and absolute volume scores, and (2) imaging-based category including various modality and application-specific metrics. This platform was benchmarked in two clinical scenarios, a pre-treatment setting and response-based setting using imaging from metastatic prostate cancer patients with high disease burden (multiple lesions) undergoing conventional treatment and receiving whole-body [18F]NaF PET/CT scans pre- and mid-treatment. Targeting of metastatic lesions was robust to different weighting ratios and candidacy for biopsy was physician confirmed. Lesion ranked as top targets for biopsy remained so for all patients in pre-treatment and post-treatment biopsy selection after sensitivity testing was completed for physician-biased or imaging-biased scenarios. After identifying candidates, biopsy feasibility was evaluated by a physician and confirmed for 90% (32/36) of high-ranking lesions, of which all top choices were confirmed. The remaining cases represented lesions with high anatomical difficulty for targeting, such as proximity to sciatic nerve. This newly developed selection method was successfully used to quantitatively identify candidate lesions for biopsies in patients with multiple lesions. In a prospective study, we were able to successfully plan, develop, and implement this technique for the selection of a pre-treatment biopsy location.

Improving health care proxy documentation using a web-based interview through a patient portal.

PubMed

Bajracharya, Adarsha S; Crotty, Bradley H; Kowaloff, Hollis B; Safran, Charles; Slack, Warner V

2016-05-01

Health care proxy (HCP) documentation is suboptimal. To improve rates of proxy selection and documentation, we sought to develop and evaluate a web-based interview to guide patients in their selection, and to capture their choices in their electronic health record (EHR). We developed and implemented a HCP interview within the patient portal of a large academic health system. We analyzed the experience, together with demographic and clinical factors, of the first 200 patients who used the portal to complete the interview. We invited users to comment about their experience and analyzed their comments using established qualitative methods. From January 20, 2015 to March 13, 2015, 139 of the 200 patients who completed the interview submitted their HCP information for their clinician to review in the EHR. These patients had a median age of 57 years (Inter Quartile Range (IQR) 45-67) and most were healthy. The 99 patients who did not previously have HCP information in their EHR were more likely to complete and then submit their information than the 101 patients who previously had a proxy in their health record (odds ratio 2.4, P = .005). Qualitative analysis identified several ways in which the portal-based interview reminded, encouraged, and facilitated patients to complete their HCP. Patients found our online interview convenient and helpful in facilitating selection and documentation of an HCP. Our study demonstrates that a web-based interview to collect and share a patient's HCP information is both feasible and useful. © The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Selection of a cardiac surgery provider in the managed care era.

PubMed

Shahian, D M; Yip, W; Westcott, G; Jacobson, J

2000-11-01

Many health planners promote the use of competition to contain cost and improve quality of care. Using a standard econometric model, we examined the evidence for "value-based" cardiac surgery provider selection in eastern Massachusetts, where there is significant competition and managed care penetration. McFadden's conditional logit model was used to study cardiac surgery provider selection among 6952 patients and eight metropolitan Boston hospitals in 1997. Hospital predictor variables included beds, cardiac surgery case volume, objective clinical and financial performance, reputation (percent out-of-state referrals, cardiac residency program), distance from patient's home to hospital, and historical referral patterns. Subgroup analyses were performed for each major payer category. Distance from patient's home to hospital (odds ratio 0.90; P =.000) and the historical referral pattern from each patient's hometown (z = 45.305; P =.000) were important predictors in all models. A cardiac surgery residency enhanced the probability of selection (odds ratio 5.25; P =.000), as did percent out-of-state referrals (odds ratio 1.10; P =.001). Higher mortality rates were associated with decreased probability of selection (odds ratio 0.51; P =.027), but higher length of stay was paradoxically associated with greater probability (odds ratio 1.72; P =.000). Total hospital costs were irrelevant (odds ratio 1.00; P =.179). When analyzed by payer subgroup, Medicare patients appeared to select hospitals with both low mortality (odds ratio 0.43; P =.176) and short length of stay (odds ratio 0.76; P =.213), although the results did not achieve statistical significance. The commercial managed care subgroup exhibited the least "value-based" behavior. The odds ratio for length of stay was the highest of any group (odds ratio = 2.589; P =.000) and there was a subset of hospitals for which higher mortality was actually associated with greater likelihood of selection. The observable determinants of cardiac surgery provider selection are related to hospital reputation, historical referral patterns, and patient proximity, not objective clinical or cost performance. The paradoxic behavior of commercial managed care probably results from unobserved choice factors that are not primarily based on objective provider performance.

The effect of morphometric atlas selection on multi-atlas-based automatic brachial plexus segmentation.

PubMed

Van de Velde, Joris; Wouters, Johan; Vercauteren, Tom; De Gersem, Werner; Achten, Eric; De Neve, Wilfried; Van Hoof, Tom

2015-12-23

The present study aimed to measure the effect of a morphometric atlas selection strategy on the accuracy of multi-atlas-based BP autosegmentation using the commercially available software package ADMIRE® and to determine the optimal number of selected atlases to use. Autosegmentation accuracy was measured by comparing all generated automatic BP segmentations with anatomically validated gold standard segmentations that were developed using cadavers. Twelve cadaver computed tomography (CT) atlases were included in the study. One atlas was selected as a patient in ADMIRE®, and multi-atlas-based BP autosegmentation was first performed with a group of morphometrically preselected atlases. In this group, the atlases were selected on the basis of similarity in the shoulder protraction position with the patient. The number of selected atlases used started at two and increased up to eight. Subsequently, a group of randomly chosen, non-selected atlases were taken. In this second group, every possible combination of 2 to 8 random atlases was used for multi-atlas-based BP autosegmentation. For both groups, the average Dice similarity coefficient (DSC), Jaccard index (JI) and Inclusion index (INI) were calculated, measuring the similarity of the generated automatic BP segmentations and the gold standard segmentation. Similarity indices of both groups were compared using an independent sample t-test, and the optimal number of selected atlases was investigated using an equivalence trial. For each number of atlases, average similarity indices of the morphometrically selected atlas group were significantly higher than the random group (p < 0,05). In this study, the highest similarity indices were achieved using multi-atlas autosegmentation with 6 selected atlases (average DSC = 0,598; average JI = 0,434; average INI = 0,733). Morphometric atlas selection on the basis of the protraction position of the patient significantly improves multi-atlas-based BP autosegmentation accuracy. In this study, the optimal number of selected atlases used was six, but for definitive conclusions about the optimal number of atlases and to improve the autosegmentation accuracy for clinical use, more atlases need to be included.

The role of chemoprevention by selective cyclooxygenase-2 inhibitors in colorectal cancer patients - a population-based study

PubMed Central

2012-01-01

Background There are limited population-based studies focusing on the chemopreventive effects of selective cyclooxygenase-2 (COX-2) inhibitors against colorectal cancer. The purpose of this study is to assess the trends and dose–response effects of various medication possession ratios (MPR) of selective COX-2 inhibitor used for chemoprevention of colorectal cancer. Methods A population-based case–control study was conducted using the Taiwan Health Insurance Research Database (NHIRD). The study comprised 21,460 colorectal cancer patients and 79,331 controls. The conditional logistic regression was applied to estimate the odds ratios (ORs) for COX-2 inhibitors used for several durations (5 years, 3 years, 1 year, 6 months and 3 months) prior to the index date. Results In patients receiving selective COX-2 inhibitors, the OR was 0.51 (95% CI=0.29~0.90, p=0.021) for an estimated 5-year period in developing colorectal cancer. ORs showing significant protection effects were found in 10% of MPRs for 5-year, 3-year, and 1-year usage. Risk reduction against colorectal cancer by selective COX-2 inhibitors was observed as early as 6 months after usage. Conclusion Our results indicate that selective COX-2 inhibitors may reduce the development of colorectal cancer by at least 10% based on the MPRs evaluated. Given the limited number of clinical reports from general populations, our results add to the knowledge of chemopreventive effects of selective COX-2 inhibitors against cancer in individuals at no increased risk of colorectal cancer. PMID:23217168

An intelligent classifier for prognosis of cardiac resynchronization therapy based on speckle-tracking echocardiograms.

PubMed

Chao, Pei-Kuang; Wang, Chun-Li; Chan, Hsiao-Lung

2012-03-01

Predicting response after cardiac resynchronization therapy (CRT) has been a challenge of cardiologists. About 30% of selected patients based on the standard selection criteria for CRT do not show response after receiving the treatment. This study is aimed to build an intelligent classifier to assist in identifying potential CRT responders by speckle-tracking radial strain based on echocardiograms. The echocardiograms analyzed were acquired before CRT from 26 patients who have received CRT. Sequential forward selection was performed on the parameters obtained by peak-strain timing and phase space reconstruction on speckle-tracking radial strain to find an optimal set of features for creating intelligent classifiers. Support vector machine (SVM) with a linear, quadratic, and polynominal kernel were tested to build classifiers to identify potential responders and non-responders for CRT by selected features. Based on random sub-sampling validation, the best classification performance is correct rate about 95% with 96-97% sensitivity and 93-94% specificity achieved by applying SVM with a quadratic kernel on a set of 3 parameters. The selected 3 parameters contain both indexes extracted by peak-strain timing and phase space reconstruction. An intelligent classifier with an averaged correct rate, sensitivity and specificity above 90% for assisting in identifying CRT responders is built by speckle-tracking radial strain. The classifier can be applied to provide objective suggestion for patient selection of CRT. Copyright © 2011 Elsevier B.V. All rights reserved.

Rule-Based Categorization Deficits in Focal Basal Ganglia Lesion and Parkinson’s Disease Patients

PubMed Central

Ell, Shawn W.; Weinstein, Andrea; Ivry, Richard B.

2010-01-01

Patients with basal ganglia (BG) pathology are consistently found to be impaired on rule-based category learning tasks in which learning is thought to depend upon the use of an explicit, hypothesis-guided strategy. The factors that influence this impairment remain unclear. Moreover, it remains unknown if the impairments observed in patients with degenerative disorders such as Parkinson's disease (PD) are also observed in those with focal BG lesions. In the present study, we tested patients with either focal BG lesions or PD on two categorization tasks that varied in terms of their demands on selective attention and working memory. Individuals with focal BG lesions were impaired on the task in which working-memory demand was high and performed similarly to healthy controls on the task in which selective-attention demand was high. In contrast, individuals with PD were impaired on both tasks, and accuracy rates did not differ between on- and off-medication states for a subset of patients who were also tested after abstaining from dopaminergic medication. Quantitative, model-based analyses attributed the performance deficit for both groups in the task with high working-memory demand to the utilization of suboptimal strategies, whereas the PD-specific impairment on the task with high selective-attention demand was driven by the inconsistent use of an optimal strategy. These data suggest that the demands on selective attention and working memory affect the presence of impairment in patients with focal BG lesions and the nature of the impairment in patients with PD. PMID:20600196

Improving the quality of the NHS workforce through values and competency-based selection.

PubMed

McGuire, Clare; Rankin, Jean; Matthews, Lynsay; Cerinus, Marie; Zaveri, Swati

2016-07-01

Robust selection processes are essential to ensure the best and most appropriate candidates for nursing, midwifery and allied health professional (NMAHP) positions are appointed, and subsequently enhance patient care. This article reports on a study that explored interviewers' and interviewees' experiences of using values and competency-based interview (VCBI) methods for NMAHPs. Results suggest that this resource could have a positive effect on the quality of the NMAHP workforce, and therefore on patient care. This method of selection could be used in other practice areas in health care, and refinement of the resource should focus on supporting interview panels to develop their VCBI skills and experience.

A Protocol-Based Decision for Choosing a Proper Surgical Treatment Option for Carotid Artery Stenosis.

PubMed

Jang, E-Wook; Chung, Joonho; Seo, Kwon-Duk; Suh, Sang Hyun; Kim, Yong Bae; Lee, Kyung-Yul

2015-06-01

There are two established surgical treatment options for carotid artery stenosis. Carotid endarterectomy (CEA) has been accepted as a gold standard for surgical treatment while carotid artery stenting (CAS) has recently become an alternative option. Each treatment option has advantages and disadvantages for the treatment outcomes. We propose a protocol for selection of a proper surgical treatment option for carotid artery stenosis. A total of 192 published articles on management of carotid artery stenosis were reviewed. Preoperatively considerable factors which had been repeatedly noted in those articles for the risk/benefits of CEA or CAS were selected. According to those factors, a protocol with four categories was established. CEA or CAS is indicated when the patient has a symptomatic stenosis ≥ 50%, or when the patient has an asymptomatic stenosis ≥ 80%. Each treatment option has absolute indications and favorable indications. Each absolute indication is scored with three points, and each favorable indication, one point. Based on the highest scores, a proper treatment option (CEA or CAS) is selected. We have been treating patients according to this protocol and evaluating the outcomes of our protocol-based decision because this protocol might be helpful in assessment of risk/benefit for selection of a proper surgical treatment option in patients with carotid artery stenosis.

The Selection of Death Place Among Patients Receiving Hospital-Based Palliative Care Service in Taiwan.

PubMed

Ho, Ching-Sung

2018-05-01

To analyze the selection of a place to die and its related factors in patients who received hospice shared care service in Taiwan. This study included patients who received hospice shared care service in a metropolitan hospital as the research participants. A total of 172 questionnaires were collected, and 146 of them were used as valid samples for analysis. This study applied the multivariate logistic regression analysis to assess the significance of independent variables associated with the selection of place of death. The results revealed that 52.6% of the patients select hospital as the place to end their life, while 43.8% of them select their home as the place of death. Furthermore, younger adult patients (<65), those who with a higher educational level (≥10 years), and those with a clear cognizance of the disease progression tended to select hospital as the place to spend their last days. The research disclosed that more patients with the hospice shared care service prefer hospital to their home as the place to die. In order to provide end-of-life care for patients with low cost and appropriate treatment, it is important to understand the related sociodemographic factors and the need of the patients to provide well-designed hospice/specialist palliative care regimen.

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

Peressutti, D; Schipaanboord, B; Kadir, T

Purpose: To investigate the effectiveness of atlas selection methods for improving atlas-based auto-contouring in radiotherapy planning. Methods: 275 H&N clinically delineated cases were employed as an atlas database from which atlases would be selected. A further 40 previously contoured cases were used as test patients against which atlas selection could be performed and evaluated. 26 variations of selection methods proposed in the literature and used in commercial systems were investigated. Atlas selection methods comprised either global or local image similarity measures, computed after rigid or deformable registration, combined with direct atlas search or with an intermediate template image. Workflow Boxmore » (Mirada-Medical, Oxford, UK) was used for all auto-contouring. Results on brain, brainstem, parotids and spinal cord were compared to random selection, a fixed set of 10 “good” atlases, and optimal selection by an “oracle” with knowledge of the ground truth. The Dice score and the average ranking with respect to the “oracle” were employed to assess the performance of the top 10 atlases selected by each method. Results: The fixed set of “good” atlases outperformed all of the atlas-patient image similarity-based selection methods (mean Dice 0.715 c.f. 0.603 to 0.677). In general, methods based on exhaustive comparison of local similarity measures showed better average Dice scores (0.658 to 0.677) compared to the use of either template image (0.655 to 0.672) or global similarity measures (0.603 to 0.666). The performance of image-based selection methods was found to be only slightly better than a random (0.645). Dice scores given relate to the left parotid, but similar results patterns were observed for all organs. Conclusion: Intuitively, atlas selection based on the patient CT is expected to improve auto-contouring performance. However, it was found that published approaches performed marginally better than random and use of a fixed set of representative atlases showed favourable performance. This research was funded via InnovateUK Grant 600277 as part of Eurostars Grant E!9297. DP,BS,MG,TK are employees of Mirada Medical Ltd.« less

The effect of community-based support services on clinical efficacy and health-related quality of life in HIV/AIDS patients in resource-limited settings in sub-Saharan Africa.

PubMed

Kabore, Inoussa; Bloem, Jeanette; Etheredge, Gina; Obiero, Walter; Wanless, Sebastian; Doykos, Patricia; Ntsekhe, Pearl; Mtshali, Nomantshali; Afrikaner, Eric; Sayed, Rauf; Bostwelelo, John; Hani, Andiswa; Moshabesha, Tiisetso; Kalaka, Agnes; Mameja, Jerry; Zwane, Nompumelelo; Shongwe, Nomvuyo; Mtshali, Phangisile; Mohr, Beryl; Smuts, Archie; Tiam, Appolinaire

2010-09-01

Antiretroviral therapy (ART) for HIV/AIDS in developing countries has been rapidly scaled up through directed public and private resources. Data on the efficacy of ART in developing countries are limited, as are operational research studies to determine the effect of selected nonmedical supportive care services on health outcomes in patients receiving ART. We report here on an investigation of the delivery of medical care combined with community-based supportive services for patients with HIV/AIDS in four resource-limited settings in sub-Saharan Africa, carried out between 2005 and 2007. The clinical and health-related quality of life (HRQOL) efficacy of ART combined with community support services was studied in a cohort of 377 HIV-infected patients followed for 18 months, in community-based clinics through patient interviews, clinical evaluations, and questionnaires. Patients exposed to community-based supportive services experienced a more rapid and greater overall increase in CD4 cell counts than unexposed patients. They also had higher levels of adherence, attributed primarily to exposure to home-based care services. In addition, patients receiving home-based care and/or food support services showed greater improvements in selected health-related QOL indicators. This report discusses the feasibility of effective ART in a large number of patients in resource-limited settings and the added value of concomitant community-based supportive care services.

[Selection of patients for transcatheter aortic valve implantation].

PubMed

Tron, Christophe; Godin, Matthieu; Litzler, Pierre-Yves; Bauer, Fabrice; Caudron, Jérome; Dacher, Jean-Nicolas; Borz, Bogdan; Canville, Alexandre; Kurtz, Baptiste; Bessou, Jean-Paul; Cribier, Alain; Eltchaninoff, Hélène

2012-06-01

A good selection of patients is a crucial step before transcatheter aortic valve implantation (TAVI) in order to select the good indications and choose the access route. TAVI should be considered only in patients with symptomatic severe aortic stenosis and either contraindication or high surgical risk. Indication for TAVI should be discussed in a multidisciplinary team meeting. Echocardiography and/or CT scan are mandatory to evaluate the aortic annulus size and select the good prosthesis size. The possibility of transfemoral implantation is evaluated by angiography and CT scan, and based on the arterial diameters, but also on the presence of tortuosities and arterial calcifications. Copyright © 2012 Elsevier Masson SAS. All rights reserved.

Evidence-based outcomes for mesh-based surgery for pelvic organ prolapse.

PubMed

Mettu, Jayadev R; Colaco, Marc; Badlani, Gopal H

2014-07-01

In light of all the recent controversy regarding the use of synthetic mesh for pelvic organ prolapse, we did a retrospective review of the evidence-based outcomes and complications for its use. A total of 18 of the most recent studies in the last 5 years were selected. Studies selected were prospective randomized or quasi-randomized controlled trials that included surgical operations for pelvic organ prolapse for this review. Additionally, Cochrane review and meta-analysis of outcomes and complication were also analyzed. In terms of outcomes, the definition of successful surgery is currently being debated. Synthetic mesh provides superior anatomical and subjective cure rates compared with native tissue repair. Success rates varied greatly depending on the nature of prolapse and surgical approach. Furthermore, recurrence rates for mesh-based surgery are significantly lower than that for native tissue repair. The main unique complication of mesh is exposure and was reported in a mean of 11.4% of patients, with 6.8% of patients requiring surgical partial excision of mesh. Mesh significantly improves anatomical outcomes with sacrocolpopexy and vaginal repair. Mesh does create the unique complication which can be reduced with training and proper patient selection. Further development of better materials is vital rather than reverting to tissue-based repair. Ultimately, the decision to use mesh should be based upon a patient's personal goals and preferences after an informed conversation with her physician.

Plan selection strategy for rectum cancer patients: An interobserver study to assess clinical feasibility.

PubMed

de Jong, Rianne; Lutkenhaus, Lotte; van Wieringen, Niek; Visser, Jorrit; Wiersma, Jan; Crama, Koen; Geijsen, Debby; Bel, Arjan

2016-08-01

In radiotherapy for rectum cancer, the target volume is highly deformable. An adaptive plan selection strategy can mitigate the effect of these variations. The purpose of this study was to evaluate the feasibility of an adaptive strategy by assessing the interobserver variation in CBCT-based plan selection. Eleven patients with rectum cancer, treated with a non-adaptive strategy, were selected. Five CBCT scans were available per patient. To simulate the plan selection strategy, per patient three PTVs were created by varying the anterior upper mesorectum margin. For each CBCT scan, twenty observers selected the smallest PTV that encompassed the target volume. After this initial baseline measurement, the gold standard was determined during a consensus meeting, followed by a second measurement one month later. Differences between both measurements were assessed using the Wilcoxon signed-rank test. In the baseline measurement, the concordance with the gold standard was 69% (range: 60-82%), which improved to 75% (range: 60-87%) in the second measurement (p=0.01). For the second measurement, 10% of plan selections were smaller than the gold standard. With a plan selection consistency between observers of 75%, a plan selection strategy for rectum cancer patients is feasible. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Parameter Optimization for Selected Correlation Analysis of Intracranial Pathophysiology.

PubMed

Faltermeier, Rupert; Proescholdt, Martin A; Bele, Sylvia; Brawanski, Alexander

2015-01-01

Recently we proposed a mathematical tool set, called selected correlation analysis, that reliably detects positive and negative correlations between arterial blood pressure (ABP) and intracranial pressure (ICP). Such correlations are associated with severe impairment of the cerebral autoregulation and intracranial compliance, as predicted by a mathematical model. The time resolved selected correlation analysis is based on a windowing technique combined with Fourier-based coherence calculations and therefore depends on several parameters. For real time application of this method at an ICU it is inevitable to adjust this mathematical tool for high sensitivity and distinct reliability. In this study, we will introduce a method to optimize the parameters of the selected correlation analysis by correlating an index, called selected correlation positive (SCP), with the outcome of the patients represented by the Glasgow Outcome Scale (GOS). For that purpose, the data of twenty-five patients were used to calculate the SCP value for each patient and multitude of feasible parameter sets of the selected correlation analysis. It could be shown that an optimized set of parameters is able to improve the sensitivity of the method by a factor greater than four in comparison to our first analyses.

Parameter Optimization for Selected Correlation Analysis of Intracranial Pathophysiology

PubMed Central

Faltermeier, Rupert; Proescholdt, Martin A.; Bele, Sylvia; Brawanski, Alexander

2015-01-01

Recently we proposed a mathematical tool set, called selected correlation analysis, that reliably detects positive and negative correlations between arterial blood pressure (ABP) and intracranial pressure (ICP). Such correlations are associated with severe impairment of the cerebral autoregulation and intracranial compliance, as predicted by a mathematical model. The time resolved selected correlation analysis is based on a windowing technique combined with Fourier-based coherence calculations and therefore depends on several parameters. For real time application of this method at an ICU it is inevitable to adjust this mathematical tool for high sensitivity and distinct reliability. In this study, we will introduce a method to optimize the parameters of the selected correlation analysis by correlating an index, called selected correlation positive (SCP), with the outcome of the patients represented by the Glasgow Outcome Scale (GOS). For that purpose, the data of twenty-five patients were used to calculate the SCP value for each patient and multitude of feasible parameter sets of the selected correlation analysis. It could be shown that an optimized set of parameters is able to improve the sensitivity of the method by a factor greater than four in comparison to our first analyses. PMID:26693250

Frontotemporal Dementia Selectively Impairs Transitive Reasoning About Familiar Spatial Environments

PubMed Central

Vartanian, Oshin; Goel, Vinod; Tierney, Michael; Huey, Edward D.; Grafman, Jordan

2010-01-01

Although patients with frontotemporal dementia (FTD) are known to exhibit a wide range of cognitive and personality difficulties, some evidence suggests that there may be a degree of selectivity in their reasoning impairments. Based on a recent review of the neuroimaging literature on reasoning, the authors hypothesized that the presence or absence of familiar content may have a selective impact on the reasoning abilities of patients with FTD. Specifically, the authors predicted that patients with frontalvariant FTD would be more impaired when reasoning about transitive arguments involving familiar spatial environments than when reasoning about identical logical arguments involving unfamiliar spatial environments. As predicted, patients with FTD were less accurate than normal controls only when the content of arguments involved familiar spatial environments. These results indicate a degree of selectivity in the cognitive deficits of this patient population and suggest that the frontal-temporal lobe system may play a necessary role in reasoning about familiar material. PMID:19702415

Measuring perceived video quality of MPEG enhancement by people with impaired vision

PubMed Central

Fullerton, Matthew; Woods, Russell L.; Vera-Diaz, Fuensanta A.; Peli, Eli

2007-01-01

We used a new method to measure the perceived quality of contrast-enhanced motion video. Patients with impaired vision (n = 24) and normally-sighted subjects (n = 6) adjusted the level of MPEG-based enhancement of 8 videos (4 minutes each) drawn from 4 categories. They selected the level of enhancement that provided the preferred view of the videos, using a reducing-step-size staircase procedure. Most patients made consistent selections of the preferred level of enhancement, indicating an appreciation of and a perceived benefit from the MPEG-based enhancement. The selections varied between patients and were correlated with letter contrast sensitivity, but the selections were not affected by training, experience or video category. We measured just noticeable differences (JNDs) directly for videos, and mapped the image manipulation (enhancement in our case) onto an approximately linear perceptual space. These tools and approaches will be of value in other evaluations of the image quality of motion video manipulations. PMID:18059909

Treatment selection in a randomized clinical trial via covariate-specific treatment effect curves.

PubMed

Ma, Yunbei; Zhou, Xiao-Hua

2017-02-01

For time-to-event data in a randomized clinical trial, we proposed two new methods for selecting an optimal treatment for a patient based on the covariate-specific treatment effect curve, which is used to represent the clinical utility of a predictive biomarker. To select an optimal treatment for a patient with a specific biomarker value, we proposed pointwise confidence intervals for each covariate-specific treatment effect curve and the difference between covariate-specific treatment effect curves of two treatments. Furthermore, to select an optimal treatment for a future biomarker-defined subpopulation of patients, we proposed confidence bands for each covariate-specific treatment effect curve and the difference between each pair of covariate-specific treatment effect curve over a fixed interval of biomarker values. We constructed the confidence bands based on a resampling technique. We also conducted simulation studies to evaluate finite-sample properties of the proposed estimation methods. Finally, we illustrated the application of the proposed method in a real-world data set.

Selecting the best haploidentical donor.

PubMed

McCurdy, Shannon R; Fuchs, Ephraim J

2016-10-01

The substantial evidence of the safety of human leukocyte antigen (HLA)-haploidentical (haplo) blood or marrow transplantation (BMT) has led to its increasing utilization. When prioritizing HLA-matched grafts, patients frequently have few or no donors from whom to choose. However, a given patient may have multiple suitable haplo donors. Therefore factors other than HLA-match become critical for selecting the best donor. We recommend a donor selection algorithm based on the donor-specific antibodies, ABO match, donor age, donor sex, and cytomegalovirus (CMV) serostatus match. Despite provocative initial evidence, further studies are warranted to determine whether there is any benefit to selecting a haplo donor based on the number of HLA-mismatches, natural killer cell alloreactivity, or the presence of non-inherited maternal HLA antigens. Copyright © 2016 Elsevier Inc. All rights reserved.

Development of a decision aid to inform patients' and families' renal replacement therapy selection decisions.

PubMed

Ameling, Jessica M; Auguste, Priscilla; Ephraim, Patti L; Lewis-Boyer, LaPricia; DePasquale, Nicole; Greer, Raquel C; Crews, Deidra C; Powe, Neil R; Rabb, Hamid; Boulware, L Ebony

2012-12-01

Few educational resources have been developed to inform patients' renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients' treatment and support patients' decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in "stages." For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals' testimonials regarding various considerations that might influence patients' and families' treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values.

Understanding Patient Experience Using Internet-based Email Surveys: A Feasibility Study at Mount Sinai Hospital.

PubMed

Morgan, Matthew; Lau, Davina; Jivraj, Tanaz; Principi, Tania; Dietrich, Sandra; Bell, Chaim M

2015-01-01

Email is becoming a widely accepted communication tool in healthcare settings. This study sought to test the feasibility of Internet-based email surveys of patient experience in the ambulatory setting. We conducted a study of email Internet-based surveys sent to patients in selected ambulatory clinics at Mount Sinai Hospital in Toronto, Canada. Our findings suggest that email links to Internet surveys are a feasible, timely and efficient method to solicit patient feedback about their experience. Further research is required to optimally leverage Internet-based email surveys as a tool to better understand the patient experience.

Responder definition of the Multiple Sclerosis Impact Scale physical impact subscale for patients with physical worsening

PubMed Central

Wyrwich, Kathleen W; Guo, Shien; Medori, Rossella; Altincatal, Arman; Wagner, Linda; Elkins, Jacob

2014-01-01

Background: The 29-item Multiple Sclerosis Impact Scale (MSIS-29) was developed to examine the impact of multiple sclerosis (MS) on physical and psychological functioning from a patient’s perspective. Objective: To determine the responder definition (RD) of the MSIS-29 physical impact subscale (PHYS) in a group of patients with relapsing–remitting MS (RRMS) participating in a clinical trial. Methods: Data from the SELECT trial comparing daclizumab high-yield process with placebo in patients with RRMS were used. Physical function was evaluated in SELECT using three patient-reported outcomes measures and the Expanded Disability Status Scale (EDSS). Anchor- and distribution-based methods were used to identify an RD for the MSIS-29. Results: Results across the anchor-based approach suggested MSIS-29 PHYS RD values of 6.91 (mean), 7.14 (median) and 7.50 (mode). Distribution-based RD estimates ranged from 6.24 to 10.40. An RD of 7.50 was selected as the most appropriate threshold for physical worsening based on corresponding changes in the EDSS (primary anchor of interest). Conclusion: These findings indicate that a ≥7.50 point worsening on the MSIS-29 PHYS is a reasonable and practical threshold for identifying patients with RRMS who have experienced a clinically significant change in the physical impact of MS. PMID:24740371

The modified Stroop paradigm as a measure of selective attention towards pain-related information in patients with chronic low back pain.

PubMed

Roelofs, Jeffrey; Peters, Madelon L; Vlaeyen, Johan W S

2003-06-01

The present study assessed, by means of a modified Stroop paradigm, whether highly fearful patients with chronic low back pain pay selective attention to words related to movement and injury. Two groups of patients (High Fear and Low Fear) were included based on their scores on the Tampa Scale of Kinesiophobia (TSK), a measure of fear of movement or (re)injury. A control group was recruited by means of advertisement in a local newspaper. Repeated-measures analysis of variance was conducted to examine whether highly fearful pain patients pay more selective attention to movement and injury words, compared to patients with low pain-related fear and controls. The results from the present study do not support the proposition that highly fearful patients with chronic low back pain selectively pay attention to words related to injury and movement. Limitations of the modified Stroop paradigm are discussed as well as the need for the application of alternative methods such as the dot-probe paradigm.

Selection Criteria for Patients With Chronic Ankle Instability in Controlled Research: A Position Statement of the International Ankle Consortium

PubMed Central

Gribble, Phillip A.; Delahunt, Eamonn; Bleakley, Christopher M.; Caulfield, Brian; Docherty, Carrie L.; Fong, Daniel Tik-Pui; Fourchet, François; Hertel, Jay; Hiller, Claire E.; Kaminski, Thomas W.; McKeon, Patrick O.; Refshauge, Kathryn M.; van der Wees, Philip; Vicenzino, William; Wikstrom, Erik A.

2014-01-01

ABSTRACT While research on chronic ankle instability (CAI) and awareness of its impact on society and health care systems has grown substantially in the last 2 decades, the inconsistency in participant or patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalize this evidence to the target patient population. Therefore, there is a need to provide standards for patient or participant selection criteria in research focused on CAI with justifications using the best available evidence. The International Ankle Consortium provides this position paper to present and discuss an endorsed set of selection criteria for patients with CAI based on the best available evidence to be used in future research and study designs. These recommendations will enhance the validity of research conducted in this clinical population with the end goal of bringing the research evidence to the clinician and patient. PMID:24377963

CRISPR-Cas9-Based Genome Editing of Human Induced Pluripotent Stem Cells.

PubMed

Giacalone, Joseph C; Sharma, Tasneem P; Burnight, Erin R; Fingert, John F; Mullins, Robert F; Stone, Edwin M; Tucker, Budd A

2018-02-28

Human induced pluripotent stem cells (hiPSCs) are the ideal cell source for autologous cell replacement. However, for patients with Mendelian diseases, genetic correction of the original disease-causing mutation is likely required prior to cellular differentiation and transplantation. The emergence of the CRISPR-Cas9 system has revolutionized the field of genome editing. By introducing inexpensive reagents that are relatively straightforward to design and validate, it is now possible to correct genetic variants or insert desired sequences at any location within the genome. CRISPR-based genome editing of patient-specific iPSCs shows great promise for future autologous cell replacement therapies. One caveat, however, is that hiPSCs are notoriously difficult to transfect, and optimized experimental design considerations are often necessary. This unit describes design strategies and methods for efficient CRISPR-based genome editing of patient- specific iPSCs. Additionally, it details a flexible approach that utilizes positive selection to generate clones with a desired genomic modification, Cre-lox recombination to remove the integrated selection cassette, and negative selection to eliminate residual hiPSCs with intact selection cassettes. © 2018 by John Wiley & Sons, Inc. Copyright © 2018 John Wiley & Sons, Inc.

High-throughput sequencing enhanced phage display enables the identification of patient-specific epitope motifs in serum.

PubMed

Christiansen, Anders; Kringelum, Jens V; Hansen, Christian S; Bøgh, Katrine L; Sullivan, Eric; Patel, Jigar; Rigby, Neil M; Eiwegger, Thomas; Szépfalusi, Zsolt; de Masi, Federico; Nielsen, Morten; Lund, Ole; Dufva, Martin

2015-08-06

Phage display is a prominent screening technique with a multitude of applications including therapeutic antibody development and mapping of antigen epitopes. In this study, phages were selected based on their interaction with patient serum and exhaustively characterised by high-throughput sequencing. A bioinformatics approach was developed in order to identify peptide motifs of interest based on clustering and contrasting to control samples. Comparison of patient and control samples confirmed a major issue in phage display, namely the selection of unspecific peptides. The potential of the bioinformatic approach was demonstrated by identifying epitopes of a prominent peanut allergen, Ara h 1, in sera from patients with severe peanut allergy. The identified epitopes were confirmed by high-density peptide micro-arrays. The present study demonstrates that high-throughput sequencing can empower phage display by (i) enabling the analysis of complex biological samples, (ii) circumventing the traditional laborious picking and functional testing of individual phage clones and (iii) reducing the number of selection rounds.

Accounting for patient size in the optimization of dose and image quality of pelvis cone beam CT protocols on the Varian OBI system.

PubMed

Wood, Tim J; Moore, Craig S; Horsfield, Carl J; Saunderson, John R; Beavis, Andrew W

2015-01-01

The purpose of this study was to develop size-based radiotherapy kilovoltage cone beam CT (CBCT) protocols for the pelvis. Image noise was measured in an elliptical phantom of varying size for a range of exposure factors. Based on a previously defined "small pelvis" reference patient and CBCT protocol, appropriate exposure factors for small, medium, large and extra-large patients were derived which approximate the image noise behaviour observed on a Philips CT scanner (Philips Medical Systems, Best, Netherlands) with automatic exposure control (AEC). Selection criteria, based on maximum tube current-time product per rotation selected during the radiotherapy treatment planning scan, were derived based on an audit of patient size. It has been demonstrated that 110 kVp yields acceptable image noise for reduced patient dose in pelvic CBCT scans of small, medium and large patients, when compared with manufacturer's default settings (125 kVp). Conversely, extra-large patients require increased exposure factors to give acceptable images. 57% of patients in the local population now receive much lower radiation doses, whereas 13% require higher doses (but now yield acceptable images). The implementation of size-based exposure protocols has significantly reduced radiation dose to the majority of patients with no negative impact on image quality. Increased doses are required on the largest patients to give adequate image quality. The development of size-based CBCT protocols that use the planning CT scan (with AEC) to determine which protocol is appropriate ensures adequate image quality whilst minimizing patient radiation dose.

A group sequential adaptive treatment assignment design for proof of concept and dose selection in headache trials.

PubMed

Hall, David B; Meier, Ulrich; Diener, Hans-Cristoph

2005-06-01

The trial objective was to test whether a new mechanism of action would effectively treat migraine headaches and to select a dose range for further investigation. The motivation for a group sequential, adaptive, placebo-controlled trial design was (1) limited information about where across the range of seven doses to focus attention, (2) a need to limit sample size for a complicated inpatient treatment and (3) a desire to reduce exposure of patients to ineffective treatment. A design based on group sequential and up and down designs was developed and operational characteristics were explored by trial simulation. The primary outcome was headache response at 2 h after treatment. Groups of four treated and two placebo patients were assigned to one dose. Adaptive dose selection was based on response rates of 60% seen with other migraine treatments. If more than 60% of treated patients responded, then the next dose was the next lower dose; otherwise, the dose was increased. A stopping rule of at least five groups at the target dose and at least four groups at that dose with more than 60% response was developed to ensure that a selected dose would be statistically significantly (p=0.05) superior to placebo. Simulations indicated good characteristics in terms of control of type 1 error, sufficient power, modest expected sample size and modest bias in estimation. The trial design is attractive for phase 2 clinical trials when response is acute and simple, ideally binary, placebo comparator is required, and patient accrual is relatively slow allowing for the collection and processing of results as a basis for the adaptive assignment of patients to dose groups. The acute migraine trial based on this design was successful in both proof of concept and dose range selection.

Towards collaborative filtering recommender systems for tailored health communications.

PubMed

Marlin, Benjamin M; Adams, Roy J; Sadasivam, Rajani; Houston, Thomas K

2013-01-01

The goal of computer tailored health communications (CTHC) is to promote healthy behaviors by sending messages tailored to individual patients. Current CTHC systems collect baseline patient "profiles" and then use expert-written, rule-based systems to target messages to subsets of patients. Our main interest in this work is the study of collaborative filtering-based CTHC systems that can learn to tailor future message selections to individual patients based explicit feedback about past message selections. This paper reports the results of a study designed to collect explicit feedback (ratings) regarding four aspects of messages from 100 subjects in the smoking cessation support domain. Our results show that most users have positive opinions of most messages and that the ratings for all four aspects of the messages are highly correlated with each other. Finally, we conduct a range of rating prediction experiments comparing several different model variations. Our results show that predicting future ratings based on each user's past ratings contributes the most to predictive accuracy.

Towards Collaborative Filtering Recommender Systems for Tailored Health Communications

PubMed Central

Marlin, Benjamin M.; Adams, Roy J.; Sadasivam, Rajani; Houston, Thomas K.

2013-01-01

The goal of computer tailored health communications (CTHC) is to promote healthy behaviors by sending messages tailored to individual patients. Current CTHC systems collect baseline patient “profiles” and then use expert-written, rule-based systems to target messages to subsets of patients. Our main interest in this work is the study of collaborative filtering-based CTHC systems that can learn to tailor future message selections to individual patients based explicit feedback about past message selections. This paper reports the results of a study designed to collect explicit feedback (ratings) regarding four aspects of messages from 100 subjects in the smoking cessation support domain. Our results show that most users have positive opinions of most messages and that the ratings for all four aspects of the messages are highly correlated with each other. Finally, we conduct a range of rating prediction experiments comparing several different model variations. Our results show that predicting future ratings based on each user’s past ratings contributes the most to predictive accuracy. PMID:24551430

Fragrance allergy in patients with hand eczema - a clinical study.

PubMed

Heydorn, Siri; Johansen, Jeanne Duus; Andersen, Klaus E; Bruze, Magnus; Svedman, Cecilia; White, Ian R; Basketter, David A; Menné, Torkil

2003-06-01

Fragrance allergy and hand eczema are both common among dermatological patients. Fragrance mix (FM) and its constituents have a recognized relevance to exposure to fine fragrances and cosmetic products. Based on extensive chemical analysis and database search, a new selection of fragrances was established, including 14 known fragrance allergens present in products to which hand exposure would occur. A non-irritating patch-test concentration for some fragrances was established in 212 consecutive patients. 658 consecutive patients presenting with hand eczema were patch tested with the European standard series and the developed selection of fragrances. 67 (10.2%) of the 658 patients had a positive reaction to 1 or more of our selection of fragrance chemicals present in the new selection. The most common reactions to fragrances not included in the FM were to citral, Lyral (hydroxyisohexyl-3-cyclohexene carboxaldehyde) and oxidized l-limonene. A concomitant reaction to the FM identified potential fragrance allergy in less than (1/2) of these patients. Exposure assessment and a statistically significant association between a positive patch test to our selected fragrances and patients' history support the relevance of this selection of fragrances. Those with a positive reaction to our selected fragrances were significantly more likely to have 1 or more positive patch tests in the standard series. This observation is the basis for the hypothesis concerning cross-reactivity and the effect of simultaneous exposure. The study found that fragrance allergy could be a common problem in patients with eczema on the hands.

Event-based Plausibility Immediately Influences On-line Language Comprehension

PubMed Central

Matsuki, Kazunaga; Chow, Tracy; Hare, Mary; Elman, Jeffrey L.; Scheepers, Christoph; McRae, Ken

2011-01-01

In some theories of sentence comprehension, linguistically-relevant lexical knowledge such as selectional restrictions is privileged in terms of the time-course of its access and influence. We examined whether event knowledge computed by combining multiple concepts can rapidly influence language understanding even in the absence of selectional restriction violations. Specifically, we investigated whether instruments can combine with actions to influence comprehension of ensuing patients. Instrument-verb-patient triplets were created in a norming study designed to tap directly into event knowledge. In self-paced reading (Experiment 1), participants were faster to read patient nouns such as hair when they were typical of the instrument-action pair (Donna used the shampoo to wash vs. the hose to wash). Experiment 2 showed that these results were not due to direct instrument-patient relations. Experiment 3 replicated Experiment 1 using eyetracking, with effects of event typicality observed in first fixation and gaze durations on the patient noun. This research demonstrates that conceptual event-based expectations are computed and used rapidly and dynamically during on-line language comprehension. We discuss relationships among plausibility and predictability, as well as their implications. We conclude that selectional restrictions may be best considered as event-based conceptual knowledge, rather than lexical-grammatical knowledge. PMID:21517222

Are outcomes reported in surgical randomized trials patient-important? A systematic review and meta-analysis

PubMed Central

Adie, Sam; Harris, Ian A.; Naylor, Justine M.; Mittal, Rajat

2017-01-01

Background The dangers of using surrogate outcomes are well documented. They may have little or no association with their patient-important correlates, leading to the approval and use of interventions that lack efficacy. We sought to assess whether primary outcomes in surgical randomized controlled trials (RCTs) are more likely to be patient-important outcomes than surrogate or laboratory-based outcomes. Methods We reviewed RCTs assessing an operative intervention published in 2008 and 2009 and indexed in MEDLINE, EMBASE or the Cochrane Central Register of Controlled Trials. After a pilot of the selection criteria, 1 reviewer selected trials and another reviewer checked the selection. We extracted information on outcome characteristics (patient-important, surrogate, or laboratory-based outcome) and whether they were primary or secondary outcomes. We calculated odds ratios (OR) and pooled in random-effects meta-analysis to obtain an overall estimate of the association between patient importance and primary outcome specification. Results In 350 included RCTs, a total of 8258 outcomes were reported (median 18 per trial. The mean proportion (per trial) of patient-important outcomes was 60%, and 66% of trials specified a patient-important primary outcome. The most commonly reported patient-important primary outcomes were morbid events (41%), intervention outcomes (11%), function (11%) and pain (9%). Surrogate and laboratory-based primary outcomes were reported in 33% and 8% of trials, respectively. Patient-important outcomes were not associated with primary outcome status (OR 0.82, 95% confidence interval 0.63–1.1, I2 = 21%). Conclusion A substantial proportion of surgical RCTs specify primary outcomes that are not patient-important. Authors, journals and trial funders should insist that patient-important outcomes are the focus of study. PMID:28234219

Max-AUC Feature Selection in Computer-Aided Detection of Polyps in CT Colonography

PubMed Central

Xu, Jian-Wu; Suzuki, Kenji

2014-01-01

We propose a feature selection method based on a sequential forward floating selection (SFFS) procedure to improve the performance of a classifier in computerized detection of polyps in CT colonography (CTC). The feature selection method is coupled with a nonlinear support vector machine (SVM) classifier. Unlike the conventional linear method based on Wilks' lambda, the proposed method selected the most relevant features that would maximize the area under the receiver operating characteristic curve (AUC), which directly maximizes classification performance, evaluated based on AUC value, in the computer-aided detection (CADe) scheme. We presented two variants of the proposed method with different stopping criteria used in the SFFS procedure. The first variant searched all feature combinations allowed in the SFFS procedure and selected the subsets that maximize the AUC values. The second variant performed a statistical test at each step during the SFFS procedure, and it was terminated if the increase in the AUC value was not statistically significant. The advantage of the second variant is its lower computational cost. To test the performance of the proposed method, we compared it against the popular stepwise feature selection method based on Wilks' lambda for a colonic-polyp database (25 polyps and 2624 nonpolyps). We extracted 75 morphologic, gray-level-based, and texture features from the segmented lesion candidate regions. The two variants of the proposed feature selection method chose 29 and 7 features, respectively. Two SVM classifiers trained with these selected features yielded a 96% by-polyp sensitivity at false-positive (FP) rates of 4.1 and 6.5 per patient, respectively. Experiments showed a significant improvement in the performance of the classifier with the proposed feature selection method over that with the popular stepwise feature selection based on Wilks' lambda that yielded 18.0 FPs per patient at the same sensitivity level. PMID:24608058

Max-AUC feature selection in computer-aided detection of polyps in CT colonography.

PubMed

Xu, Jian-Wu; Suzuki, Kenji

2014-03-01

We propose a feature selection method based on a sequential forward floating selection (SFFS) procedure to improve the performance of a classifier in computerized detection of polyps in CT colonography (CTC). The feature selection method is coupled with a nonlinear support vector machine (SVM) classifier. Unlike the conventional linear method based on Wilks' lambda, the proposed method selected the most relevant features that would maximize the area under the receiver operating characteristic curve (AUC), which directly maximizes classification performance, evaluated based on AUC value, in the computer-aided detection (CADe) scheme. We presented two variants of the proposed method with different stopping criteria used in the SFFS procedure. The first variant searched all feature combinations allowed in the SFFS procedure and selected the subsets that maximize the AUC values. The second variant performed a statistical test at each step during the SFFS procedure, and it was terminated if the increase in the AUC value was not statistically significant. The advantage of the second variant is its lower computational cost. To test the performance of the proposed method, we compared it against the popular stepwise feature selection method based on Wilks' lambda for a colonic-polyp database (25 polyps and 2624 nonpolyps). We extracted 75 morphologic, gray-level-based, and texture features from the segmented lesion candidate regions. The two variants of the proposed feature selection method chose 29 and 7 features, respectively. Two SVM classifiers trained with these selected features yielded a 96% by-polyp sensitivity at false-positive (FP) rates of 4.1 and 6.5 per patient, respectively. Experiments showed a significant improvement in the performance of the classifier with the proposed feature selection method over that with the popular stepwise feature selection based on Wilks' lambda that yielded 18.0 FPs per patient at the same sensitivity level.

Selecting Statistical Quality Control Procedures for Limiting the Impact of Increases in Analytical Random Error on Patient Safety.

PubMed

Yago, Martín

2017-05-01

QC planning based on risk management concepts can reduce the probability of harming patients due to an undetected out-of-control error condition. It does this by selecting appropriate QC procedures to decrease the number of erroneous results reported. The selection can be easily made by using published nomograms for simple QC rules when the out-of-control condition results in increased systematic error. However, increases in random error also occur frequently and are difficult to detect, which can result in erroneously reported patient results. A statistical model was used to construct charts for the 1 ks and X /χ 2 rules. The charts relate the increase in the number of unacceptable patient results reported due to an increase in random error with the capability of the measurement procedure. They thus allow for QC planning based on the risk of patient harm due to the reporting of erroneous results. 1 ks Rules are simple, all-around rules. Their ability to deal with increases in within-run imprecision is minimally affected by the possible presence of significant, stable, between-run imprecision. X /χ 2 rules perform better when the number of controls analyzed during each QC event is increased to improve QC performance. Using nomograms simplifies the selection of statistical QC procedures to limit the number of erroneous patient results reported due to an increase in analytical random error. The selection largely depends on the presence or absence of stable between-run imprecision. © 2017 American Association for Clinical Chemistry.

A Systematic Review of the Factors that Patients Use to Choose their Surgeon.

PubMed

Yahanda, Alexander T; Lafaro, Kelly J; Spolverato, Gaya; Pawlik, Timothy M

2016-01-01

Given surgery's inherent risks, a patient should be able to make the most informed decisions possible in selecting surgical treatment. However, there is little information on what factors patients deem important when choosing a surgeon. We performed a systematic review of the literature focused on how patients select surgical care, focusing on identification of factors that influence patient choice as well as important sources of information used by patients. A search of all available literature on factors associated with choice of surgeon/surgical care, as well as sources of information used by patients before undergoing surgery, was conducted using the MEDLINE/PubMed electronic database. Of the 2315 publications identified, 86 studies met inclusion criteria. Overall, patients draw upon a wide range of factors when choosing surgical care. Surgeon reputation and competency stood out as the most valued professional attributes. Patients also often selected surgeons based on their interpersonal skills. Many patients chose surgical care using hospital, rather than surgeon, characteristics. For these patients, hospital reputation and hospital distance were factors of primary importance. Importantly, most patients relied on word-of-mouth and physician referrals when choosing a surgeon. Patients also expressed interest in quality information on surgeons, indicating that these data would be useful in decision-making. Patients draw upon a myriad of factors when choosing a surgeon and the circumstances surrounding patients' decisions maybe differ based on sociodemographic, cultural, as well as other factors. Additional information on how patients choose surgeons or hospitals will help providers assist patients in finding their preferred caregivers.

Patients prefer electronic medical records - fact or fiction?

PubMed

Masiza, Melissa; Mostert-Phipps, Nicky; Pottasa, Dalenca

2013-01-01

Incomplete patient medical history compromises the quality of care provided to a patient while well-kept, adequate patient medical records are central to the provision of good quality of care. According to research, patients have the right to contribute to decision-making affecting their health. Hence, the researchers investigated their views regarding a paper-based system and an electronic medical record (EMR). An explorative approach was used in conducting a survey within selected general practices in the Nelson Mandela Metropole. The majority of participants thought that the use of a paper-based system had no negative impact on their health. Participants expressed concerns relating to the confidentiality of their medical records with both storage mediums. The majority of participants indicated they prefer their GP to computerise their consultation details. The main objective of the research on which this poster is based was to investigate the storage medium of preference for patients and the reasons for their preference. Overall, 48% of the 85 participants selected EMRs as their preferred storage medium and the reasons for their preference were also uncovered.

In search of patient characteristics that may guide empirically based treatment selection for personality disorder patients-a concept map approach.

PubMed

van Manen, J G; Kamphuis, J H; Goossensen, A; Timman, R; Busschbach, J J V; Verheul, R

2012-08-01

Using the concept map method, this study aimed to summarize and describe patient characteristics pertinent to treatment selection for patients with personality disorders (PDs). Initial patient characteristics were derived from the research literature and a survey among Dutch expert clinicians. Concept mapping is a formalized conceptualization procedure that describes the underlying cognitive structures people use in complex tasks, such as treatment allocation. Based on expert opinions of 29 Dutch clinicians, a concept map was generated that yielded eight domains of patient characteristics, i.e., Severity of symptoms, Severity of personality pathology, Ego-adaptive capacities, Motivation and working alliance, Social context, Social demographic characteristics, Trauma, and Treatment history and medical condition. These domains can be ordered along two bipolar axes, running from internal to external concepts and from vulnerability to strength concepts, respectively. Our findings may serve as input for the delineation of algorithms for patient-treatment matching research in PD.

Treatment options following single-rooted tooth removal: a literature review and proposed hierarchy of treatment selection.

PubMed

Fugazzotto, Paul A

2005-05-01

Alveolar bone changes following tooth extraction have been well documented and have given rise to a number of treatment approaches. Included in these approaches are placement of various grafting materials, immediate implant placement, and a combination of both. A review of all pertinent literature discussing regenerative therapy at the time of tooth extraction or immediate implant placement with or without concomitant regenerative therapy was carried out. A clinically-based hierarchy of treatment selection following extraction of single rooted teeth is proposed, based upon the available literature and clinical experience. The role of patient phenotype is considered. Utilization of the proposed hierarchy of treatment selection affords a logical framework within which to predictably treat a variety of patients.

Voxel-based dose prediction with multi-patient atlas selection for automated radiotherapy treatment planning

NASA Astrophysics Data System (ADS)

McIntosh, Chris; Purdie, Thomas G.

2017-01-01

Automating the radiotherapy treatment planning process is a technically challenging problem. The majority of automated approaches have focused on customizing and inferring dose volume objectives to be used in plan optimization. In this work we outline a multi-patient atlas-based dose prediction approach that learns to predict the dose-per-voxel for a novel patient directly from the computed tomography planning scan without the requirement of specifying any objectives. Our method learns to automatically select the most effective atlases for a novel patient, and then map the dose from those atlases onto the novel patient. We extend our previous work to include a conditional random field for the optimization of a joint distribution prior that matches the complementary goals of an accurately spatially distributed dose distribution while still adhering to the desired dose volume histograms. The resulting distribution can then be used for inverse-planning with a new spatial dose objective, or to create typical dose volume objectives for the canonical optimization pipeline. We investigated six treatment sites (633 patients for training and 113 patients for testing) and evaluated the mean absolute difference in all DVHs for the clinical and predicted dose distribution. The results on average are favorable in comparison to our previous approach (1.91 versus 2.57). Comparing our method with and without atlas-selection further validates that atlas-selection improved dose prediction on average in whole breast (0.64 versus 1.59), prostate (2.13 versus 4.07), and rectum (1.46 versus 3.29) while it is less important in breast cavity (0.79 versus 0.92) and lung (1.33 versus 1.27) for which there is high conformity and minimal dose shaping. In CNS brain, atlas-selection has the potential to be impactful (3.65 versus 5.09), but selecting the ideal atlas is the most challenging.

Accounting for patient size in the optimization of dose and image quality of pelvis cone beam CT protocols on the Varian OBI system

PubMed Central

Moore, Craig S; Horsfield, Carl J; Saunderson, John R; Beavis, Andrew W

2015-01-01

Objective: The purpose of this study was to develop size-based radiotherapy kilovoltage cone beam CT (CBCT) protocols for the pelvis. Methods: Image noise was measured in an elliptical phantom of varying size for a range of exposure factors. Based on a previously defined “small pelvis” reference patient and CBCT protocol, appropriate exposure factors for small, medium, large and extra-large patients were derived which approximate the image noise behaviour observed on a Philips CT scanner (Philips Medical Systems, Best, Netherlands) with automatic exposure control (AEC). Selection criteria, based on maximum tube current–time product per rotation selected during the radiotherapy treatment planning scan, were derived based on an audit of patient size. Results: It has been demonstrated that 110 kVp yields acceptable image noise for reduced patient dose in pelvic CBCT scans of small, medium and large patients, when compared with manufacturer's default settings (125 kVp). Conversely, extra-large patients require increased exposure factors to give acceptable images. 57% of patients in the local population now receive much lower radiation doses, whereas 13% require higher doses (but now yield acceptable images). Conclusion: The implementation of size-based exposure protocols has significantly reduced radiation dose to the majority of patients with no negative impact on image quality. Increased doses are required on the largest patients to give adequate image quality. Advances in knowledge: The development of size-based CBCT protocols that use the planning CT scan (with AEC) to determine which protocol is appropriate ensures adequate image quality whilst minimizing patient radiation dose. PMID:26419892

Selection of Shared and Neoantigen-Reactive T Cells for Adoptive Cell Therapy Based on CD137 Separation.

PubMed

Seliktar-Ofir, Sivan; Merhavi-Shoham, Efrat; Itzhaki, Orit; Yunger, Sharon; Markel, Gal; Schachter, Jacob; Besser, Michal J

2017-01-01

Adoptive cell therapy (ACT) of autologous tumor infiltrating lymphocytes (TIL) is an effective immunotherapy for patients with solid tumors, yielding objective response rates of around 40% in refractory patients with metastatic melanoma. Most clinical centers utilize bulk, randomly isolated TIL from the tumor tissue for ex vivo expansion and infusion. Only a minor fraction of the administered T cells recognizes tumor antigens, such as shared and mutation-derived neoantigens, and consequently eliminates the tumor. Thus, there are many ongoing effects to identify and select tumor-specific TIL for therapy; however, those approaches are very costly and require months, which is unreasonable for most metastatic patients. CD137 (4-1BB) has been identified as a co-stimulatory marker, which is induced upon the specific interaction of T cells with their target cell. Therefore, CD137 can be a useful biomarker and an important tool for the selection of tumor-reactive T cells. Here, we developed and validated a simple and time efficient method for the selection of CD137-expressing T cells for therapy based on magnetic bead separation. CD137 selection was performed with clinical grade compliant reagents, and TIL were expanded in a large-scale manner to meet cell numbers required for the patient setting in a GMP facility. For the first time, the methodology was designed to comply with both clinical needs and limitations, and its feasibility was assessed. CD137-selected TIL demonstrated significantly increased antitumor reactivity and were enriched for T cells recognizing neoantigens as well as shared tumor antigens. CD137-based selection enabled the enrichment of tumor-reactive T cells without the necessity of knowing the epitope specificity or the antigen type. The direct implementation of the CD137 separation method to the cell production of TIL may provide a simple way to improve the clinical efficiency of TIL ACT.

Selection of Shared and Neoantigen-Reactive T Cells for Adoptive Cell Therapy Based on CD137 Separation

PubMed Central

Seliktar-Ofir, Sivan; Merhavi-Shoham, Efrat; Itzhaki, Orit; Yunger, Sharon; Markel, Gal; Schachter, Jacob; Besser, Michal J.

2017-01-01

Adoptive cell therapy (ACT) of autologous tumor infiltrating lymphocytes (TIL) is an effective immunotherapy for patients with solid tumors, yielding objective response rates of around 40% in refractory patients with metastatic melanoma. Most clinical centers utilize bulk, randomly isolated TIL from the tumor tissue for ex vivo expansion and infusion. Only a minor fraction of the administered T cells recognizes tumor antigens, such as shared and mutation-derived neoantigens, and consequently eliminates the tumor. Thus, there are many ongoing effects to identify and select tumor-specific TIL for therapy; however, those approaches are very costly and require months, which is unreasonable for most metastatic patients. CD137 (4-1BB) has been identified as a co-stimulatory marker, which is induced upon the specific interaction of T cells with their target cell. Therefore, CD137 can be a useful biomarker and an important tool for the selection of tumor-reactive T cells. Here, we developed and validated a simple and time efficient method for the selection of CD137-expressing T cells for therapy based on magnetic bead separation. CD137 selection was performed with clinical grade compliant reagents, and TIL were expanded in a large-scale manner to meet cell numbers required for the patient setting in a GMP facility. For the first time, the methodology was designed to comply with both clinical needs and limitations, and its feasibility was assessed. CD137-selected TIL demonstrated significantly increased antitumor reactivity and were enriched for T cells recognizing neoantigens as well as shared tumor antigens. CD137-based selection enabled the enrichment of tumor-reactive T cells without the necessity of knowing the epitope specificity or the antigen type. The direct implementation of the CD137 separation method to the cell production of TIL may provide a simple way to improve the clinical efficiency of TIL ACT. PMID:29067023

Developing a pathway for high-value, patient-centered total joint arthroplasty.

PubMed

Van Citters, Aricca D; Fahlman, Cheryl; Goldmann, Donald A; Lieberman, Jay R; Koenig, Karl M; DiGioia, Anthony M; O'Donnell, Beth; Martin, John; Federico, Frank A; Bankowitz, Richard A; Nelson, Eugene C; Bozic, Kevin J

2014-05-01

Total joint arthroplasty (TJA) is one of the most widely performed elective procedures; however, there are wide variations in cost and quality among facilities where the procedure is performed. The purposes of this study were to (1) develop a generalizable clinical care pathway for primary TJA using inputs from clinical, academic, and patient stakeholders; and (2) identify system- and patient-level processes to provide safe, effective, efficient, and patient-centered care for patients undergoing TJA. We used a combination of quantitative and qualitative methods to design a care pathway that spans 14 months beginning with the presurgical office visit and concluding 12 months after discharge. We derived care suggestions from interviews with 16 hospitals selected based on readmission rates, cost, and quality (n = 10) and author opinion (n = 6). A 32-member multistakeholder panel refined the pathway during a 1-day workshop. Participants were selected based on leadership in orthopaedic (n = 4) and anesthesia (n = 1) specialty societies; involvement in organizations specializing in safety and high reliability care (n = 3), lean production/consumption of care (n = 3), and patient experience of care (n = 3); membership in an interdisciplinary care team of a hospital selected for interviewing (n = 8); recent receipt of a TJA (n = 1); and participation in the pathway development team (n = 9). The care pathway includes 40 suggested processes to improve care, 37 techniques to reduce waste, and 55 techniques to improve communication. Central themes include standardization and process improvement, interdisciplinary communication and collaboration, and patient/family engagement and education. Selected recommendations include standardizing care protocols and staff roles; aligning information flow with patient and process flow; identifying a role accountable for care delivery and communication; managing patient expectations; and stratifying patients into the most appropriate care level. We developed a multidisciplinary clinical care pathway for patients undergoing TJA based on principles of high-value care. The pathway is ready for clinical testing and context-specific adaptation. Level V, therapeutic study. See the Instructions for Authors for a complete description of levels of evidence.

A PCT-wide collaborative clinical audit selecting recall intervals for patients according to risk.

PubMed

Cannell, P J

2011-03-26

This audit was carried out to assess the level to which recall intervals were individually and appropriately selected for patients attending dental practices across a primary care trust (PCT) area in Essex. A retrospective audit was carried out by reference to patient records to assess various criteria, including whether patients were categorised according to risk of oral disease, whether an appropriate recall had been selected and whether a discussion regarding a recall interval had been undertaken. An educational event highlighting the issue of recall intervals was held. Subsequent to this a prospective audit was undertaken to assess relevant criteria. Prospective audit data showed a marked increase in the use of patient risk assessments for caries, periodontal disease, oral cancer and non-carious tooth surface loss (NCTSL). Recall intervals were also more often selected based on a patient's risk status and discussed with the patient compared to that observed in the retrospective audit data. This audit was successful as a tool to bring about change in the behaviour of dentists regarding their determination of appropriate recall intervals for patients. Whether that change in behaviour is long-term or transient requires further investigation.

A web-based appointment system to reduce waiting for outpatients: a retrospective study.

PubMed

Cao, Wenjun; Wan, Yi; Tu, Haibo; Shang, Fujun; Liu, Danhong; Tan, Zhijun; Sun, Caihong; Ye, Qing; Xu, Yongyong

2011-11-22

Long waiting times for registration to see a doctor is problematic in China, especially in tertiary hospitals. To address this issue, a web-based appointment system was developed for the Xijing hospital. The aim of this study was to investigate the efficacy of the web-based appointment system in the registration service for outpatients. Data from the web-based appointment system in Xijing hospital from January to December 2010 were collected using a stratified random sampling method, from which participants were randomly selected for a telephone interview asking for detailed information on using the system. Patients who registered through registration windows were randomly selected as a comparison group, and completed a questionnaire on-site. A total of 5641 patients using the online booking service were available for data analysis. Of them, 500 were randomly selected, and 369 (73.8%) completed a telephone interview. Of the 500 patients using the usual queuing method who were randomly selected for inclusion in the study, responses were obtained from 463, a response rate of 92.6%. Between the two registration methods, there were significant differences in age, degree of satisfaction, and total waiting time (P<0.001). However, gender, urban residence, and valid waiting time showed no significant differences (P>0.05). Being ignorant of online registration, not trusting the internet, and a lack of ability to use a computer were three main reasons given for not using the web-based appointment system. The overall proportion of non-attendance was 14.4% for those using the web-based appointment system, and the non-attendance rate was significantly different among different hospital departments, day of the week, and time of the day (P<0.001). Compared to the usual queuing method, the web-based appointment system could significantly increase patient's satisfaction with registration and reduce total waiting time effectively. However, further improvements are needed for broad use of the system.

Predicting distant failure in early stage NSCLC treated with SBRT using clinical parameters.

PubMed

Zhou, Zhiguo; Folkert, Michael; Cannon, Nathan; Iyengar, Puneeth; Westover, Kenneth; Zhang, Yuanyuan; Choy, Hak; Timmerman, Robert; Yan, Jingsheng; Xie, Xian-J; Jiang, Steve; Wang, Jing

2016-06-01

The aim of this study is to predict early distant failure in early stage non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT) using clinical parameters by machine learning algorithms. The dataset used in this work includes 81 early stage NSCLC patients with at least 6months of follow-up who underwent SBRT between 2006 and 2012 at a single institution. The clinical parameters (n=18) for each patient include demographic parameters, tumor characteristics, treatment fraction schemes, and pretreatment medications. Three predictive models were constructed based on different machine learning algorithms: (1) artificial neural network (ANN), (2) logistic regression (LR) and (3) support vector machine (SVM). Furthermore, to select an optimal clinical parameter set for the model construction, three strategies were adopted: (1) clonal selection algorithm (CSA) based selection strategy; (2) sequential forward selection (SFS) method; and (3) statistical analysis (SA) based strategy. 5-cross-validation is used to validate the performance of each predictive model. The accuracy was assessed by area under the receiver operating characteristic (ROC) curve (AUC), sensitivity and specificity of the system was also evaluated. The AUCs for ANN, LR and SVM were 0.75, 0.73, and 0.80, respectively. The sensitivity values for ANN, LR and SVM were 71.2%, 72.9% and 83.1%, while the specificity values for ANN, LR and SVM were 59.1%, 63.6% and 63.6%, respectively. Meanwhile, the CSA based strategy outperformed SFS and SA in terms of AUC, sensitivity and specificity. Based on clinical parameters, the SVM with the CSA optimal parameter set selection strategy achieves better performance than other strategies for predicting distant failure in lung SBRT patients. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Eleven-Year Retrospective Report of Super-Selective Venous Sampling for the Evaluation of Recurrent or Persistent Hyperparathyroidism in 32 Patients.

PubMed

Habibollahi, Peiman; Shin, Benjamin; Shamchi, Sara P; Wachtel, Heather; Fraker, Douglas L; Trerotola, Scott O

2018-01-01

Parathyroid venous sampling (PAVS) is usually reserved for patients with persistent or recurrent hyperparathyroidism after parathyroidectomy with inconclusive noninvasive imaging studies. A retrospective study was performed to evaluate the diagnostic efficacy of super-selective PAVS (SSVS) in patients needing revision neck surgery with inconclusive imaging. Patients undergoing PAVS between 2005 and 2016 due to persistent or recurrent hyperparathyroidism following surgery were reviewed. PAVS was performed in all patients using super-selective technique. Single-value measurements within central neck veins performed as part of super-selective PAVS were used to simulate selective venous sampling (SVS) and allow for comparison to data, which might be obtained in a non-super-selective approach. 32 patients (mean age 51 ± 15 years; 8 men and 24 women) met inclusion and exclusion criteria. The sensitivity and positive predictive value (PPV) of SSVS for localizing the source of elevated PTH to a limited area in the neck or chest was 96 and 84%, respectively. Simulated SVS, on the other hand, had a sensitivity of 28% and a PPV of 89% based on the predefined gold standard. SSVS had a significantly higher sensitivity compared to simulated SVS (p < 0.001). SSVS is highly effective in localizing the source of hyperparathyroidism in patients undergoing revision surgery for hyperparathyroidism in whom noninvasive imaging studies are inconclusive. SSVS data had also markedly higher sensitivity for localizing disease in these patients compared to simulated SVS.

Gram-stain-based antimicrobial selection reduces cost and overuse compared with Japanese guidelines.

PubMed

Taniguchi, Tomohiro; Tsuha, Sanefumi; Shiiki, Soichi; Narita, Masashi

2015-10-26

The Gram stain has been used as an essential tool for antimicrobial stewardship in our hospital since the 1970s. The objective of this study was to clarify the difference in the targeted therapies selected based on the Gram stain and simulated empirical therapies based on the antimicrobial guidelines used in Japan. A referral-hospital-based prospective descriptive study was undertaken between May 2013 and April 2014 in Okinawa, Japan. All enrolled patients were adults who had been admitted to the Division of Infectious Diseases through the emergency room with suspected bacterial infection at one of three sites: respiratory system, urinary tract, or skin and soft tissues. The study outcomes were the types and effectiveness of the antibiotics initially selected, and their total costs. Two hundred eight patients were enrolled in the study. The median age was 80 years. A significantly narrower spectrum of antibiotics was selected based on the Gram stain than was selected based on the Japanese guidelines. The treatments based on the Gram stain and on the guidelines were estimated to be equally highly effective. The total cost of antimicrobials after Gram-stain testing was less than half the cost after the guidelines were followed. Compared with the Japanese guidelines, the Gram stain dramatically reduced the overuse of broad-spectrum antimicrobials without affecting the effectiveness of the treatment. Drug costs were reduced by half when the Gram stain was used. The Gram stain should be included in all antimicrobial stewardship programs.

Selection criteria for patients with chronic ankle instability in controlled research: a position statement of the International Ankle Consortium.

PubMed

Gribble, Phillip A; Delahunt, Eamonn; Bleakley, Chris; Caulfield, Brian; Docherty, Carrie; Fourchet, François; Fong, Daniel Tik-Pui; Hertel, Jay; Hiller, Claire; Kaminski, Thomas; McKeon, Patrick; Refshauge, Kathryn; van der Wees, Philip; Vincenzino, Bill; Wikstrom, Erik

2014-07-01

While research on chronic ankle instability (CAI) and awareness of its impact on society and health care systems has grown substantially in the last 2 decades, the inconsistency in participant/patient selection criteria across studies presents a potential obstacle to addressing the problem properly. This major gap within the literature limits the ability to generalise this evidence to the target patient population. Therefore, there is a need to provide standards for patient/participant selection criteria in research focused on CAI with justifications using the best available evidence. The International Ankle Consortium provides this position paper to present and discuss an endorsed set of selection criteria for patients with CAI based on the best available evidence to be used in future research and study designs. These recommendations will enhance the validity of research conducted in this clinical population with the end goal of bringing the research evidence to the clinician and patient. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Grey matter, an endophenotype for schizophrenia? A voxel-based morphometry study in siblings of patients with schizophrenia.

PubMed

van der Velde, Jorien; Gromann, Paula M; Swart, Marte; de Haan, Lieuwe; Wiersma, Durk; Bruggeman, Richard; Krabbendam, Lydia; Aleman, André

2015-05-01

Grey matter, both volume and concentration, has been proposed as an endophenotype for schizophrenia given a number of reports of grey matter abnormalities in relatives of patients with schizophrenia. However, previous studies on grey matter abnormalities in relatives have produced inconsistent results. The aim of the present study was to examine grey matter differences between controls and siblings of patients with schizophrenia and to examine whether the age, genetic loading or subclinical psychotic symptoms of selected individuals could explain the previously reported inconsistencies. We compared the grey matter volume and grey matter concentration of healthy siblings of patients with schizophrenia and healthy controls matched for age, sex and education using voxel-based morphometry (VBM). Furthermore, we selected subsamples based on age (< 30 yr), genetic loading and subclinical psychotic symptoms to examine whether this would lead to different results. We included 89 siblings and 69 controls in our study. The results showed that siblings and controls did not differ significantly on grey matter volume or concentration. Furthermore, specifically selecting participants based on age, genetic loading or subclinical psychotic symptoms did not alter these findings. The main limitation was that subdividing the sample resulted in smaller samples for the subanalyses. Furthermore, we used MRI data from 2 different scanner sites. These results indicate that grey matter measured through VBM might not be a suitable endophenotype for schizophrenia.

Improving results for carotid artery stenting by validation of the anatomic scoring system for carotid artery stenting with patient-specific simulated rehearsal.

PubMed

Willaert, Willem I M; Cheshire, Nicholas J; Aggarwal, Rajesh; Van Herzeele, Isabelle; Stansby, Gerard; Macdonald, Sumaira; Vermassen, Frank E

2012-12-01

Carotid artery stenting (CAS) is a technically demanding procedure with a risk of periprocedural stroke. A scoring system based on anatomic criteria has been developed to facilitate patient selection for CAS. Advancements in simulation science also enable case evaluation through patient-specific virtual reality (VR) rehearsal on an endovascular simulator. This study aimed to validate the anatomic scoring system for CAS using the patient-specific VR technology. Three patients were selected and graded according to the CAS scoring system (maximum score, 9): one easy (score, <4.9), one intermediate (score, 5.0-5.9), and one difficult (score, >7.0). The three cases were performed on the simulator in random order by 20 novice interventionalists pretrained in CAS. Technical performances were assessed using simulator-based metrics and expert-based ratings. The interventionalists took significantly longer to perform the difficult CAS case (median, 31.6 vs 19.7 vs 14.6 minutes; P<.0001) compared with the intermediate and easy cases; similarly, more fluoroscopy time (20.7 vs 12.1 vs 8.2 minutes; P<.0001), contrast volume (56.5 vs 51.5 vs 50.0 mL; P=.0060), and roadmaps (10 vs 9 vs 9; P=.0040) were used. The quality of performance declined significantly as the cases became more challenging (score, 24 vs 22 vs 19; P<.0001). The anatomic scoring system for CAS can predict the difficulty of a CAS procedure as measured by patient-specific VR. This scoring system, with or without the additional use of patient-specific VR, can guide novice interventionalists in selecting appropriate patients for CAS. This may reduce the perioperative stroke risk and enhance patient safety. Copyright © 2012 Society for Vascular Surgery. Published by Mosby, Inc. All rights reserved.

[Cyclooxygenase inhibitors and antiplatelet effect of acetylsalicylic acid. selective approach to nonsteroidal anti-inflammatory drugs in cardiological practice].

PubMed

Lomakin, N V; Gruzdev, A K

2011-01-01

Nonsteroidal anti-inflammatory drugs (NSAIDs) represent class of medicines which is wide concerning chemical structure and mechanism of action. In the light of contradictory data on efficacy and safety of NSAID in cardiovascular patients selection of most appropriate NSAID (basing on profile of efficacy and safety) in patients receiving continuous therapy with low dose aspirin appears to be a problem. In this paper we discuss peculiarities of drug interaction between cyclooxygenase inhibitors and acetylsalicylic acid, and principles of selection of adequate NSAI.

Preimplantation sex selection demand and preferences in an infertility population.

PubMed

Jain, Tarun; Missmer, Stacey A; Gupta, Raina S; Hornstein, Mark D

2005-03-01

To determine the demand and preferences of infertility patients for sex selection and the method and sex they would choose, and to investigate the relationship between these choices and their demographic and socioeconomic characteristics. Cross-sectional survey. University hospital-based fertility center. One thousand five hundred consecutive women who presented for infertility care. None. Self-report questionnaire assessing the demand and preferences for sex selection. Of respondents, 40.8% wanted to select the sex of their next child for no added cost. Of these patients, 45.9% had no living children and 48.4% had children all of one sex. After adjustment for observed predictors of gender preference, we found a significant preference for a female child among women who were older, not religious, willing to pay for sex selection, had more living children, had only sons, or had a diagnosis of male infertility. Nulliparous women did not significantly prefer one sex over the other. Among parous women, those with only daughters significantly desired to select a male child, whereas those with sons significantly desired to select a female child. In terms of the method of sex selection, 55.0%, 41.0%, and 4.0% of the patients would use sperm separation, preimplantation genetic diagnosis, or neither method, respectively. There is significant demand among infertility patients for preimplantation sex selection, with a significant portion of this demand coming from patients who do not have any children or have children all of one sex.

Towards a model-based patient selection strategy for proton therapy: External validation of photon-derived Normal Tissue Complication Probability models in a head and neck proton therapy cohort

PubMed Central

Blanchard, P; Wong, AJ; Gunn, GB; Garden, AS; Mohamed, ASR; Rosenthal, DI; Crutison, J; Wu, R; Zhang, X; Zhu, XR; Mohan, R; Amin, MV; Fuller, CD; Frank, SJ

2017-01-01

Objective To externally validate head and neck cancer (HNC) photon-derived normal tissue complication probability (NTCP) models in patients treated with proton beam therapy (PBT). Methods This prospective cohort consisted of HNC patients treated with PBT at a single institution. NTCP models were selected based on the availability of data for validation and evaluated using the leave-one-out cross-validated area under the curve (AUC) for the receiver operating characteristics curve. Results 192 patients were included. The most prevalent tumor site was oropharynx (n=86, 45%), followed by sinonasal (n=28), nasopharyngeal (n=27) or parotid (n=27) tumors. Apart from the prediction of acute mucositis (reduction of AUC of 0.17), the models overall performed well. The validation (PBT) AUC and the published AUC were respectively 0.90 versus 0.88 for feeding tube 6 months post-PBT; 0.70 versus 0.80 for physician rated dysphagia 6 months post-PBT; 0.70 versus 0.80 for dry mouth 6 months post-PBT; and 0.73 versus 0.85 for hypothyroidism 12 months post-PBT. Conclusion While the drop in NTCP model performance was expected in PBT patients, the models showed robustness and remained valid. Further work is warranted, but these results support the validity of the model-based approach for treatment selection for HNC patients. PMID:27641784

A bioinformatics approach for precision medicine off-label drug drug selection among triple negative breast cancer patients

PubMed Central

Cheng, Lijun; Schneider, Bryan P

2016-01-01

Background Cancer has been extensively characterized on the basis of genomics. The integration of genetic information about cancers with data on how the cancers respond to target based therapy to help to optimum cancer treatment. Objective The increasing usage of sequencing technology in cancer research and clinical practice has enormously advanced our understanding of cancer mechanisms. The cancer precision medicine is becoming a reality. Although off-label drug usage is a common practice in treating cancer, it suffers from the lack of knowledge base for proper cancer drug selections. This eminent need has become even more apparent considering the upcoming genomics data. Methods In this paper, a personalized medicine knowledge base is constructed by integrating various cancer drugs, drug-target database, and knowledge sources for the proper cancer drugs and their target selections. Based on the knowledge base, a bioinformatics approach for cancer drugs selection in precision medicine is developed. It integrates personal molecular profile data, including copy number variation, mutation, and gene expression. Results By analyzing the 85 triple negative breast cancer (TNBC) patient data in the Cancer Genome Altar, we have shown that 71.7% of the TNBC patients have FDA approved drug targets, and 51.7% of the patients have more than one drug target. Sixty-five drug targets are identified as TNBC treatment targets and 85 candidate drugs are recommended. Many existing TNBC candidate targets, such as Poly (ADP-Ribose) Polymerase 1 (PARP1), Cell division protein kinase 6 (CDK6), epidermal growth factor receptor, etc., were identified. On the other hand, we found some additional targets that are not yet fully investigated in the TNBC, such as Gamma-Glutamyl Hydrolase (GGH), Thymidylate Synthetase (TYMS), Protein Tyrosine Kinase 6 (PTK6), Topoisomerase (DNA) I, Mitochondrial (TOP1MT), Smoothened, Frizzled Class Receptor (SMO), etc. Our additional analysis of target and drug selection strategy is also fully supported by the drug screening data on TNBC cell lines in the Cancer Cell Line Encyclopedia. Conclusions The proposed bioinformatics approach lays a foundation for cancer precision medicine. It supplies much needed knowledge base for the off-label cancer drug usage in clinics. PMID:27107440

Symptom-Based Controller Therapy: A New Paradigm for Asthma Management

PubMed Central

Divekar, Rohit; Ameredes, Bill T.; Calhoun, William J.

2013-01-01

Appropriate management of persistent asthma, according to US and international guidelines, requires daily use of controller medications, most generally, inhaled corticosteroids (ICS). This approach, although effective and well established, imposes burdens of treatment and side effects onto asthma patients. A growing body of evidence suggests that patients with persistent asthma need not be managed with daily ICS, but rather can use them on an intermittent basis, occasioned by the occurrence of symptoms sufficient to warrant treatment with a rescue inhaler. Large, randomized, controlled studies, over a range of asthma severity, and in a range of ages from pediatrics to adults, suggest that in well-selected patients, a symptom based approach to administering controller therapy may produce equivalent outcomes, while reducing exposure to ICS. The concept of providing anti-inflammatory treatment to the patient, at the time inflammation is developing, is termed ‘temporal personalization’. The evidence to date suggests that symptom-based controller therapy is broadly useful in selected asthma patients, and is a management approach that could be incorporated into US and international guidelines for asthma. PMID:23904098

DisTeam: A decision support tool for surgical team selection.

PubMed

Ebadi, Ashkan; Tighe, Patrick J; Zhang, Lei; Rashidi, Parisa

2017-02-01

Surgical service providers play a crucial role in the healthcare system. Amongst all the influencing factors, surgical team selection might affect the patients' outcome significantly. The performance of a surgical team not only can depend on the individual members, but it can also depend on the synergy among team members, and could possibly influence patient outcome such as surgical complications. In this paper, we propose a tool for facilitating decision making in surgical team selection based on considering history of the surgical team, as well as the specific characteristics of each patient. DisTeam (a decision support tool for surgical team selection) is a metaheuristic framework for objective evaluation of surgical teams and finding the optimal team for a given patient, in terms of number of complications. It identifies a ranked list of surgical teams personalized for each patient, based on prior performance of the surgical teams. DisTeam takes into account the surgical complications associated with teams and their members, their teamwork history, as well as patient's specific characteristics such as age, body mass index (BMI) and Charlson comorbidity index score. We tested DisTeam using intra-operative data from 6065 unique orthopedic surgery cases. Our results suggest high effectiveness of the proposed system in a health-care setting. The proposed framework converges quickly to the optimal solution and provides two sets of answers: a) The best surgical team over all the generations, and b) The best population which consists of different teams that can be used as an alternative solution. This increases the flexibility of the system as a complementary decision support tool. DisTeam is a decision support tool for assisting in surgical team selection. It can facilitate the job of scheduling personnel in the hospital which involves an overwhelming number of factors pertaining to patients, individual team members, and team dynamics and can be used to compose patient-personalized surgical teams with minimum (potential) surgical complications. Copyright © 2017 Elsevier B.V. All rights reserved.

Gene-Based Multiclass Cancer Diagnosis with Class-Selective Rejections

PubMed Central

Jrad, Nisrine; Grall-Maës, Edith; Beauseroy, Pierre

2009-01-01

Supervised learning of microarray data is receiving much attention in recent years. Multiclass cancer diagnosis, based on selected gene profiles, are used as adjunct of clinical diagnosis. However, supervised diagnosis may hinder patient care, add expense or confound a result. To avoid this misleading, a multiclass cancer diagnosis with class-selective rejection is proposed. It rejects some patients from one, some, or all classes in order to ensure a higher reliability while reducing time and expense costs. Moreover, this classifier takes into account asymmetric penalties dependant on each class and on each wrong or partially correct decision. It is based on ν-1-SVM coupled with its regularization path and minimizes a general loss function defined in the class-selective rejection scheme. The state of art multiclass algorithms can be considered as a particular case of the proposed algorithm where the number of decisions is given by the classes and the loss function is defined by the Bayesian risk. Two experiments are carried out in the Bayesian and the class selective rejection frameworks. Five genes selected datasets are used to assess the performance of the proposed method. Results are discussed and accuracies are compared with those computed by the Naive Bayes, Nearest Neighbor, Linear Perceptron, Multilayer Perceptron, and Support Vector Machines classifiers. PMID:19584932

Cost-effectiveness of a new urinary biomarker-based risk score compared to standard of care in prostate cancer diagnostics - a decision analytical model.

PubMed

Dijkstra, Siebren; Govers, Tim M; Hendriks, Rianne J; Schalken, Jack A; Van Criekinge, Wim; Van Neste, Leander; Grutters, Janneke P C; Sedelaar, John P Michiel; van Oort, Inge M

2017-11-01

To assess the cost-effectiveness of a new urinary biomarker-based risk score (SelectMDx; MDxHealth, Inc., Irvine, CA, USA) to identify patients for transrectal ultrasonography (TRUS)-guided biopsy and to compare this with the current standard of care (SOC), using only prostate-specific antigen (PSA) to select for TRUS-guided biopsy. A decision tree and Markov model were developed to evaluate the cost-effectiveness of SelectMDx as a reflex test vs SOC in men with a PSA level of >3 ng/mL. Transition probabilities, utilities and costs were derived from the literature and expert opinion. Cost-effectiveness was expressed in quality-adjusted life years (QALYs) and healthcare costs of both diagnostic strategies, simulating the course of patients over a time horizon representing 18 years. Deterministic sensitivity analyses were performed to address uncertainty in assumptions. A diagnostic strategy including SelectMDx with a cut-off chosen at a sensitivity of 95.7% for high-grade prostate cancer resulted in savings of €128 and a gain of 0.025 QALY per patient compared to the SOC strategy. The sensitivity analyses showed that the disutility assigned to active surveillance had a high impact on the QALYs gained and the disutility attributed to TRUS-guided biopsy only slightly influenced the outcome of the model. Based on the currently available evidence, the reduction of over diagnosis and overtreatment due to the use of the SelectMDx test in men with PSA levels of >3 ng/mL may lead to a reduction in total costs per patient and a gain in QALYs. © 2017 The Authors BJU International © 2017 BJU International Published by John Wiley & Sons Ltd.

Predicting Treatment Response in Social Anxiety Disorder From Functional Magnetic Resonance Imaging

PubMed Central

Doehrmann, Oliver; Ghosh, Satrajit S.; Polli, Frida E.; Reynolds, Gretchen O.; Horn, Franziska; Keshavan, Anisha; Triantafyllou, Christina; Saygin, Zeynep M.; Whitfield-Gabrieli, Susan; Hofmann, Stefan G.; Pollack, Mark; Gabrieli, John D.

2013-01-01

Context Current behavioral measures poorly predict treatment outcome in social anxiety disorder (SAD). To our knowledge, this is the first study to examine neuroimaging-based treatment prediction in SAD. Objective To measure brain activation in patients with SAD as a biomarker to predict subsequent response to cognitive behavioral therapy (CBT). Design Functional magnetic resonance imaging (fMRI) data were collected prior to CBT intervention. Changes in clinical status were regressed on brain responses and tested for selectivity for social stimuli. Setting Patients were treated with protocol-based CBT at anxiety disorder programs at Boston University or Massachusetts General Hospital and underwent neuroimaging data collection at Massachusetts Institute of Technology. Patients Thirty-nine medication-free patients meeting DSM-IV criteria for the generalized subtype of SAD. Interventions Brain responses to angry vs neutral faces or emotional vs neutral scenes were examined with fMRI prior to initiation of CBT. Main Outcome Measures Whole-brain regression analyses with differential fMRI responses for angry vs neutral faces and changes in Liebowitz Social Anxiety Scale score as the treatment outcome measure. Results Pretreatment responses significantly predicted subsequent treatment outcome of patients selectively for social stimuli and particularly in regions of higher-order visual cortex. Combining the brain measures with information on clinical severity accounted for more than 40% of the variance in treatment response and substantially exceeded predictions based on clinical measures at baseline. Prediction success was unaffected by testing for potential confounding factors such as depression severity at baseline. Conclusions The results suggest that brain imaging can provide biomarkers that substantially improve predictions for the success of cognitive behavioral interventions and more generally suggest that such biomarkers may offer evidence-based, personalized medicine approaches for optimally selecting among treatment options for a patient. PMID:22945462

Genetic variation predicting cisplatin cytotoxicity associated with overall survival in lung cancer patients receiving platinum-based chemotherapy †, ‡

PubMed Central

Tan, Xiang-Lin; Moyer, Ann M.; Fridley, Brooke L.; Schaid, Daniel J.; Niu, Nifang; Batzler, Anthony J.; Jenkins, Gregory D.; Abo, Ryan P.; Li, Liang; Cunningham, Julie M.; Sun, Zhifu; Yang, Ping; Wang, Liewei

2011-01-01

Purpose Inherited variability in the prognosis of lung cancer patients treated with platinum-based chemotherapy has been widely investigated. However, the overall contribution of genetic variation to platinum response is not well established. To identify novel candidate SNPs/genes, we performed a genome-wide association study (GWAS) for cisplatin cytotoxicity using lymphoblastoid cell lines (LCLs), followed by an association study of selected SNPs from the GWAS with overall survival (OS) in lung cancer patients. Experimental Design GWAS for cisplatin were performed with 283 ethnically diverse LCLs. 168 top SNPs were genotyped in 222 small cell and 961 non-small cell lung cancer (SCLC, NSCLC) patients treated with platinum-based therapy. Association of the SNPs with OS was determined using the Cox regression model. Selected candidate genes were functionally validated by siRNA knockdown in human lung cancer cells. Results Among 157 successfully genotyped SNPs, 9 and 10 SNPs were top SNPs associated with OS for patients with NSCLC and SCLC, respectively, although they were not significant after adjusting for multiple testing. Fifteen genes, including 7 located within 200 kb up or downstream of the four top SNPs and 8 genes for which expression was correlated with three SNPs in LCLs were selected for siRNA screening. Knockdown of DAPK3 and METTL6, for which expression levels were correlated with the rs11169748 and rs2440915 SNPs, significantly decreased cisplatin sensitivity in lung cancer cells. Conclusions This series of clinical and complementary laboratory-based functional studies identified several candidate genes/SNPs that might help predict treatment outcomes for platinum-based therapy of lung cancer. PMID:21775533

Nomogram for predicting the benefit of neoadjuvant chemoradiotherapy for patients with esophageal cancer: a SEER-Medicare analysis.

PubMed

Eil, Robert; Diggs, Brian S; Wang, Samuel J; Dolan, James P; Hunter, John G; Thomas, Charles R

2014-02-15

The survival impact of neoadjuvant chemoradiotherapy (CRT) on esophageal cancer remains difficult to establish for specific patients. The aim of the current study was to create a Web-based prediction tool providing individualized survival projections based on tumor and treatment data. Patients diagnosed with esophageal cancer between 1997 and 2005 were selected from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database. The covariates analyzed were sex, T and N classification, histology, total number of lymph nodes examined, and treatment with esophagectomy or CRT followed by esophagectomy. After propensity score weighting, a log-logistic regression model for overall survival was selected based on the Akaike information criterion. A total of 824 patients with esophageal cancer who were treated with esophagectomy or trimodal therapy met the selection criteria. On multivariate analysis, age, sex, T and N classification, number of lymph nodes examined, treatment, and histology were found to be significantly associated with overall survival and were included in the regression analysis. Preoperative staging data and final surgical margin status were not available within the SEER-Medicare data set and therefore were not included. The model predicted that patients with T4 or lymph node disease benefitted from CRT. The internally validated concordance index was 0.72. The SEER-Medicare database of patients with esophageal cancer can be used to produce a survival prediction tool that: 1) serves as a counseling and decision aid to patients and 2) assists in risk modeling. Patients with T4 or lymph node disease appeared to benefit from CRT. This nomogram may underestimate the benefit of CRT due to its variable downstaging effect on pathologic stage. It is available at skynet.ohsu.edu/nomograms. © 2013 American Cancer Society.

Quality Pain Management in Adult Hospitalized Patients: A Concept Evaluation.

PubMed

Zoëga, Sigridur; Gunnarsdottir, Sigridur; Wilson, Margaret E; Gordon, Debra B

2016-01-01

To explore the concept of quality pain management (QPM) in adult hospitalized patients. Pain is common in hospitalized patients, and pain management remains suboptimal in some settings. A concept evaluation based on Morse et al.'s method. Of more than 5,000 articles found, data were restricted to 37 selected key articles published in peer-reviewed journals. Data were extracted from the selected articles and then synthesized according to the following: definition, characteristics, boundaries, preconditions, and outcomes. QPM relates to the Structure: organizationally supported evidence-based policies, competent staff, interprofessional and specialized care, and staff accountability; screening, assessment/reassessment and communication of pain and its treatment, patient/family education, individualized evidence-based treatment, embedded in safe, effective, patient-centered, timely, efficient, and equitable services; and reduced pain severity and functional interference, decreased prevalence/severity of adverse consequences from pain or pain treatment, and increase in patient satisfaction. QPM is a multifaceted concept that remains poorly defined in the literature. Studies should aim to develop valid, reliable, and operational measures of the pillars of QPM and to look at the relationship among these factors. Authors need to state how they define and what aspects of QPM they are measuring. © 2014 Wiley Periodicals, Inc.

[Organ transplants for HIV-infected patients--time for reevaluation?].

PubMed

Katzenstein, Terese L

2005-11-14

With the improvement in antiretroviral therapy, comorbidity is increasingly a cause of morbidity among HIV-infected patients. In the United States and several European countries, kidney and liver transplantations have been performed on selected HIV-infected patients. The short-term results have been comparable to those among HIV-negative recipients. Based on these results, it is recommended that kidney and liver transplants be offered to Danish HIV patients based on the same criteria as those that apply for non-HIV-infected patients with end-stage kidney or liver disease.

Nessi: An EEG-Controlled Web Browser for Severely Paralyzed Patients

PubMed Central

Bensch, Michael; Karim, Ahmed A.; Mellinger, Jürgen; Hinterberger, Thilo; Tangermann, Michael; Bogdan, Martin; Rosenstiel, Wolfgang; Birbaumer, Niels

2007-01-01

We have previously demonstrated that an EEG-controlled web browser based on self-regulation of slow cortical potentials (SCPs) enables severely paralyzed patients to browse the internet independently of any voluntary muscle control. However, this system had several shortcomings, among them that patients could only browse within a limited number of web pages and had to select links from an alphabetical list, causing problems if the link names were identical or if they were unknown to the user (as in graphical links). Here we describe a new EEG-controlled web browser, called Nessi, which overcomes these shortcomings. In Nessi, the open source browser, Mozilla, was extended by graphical in-place markers, whereby different brain responses correspond to different frame colors placed around selectable items, enabling the user to select any link on a web page. Besides links, other interactive elements are accessible to the user, such as e-mail and virtual keyboards, opening up a wide range of hypertext-based applications. PMID:18350132

Suicidal drug overdose in patients with systemic lupus erythematosus, a nationwide population-based case-control study.

PubMed

Tang, K T; Lin, C H; Chen, H H; Chen, Y H; Chen, D Y

2016-02-01

A four-fold increase of suicide mortality has been demonstrated in systemic lupus erythematosus (SLE) patients. Prior studies showed that the most common method of suicide attempts in SLE patients involves drug overdose. Therefore, we conducted a nationwide population-based case-control study to elucidate factors associated with drug overdose as suicide attempt in SLE patients. This study was based on the National Health Insurance Research Database in Taiwan. We identified all SLE patients from January 1, 2000 to December 31, 2010. Patients who had suicidal drug overdose (SDO) were selected as cases while age- and gender-matched patients who did not have SDO were selected as controls. The incidence rate of SDO in SLE patients was 291 cases per 100,000 person-years, higher than that in the general population (160 cases per 100,000 person-years). In a multivariate logistic regression analysis, we observed that SDO was associated with psychiatric disorders such as depressive disorders (odds ratio: 8.36, 95% confidence interval (CI): 5.60-12.48) and insomnia (odds ratio: 2.71, 95% CI: 1.73-4.25), and lower monthly income (odds ratios: 2.74 to 3.50) in SLE patients. SDO is associated with psychiatric disorders such as depressive disorders and insomnia, and lower monthly income in SLE patients. © The Author(s) 2015.

Next generation sequencing techniques in liquid biopsy: focus on non-small cell lung cancer patients.

PubMed

Malapelle, Umberto; Pisapia, Pasquale; Rocco, Danilo; Smeraglio, Riccardo; di Spirito, Maria; Bellevicine, Claudio; Troncone, Giancarlo

2016-10-01

The advent of genomic based personalized medicine has led to multiple advances in the molecular characterization of many tumor types, such as non-small cell lung cancer (NSCLC). NSCLC is diagnosed in most cases on small tissue samples that may be not always sufficient for EGFR mutational assessment to select patients for first and second generations' tyrosine kinase inhibitors (TKIs) therapy. In patients without tissue availability at presentation, the analysis of cell free DNA (cfDNA) derived from liquid biopsy samples, in particular from plasma, represent an established alternative to provide EGFR mutational testing for treatment decision making. In addition, a new paradigm for TKIs resistance management was recently approved by Food and Drug Administration, supporting the liquid biopsy based genotyping prior to tissue based genotyping for the detection of T790M mutation to select patients for third generation TKIs. In these settings, real time PCR (RT-PCR) and digital PCR 'targeted' methods, which detect known mutations by specific probes, have extensively been adopted. Taking into account the restricted reference range and the limited multiplexing power of these targeted methods, the performance of liquid biopsy analyses may be further improved by next generation sequencing (NGS). While most tissue based NGS genotyping is well established, liquid biopsy NGS application is challenging, requiring a careful validation of the whole process, from blood collection to variant calling. Here we review this evolving field, highlighting those methodological points that are crucial to accurately select NSCLC patients for TKIs treatment administration by NGS on cfDNA.

Clinical application of pharmacogenetics: focusing on practical issues.

PubMed

Chang, Matthew T; McCarthy, Jeanette J; Shin, Jaekyu

2015-01-01

Recent large-scale genetic-based studies have transformed the field of pharmacogenetics to identify, characterize and leverage genetic information to inform patient care. Genetic testing can be used to alter drug selection, optimize drug dosing and prevent unnecessary adverse events. As precision medicine becomes the mainstay in the clinic, it becomes critical for clinicians to utilize pharmacogenetics to guide patient care. One primary challenge is identifying patients where genetic tests that can potentially impact patient care. To address this challenge, our review highlights many practical issues clinicians may encounter: identifying candidate patients and clinical laboratories for pharmacogenetic testing, selecting highly curated resources to help asses test validity, reimbursing costs of pharmacogenetic tests, and interpreting of pharmacogenetic test results.

Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment.

PubMed

Stuck, Amy; Crowley, Christopher; Martinez, Tracy; Wittgrove, Alan; Brennan, Jesse J; Chan, Theodore C; Castillo, Edward M

2017-06-01

The study objective was to explore emergency physicians' (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization. We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews. Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked "reduce unnecessary hospitalizations and observation stays" among their top three perceived motivators for using home-based care, and 77% ranked "no existing process in place to refer to home-based care" among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours. The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process.

Perspectives on Home-based Healthcare as an Alternative to Hospital Admission After Emergency Treatment

PubMed Central

Stuck, Amy; Crowley, Christopher; Martinez, Tracy; Wittgrove, Alan; Brennan, Jesse J.; Chan, Theodore C.; Castillo, Edward M.

2017-01-01

Introduction The study objective was to explore emergency physicians’ (EP) awareness, willingness, and prior experience regarding transitioning patients to home-based healthcare following emergency department (ED) evaluation and treatment; and to explore patient selection criteria, processes, and services that would facilitate use of home-based healthcare as an alternative to hospitalization. Methods We provided a five-question survey to 52 EPs, gauging previous experience referring patients to home-based healthcare, patient selection, and motivators and challenges when considering home-based options as an alternative to admission. In addition, we conducted three focus groups and four interviews. Results Of participating EPs, 92% completed the survey, 38% reported ordering home-based healthcare from the ED as an alternative to admission, 90% ranked cellulitis among the top three medical conditions for home-based healthcare, 90% ranked “reduce unnecessary hospitalizations and observation stays” among their top three perceived motivators for using home-based care, and 77% ranked “no existing process in place to refer to home-based care” among their top three perceived barriers. Focus group and interview themes included the need for alternatives to admission; the longer-term benefits of home-based healthcare; the need for streamlined transition processes; and the need for highly qualified home-care staff capable of responding the same day or within 24 hours. Conclusion The study found that EPs are receptive to referring patients for home-based healthcare following ED treatment and believe people with certain diagnoses are likely to benefit, with the dominant barrier being the absence of an efficient referral process. PMID:28611899

A Personalized Predictive Framework for Multivariate Clinical Time Series via Adaptive Model Selection.

PubMed

Liu, Zitao; Hauskrecht, Milos

2017-11-01

Building of an accurate predictive model of clinical time series for a patient is critical for understanding of the patient condition, its dynamics, and optimal patient management. Unfortunately, this process is not straightforward. First, patient-specific variations are typically large and population-based models derived or learned from many different patients are often unable to support accurate predictions for each individual patient. Moreover, time series observed for one patient at any point in time may be too short and insufficient to learn a high-quality patient-specific model just from the patient's own data. To address these problems we propose, develop and experiment with a new adaptive forecasting framework for building multivariate clinical time series models for a patient and for supporting patient-specific predictions. The framework relies on the adaptive model switching approach that at any point in time selects the most promising time series model out of the pool of many possible models, and consequently, combines advantages of the population, patient-specific and short-term individualized predictive models. We demonstrate that the adaptive model switching framework is very promising approach to support personalized time series prediction, and that it is able to outperform predictions based on pure population and patient-specific models, as well as, other patient-specific model adaptation strategies.

[Effects of "menstrual cycle-based acupuncture therapy" on IVF-ET in patients with decline in ovarian reserve].

PubMed

Zhou, Li; Xia, Youbing; Ma, Xiang; Tang, Limei; Lu, Jing; Tang, Qingqing; Wang, Yinping

2016-01-01

To observe the effects of "menstrual cycle-based acupuncture therapy" on ovarian function and pregnancy results of in vitro fertilization-embryo transfer (IVF-ET) in patients with decline in ovarian reserve (DOR). A total of 63 patients of DOR who received treatment of IVF/intracytoplasmic sperm injection (ICSI) were randomly divided into an observation group (30 cases) and a control group (33 cases). The patients in the observation group were treated with "menstrual cycle-based acupuncture therapy". The syndrome differentiation and treatment were given based on different phases of menstruation. Shiqizhui (EX-B 8) and Mingmen (GV 4) were selected during menstrual phase, Shenshu (BL 23), Geshu (BL 17), Sanyinjiao (SP 6) and Taixi (KI 3) were selected after menstruation, Qihai (CV 6), Guanyuan (CV 4), Zigong (EX-CA 1), Zusanli (ST 36) were selected during ovulatory period, Qihai (CV 6), Guanyuan (CV 4), Yanglingquan (GB 34), Taichong (LR 3) were selected before menstruation. The acupuncture was given twice a week until second menstrual cycle of oocyte retrieval. The total times of acupuncture was (15 ± 2). After acupuncture, patients were treated with IVF-ET. The patients in the control group were treated with IVF-ET but no acupuncture. The indices of ovarian reserve function, including basic follicle-stimulating hormone (FSH), estradiol (E2), antral follicle count (AFC), number of retrieved oocytes, number of fertilization and number of high quality embryo, were compared and analyzed before and after acupuncture in the observation group. The differences of outcomes of IVF-ET, including the cycle cancellation rate, implantation rate, the clinical pregnancy rate, were compared between the two groups. Compared before acupuncture, the E2, AFC, number of retrieved oocytes, number of high quality embrgo and number of fertilization were all increased after acupuncture in the observation group (all P< 0. 05). Compared with the control group, levels of the E2, the number of retrieved oocytes, number of fertilization and number of high quality embryo were all increased in the observation group (all P < 0.05). Also, the implantation rate, the clinical pregnancy rate were improved (both P < 0.01) and cycle cancellation rate was reduced (P< 0.01). The "menstrual cycle-based acupuncture therapy" can effectively improve the ovarian reserve function in DOR patients, leading to an improved clinical pregnancy rate of IVF-ET.

Improving lung cancer prognosis assessment by incorporating synthetic minority oversampling technique and score fusion method

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

Yan, Shiju; Qian, Wei; Guan, Yubao

2016-06-15

Purpose: This study aims to investigate the potential to improve lung cancer recurrence risk prediction performance for stage I NSCLS patients by integrating oversampling, feature selection, and score fusion techniques and develop an optimal prediction model. Methods: A dataset involving 94 early stage lung cancer patients was retrospectively assembled, which includes CT images, nine clinical and biological (CB) markers, and outcome of 3-yr disease-free survival (DFS) after surgery. Among the 94 patients, 74 remained DFS and 20 had cancer recurrence. Applying a computer-aided detection scheme, tumors were segmented from the CT images and 35 quantitative image (QI) features were initiallymore » computed. Two normalized Gaussian radial basis function network (RBFN) based classifiers were built based on QI features and CB markers separately. To improve prediction performance, the authors applied a synthetic minority oversampling technique (SMOTE) and a BestFirst based feature selection method to optimize the classifiers and also tested fusion methods to combine QI and CB based prediction results. Results: Using a leave-one-case-out cross-validation (K-fold cross-validation) method, the computed areas under a receiver operating characteristic curve (AUCs) were 0.716 ± 0.071 and 0.642 ± 0.061, when using the QI and CB based classifiers, respectively. By fusion of the scores generated by the two classifiers, AUC significantly increased to 0.859 ± 0.052 (p < 0.05) with an overall prediction accuracy of 89.4%. Conclusions: This study demonstrated the feasibility of improving prediction performance by integrating SMOTE, feature selection, and score fusion techniques. Combining QI features and CB markers and performing SMOTE prior to feature selection in classifier training enabled RBFN based classifier to yield improved prediction accuracy.« less

Selective Group Approaches in Hospital Settings.

ERIC Educational Resources Information Center

Leopold, Harold S.

The author considers group therapy as one of the most appropriate approaches to help psychotic patients, especially schizophrenics. He advocates the formation of four graded groups of patients based on the seriousness of their problems. The first is an intake group formed of newly admitted patients. Interaction in a group situation provides the…

Factors Influencing the Prescribing Preferences of Physicians for Drug-Naive Patients with Type 2 Diabetes Mellitus in the Real-World Setting in Japan: Insight from a Web Survey.

PubMed

Murayama, Hiroki; Imai, Kota; Odawara, Masato

2018-06-01

The Japanese guidelines for type 2 diabetes mellitus (T2DM) emphasize individualization of treatment based on patient need and encourage physicians to select an appropriate oral antidiabetes drug (OAD). However, limited evidence is available on the factors influencing the selection by physicians (diabetes specialists and nonspecialists) of the first-line OAD to treat drug-naive patients with T2DM. A survey was designed to explore the treatment factors and patient characteristics that influence physicians when they choose an initial OAD to prescribe to a drug-naive patient with T2DM in a real-world setting in Japan. The 25-min web-based online survey consisted of simple and focused multiple-choice questions, and was circulated to physicians across eight selected regions in Japan. The primary endpoints were the proportions of physicians who considered particular treatment factors and patient characteristics when selecting the appropriate treatment for drug-naive T2DM patients. A total of 491 physicians participated in the survey. Dipeptidyl peptidase-4 inhibitors (DPP-4is) were the most-preferred first-line OADs, followed by metformin, of both specialists (69% vs. 60%) and nonspecialists (73% vs. 47%). The most influential factors when a DPP-4i was selected were found to be glycated hemoglobin (HbA1c), postprandial glucose (PPG)-lowering effect, and a low risk of hypoglycemia, which were considered by > 80% of physicians, whereas the key factors when metformin was selected were improvement in insulin resistance, low cost, low risk of hypoglycemia, and PPG- and HbA1c-lowering effects, which were considered by > 85% of physicians. Regression analysis revealed that the dominant reason for choosing DPP-4is over metformin was their ease of use in patients with renal impairment, whereas the dominant reasons for choosing metformin over DPP-4is were improvement in insulin resistance and low cost. The key patient characteristics driving the choice of DPP-4is or metformin as the first-line OAD by physicians were similar to those that influenced the treatment intensification decision (DPP-4is: PPG and renal function; metformin: age, BMI, insulin resistance, and renal function). In Japan, DPP-4is are the preferred first-line OADs, followed by metformin. The key treatment factors and patient characteristics considered when selecting DPP-4is or metformin are similar for both specialists and nonspecialists. These results may prompt further discussion of the differences in T2DM treatment between Japan and other counties. Novartis.

Feature selection for wearable smartphone-based human activity recognition with able bodied, elderly, and stroke patients.

PubMed

Capela, Nicole A; Lemaire, Edward D; Baddour, Natalie

2015-01-01

Human activity recognition (HAR), using wearable sensors, is a growing area with the potential to provide valuable information on patient mobility to rehabilitation specialists. Smartphones with accelerometer and gyroscope sensors are a convenient, minimally invasive, and low cost approach for mobility monitoring. HAR systems typically pre-process raw signals, segment the signals, and then extract features to be used in a classifier. Feature selection is a crucial step in the process to reduce potentially large data dimensionality and provide viable parameters to enable activity classification. Most HAR systems are customized to an individual research group, including a unique data set, classes, algorithms, and signal features. These data sets are obtained predominantly from able-bodied participants. In this paper, smartphone accelerometer and gyroscope sensor data were collected from populations that can benefit from human activity recognition: able-bodied, elderly, and stroke patients. Data from a consecutive sequence of 41 mobility tasks (18 different tasks) were collected for a total of 44 participants. Seventy-six signal features were calculated and subsets of these features were selected using three filter-based, classifier-independent, feature selection methods (Relief-F, Correlation-based Feature Selection, Fast Correlation Based Filter). The feature subsets were then evaluated using three generic classifiers (Naïve Bayes, Support Vector Machine, j48 Decision Tree). Common features were identified for all three populations, although the stroke population subset had some differences from both able-bodied and elderly sets. Evaluation with the three classifiers showed that the feature subsets produced similar or better accuracies than classification with the entire feature set. Therefore, since these feature subsets are classifier-independent, they should be useful for developing and improving HAR systems across and within populations.

Feature Selection for Wearable Smartphone-Based Human Activity Recognition with Able bodied, Elderly, and Stroke Patients

PubMed Central

2015-01-01

Human activity recognition (HAR), using wearable sensors, is a growing area with the potential to provide valuable information on patient mobility to rehabilitation specialists. Smartphones with accelerometer and gyroscope sensors are a convenient, minimally invasive, and low cost approach for mobility monitoring. HAR systems typically pre-process raw signals, segment the signals, and then extract features to be used in a classifier. Feature selection is a crucial step in the process to reduce potentially large data dimensionality and provide viable parameters to enable activity classification. Most HAR systems are customized to an individual research group, including a unique data set, classes, algorithms, and signal features. These data sets are obtained predominantly from able-bodied participants. In this paper, smartphone accelerometer and gyroscope sensor data were collected from populations that can benefit from human activity recognition: able-bodied, elderly, and stroke patients. Data from a consecutive sequence of 41 mobility tasks (18 different tasks) were collected for a total of 44 participants. Seventy-six signal features were calculated and subsets of these features were selected using three filter-based, classifier-independent, feature selection methods (Relief-F, Correlation-based Feature Selection, Fast Correlation Based Filter). The feature subsets were then evaluated using three generic classifiers (Naïve Bayes, Support Vector Machine, j48 Decision Tree). Common features were identified for all three populations, although the stroke population subset had some differences from both able-bodied and elderly sets. Evaluation with the three classifiers showed that the feature subsets produced similar or better accuracies than classification with the entire feature set. Therefore, since these feature subsets are classifier-independent, they should be useful for developing and improving HAR systems across and within populations. PMID:25885272

Targeted training of the decision rule benefits rule-guided behavior in Parkinson's disease.

PubMed

Ell, Shawn W

2013-12-01

The impact of Parkinson's disease (PD) on rule-guided behavior has received considerable attention in cognitive neuroscience. The majority of research has used PD as a model of dysfunction in frontostriatal networks, but very few attempts have been made to investigate the possibility of adapting common experimental techniques in an effort to identify the conditions that are most likely to facilitate successful performance. The present study investigated a targeted training paradigm designed to facilitate rule learning and application using rule-based categorization as a model task. Participants received targeted training in which there was no selective-attention demand (i.e., stimuli varied along a single, relevant dimension) or nontargeted training in which there was selective-attention demand (i.e., stimuli varied along a relevant dimension as well as an irrelevant dimension). Following training, all participants were tested on a rule-based task with selective-attention demand. During the test phase, PD patients who received targeted training performed similarly to control participants and outperformed patients who did not receive targeted training. As a preliminary test of the generalizability of the benefit of targeted training, a subset of the PD patients were tested on the Wisconsin card sorting task (WCST). PD patients who received targeted training outperformed PD patients who did not receive targeted training on several WCST performance measures. These data further characterize the contribution of frontostriatal circuitry to rule-guided behavior. Importantly, these data also suggest that PD patient impairment, on selective-attention-demanding tasks of rule-guided behavior, is not inevitable and highlight the potential benefit of targeted training.

Recommending blood glucose monitors, a pharmacy perspective.

PubMed

Carter, Alan

2007-03-01

Selection of what blood glucose monitoring system to utilize has become an issue for physicians, diabetes educators, pharmacists, and patients. The field of competing makes and models of blood glucose monitoring systems has become crowded, with manufacturers touting improvements in accuracy, ease of use/alternate site options, stored results capacity, software evaluation tools, and/or price point. Personal interviews of 12 pharmacists from community and academic practice settings about monitor preference, as well as results from a national survey of pharmacist recommendations, were compared to actual wholesale sales data to estimate the impact of such recommendations on final monitor selection by the patient. Accu-Chek monitors were recommended 34.65% of the time and represented 28.58% of sales, with a success rate of 82.48% of being the monitor selected. OneTouch monitors had 27.72% of recommendations but represented 31.43% of sales, indicating possible patient brand loyalty or formulary preference for that product. FreeStyle(R) monitors came in third for pharmacist recommendations and were selected by the patient 61.68% of the time when recommended. The category of "other monitor" choices was selected 60.89% of the time by patients given those suggestions. Included in the "other monitor" category was the new disposable monitor marketed as the Sidekick. Based on sales data provided, the Sidekick made up 2.87% of "other monitor" category sales, representing 68% of the "other monitor" segment. While patients frequently follow pharmacist monitoring system suggestions, the ultimate deciding factor is most often the final out-of-pocket cost to the patient. As a result, cost of supplies often becomes the most important determining factor in final monitor selection at the patient level. If the patient cannot afford to perform the recommended daily testing intervals, all other determining factors and suggestions become moot.

An Automatic Prediction of Epileptic Seizures Using Cloud Computing and Wireless Sensor Networks.

PubMed

Sareen, Sanjay; Sood, Sandeep K; Gupta, Sunil Kumar

2016-11-01

Epilepsy is one of the most common neurological disorders which is characterized by the spontaneous and unforeseeable occurrence of seizures. An automatic prediction of seizure can protect the patients from accidents and save their life. In this article, we proposed a mobile-based framework that automatically predict seizures using the information contained in electroencephalography (EEG) signals. The wireless sensor technology is used to capture the EEG signals of patients. The cloud-based services are used to collect and analyze the EEG data from the patient's mobile phone. The features from the EEG signal are extracted using the fast Walsh-Hadamard transform (FWHT). The Higher Order Spectral Analysis (HOSA) is applied to FWHT coefficients in order to select the features set relevant to normal, preictal and ictal states of seizure. We subsequently exploit the selected features as input to a k-means classifier to detect epileptic seizure states in a reasonable time. The performance of the proposed model is tested on Amazon EC2 cloud and compared in terms of execution time and accuracy. The findings show that with selected HOS based features, we were able to achieve a classification accuracy of 94.6 %.

A method and knowledge base for automated inference of patient problems from structured data in an electronic medical record.

PubMed

Wright, Adam; Pang, Justine; Feblowitz, Joshua C; Maloney, Francine L; Wilcox, Allison R; Ramelson, Harley Z; Schneider, Louise I; Bates, David W

2011-01-01

Accurate knowledge of a patient's medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete. To develop and validate methods of automatically inferring patient problems from clinical and billing data, and to provide a knowledge base for inferring problems. We identified 17 target conditions and designed and validated a set of rules for identifying patient problems based on medications, laboratory results, billing codes, and vital signs. A panel of physicians provided input on a preliminary set of rules. Based on this input, we tested candidate rules on a sample of 100,000 patient records to assess their performance compared to gold standard manual chart review. The physician panel selected a final rule for each condition, which was validated on an independent sample of 100,000 records to assess its accuracy. Seventeen rules were developed for inferring patient problems. Analysis using a validation set of 100,000 randomly selected patients showed high sensitivity (range: 62.8-100.0%) and positive predictive value (range: 79.8-99.6%) for most rules. Overall, the inference rules performed better than using either the problem list or billing data alone. We developed and validated a set of rules for inferring patient problems. These rules have a variety of applications, including clinical decision support, care improvement, augmentation of the problem list, and identification of patients for research cohorts.

Development of a decision aid to inform patients’ and families’ renal replacement therapy selection decisions

PubMed Central

2012-01-01

Background Few educational resources have been developed to inform patients’ renal replacement therapy (RRT) selection decisions. Patients progressing toward end stage renal disease (ESRD) must decide among multiple treatment options with varying characteristics. Complex information about treatments must be adequately conveyed to patients with different educational backgrounds and informational needs. Decisions about treatment options also require family input, as families often participate in patients’ treatment and support patients’ decisions. We describe the development, design, and preliminary evaluation of an informational, evidence-based, and patient-and family-centered decision aid for patients with ESRD and varying levels of health literacy, health numeracy, and cognitive function. Methods We designed a decision aid comprising a complementary video and informational handbook. We based our development process on data previously obtained from qualitative focus groups and systematic literature reviews. We simultaneously developed the video and handbook in “stages.” For the video, stages included (1) directed interviews with culturally appropriate patients and families and preliminary script development, (2) video production, and (3) screening the video with patients and their families. For the handbook, stages comprised (1) preliminary content design, (2) a mixed-methods pilot study among diverse patients to assess comprehension of handbook material, and (3) screening the handbook with patients and their families. Results The video and handbook both addressed potential benefits and trade-offs of treatment selections. The 50-minute video consisted of demographically diverse patients and their families describing their positive and negative experiences with selecting a treatment option. The video also incorporated health professionals’ testimonials regarding various considerations that might influence patients’ and families’ treatment selections. The handbook was comprised of written words, pictures of patients and health care providers, and diagrams describing the findings and quality of scientific studies comparing treatments. The handbook text was written at a 4th to 6th grade reading level. Pilot study results demonstrated that a majority of patients could understand information presented in the handbook. Patient and families screening the nearly completed video and handbook reviewed the materials favorably. Conclusions This rigorously designed decision aid may help patients and families make informed decisions about their treatment options for RRT that are well aligned with their values. PMID:23198793

A randomized controlled trial investigating the use of a predictive nomogram for the selection of the FSH starting dose in IVF/ICSI cycles.

PubMed

Allegra, Adolfo; Marino, Angelo; Volpes, Aldo; Coffaro, Francesco; Scaglione, Piero; Gullo, Salvatore; La Marca, Antonio

2017-04-01

The number of oocytes retrieved is a relevant intermediate outcome in women undergoing IVF/intracytoplasmic sperm injection (ICSI). This trial compared the efficiency of the selection of the FSH starting dose according to a nomogram based on multiple biomarkers (age, day 3 FSH, anti-Müllerian hormone) versus an age-based strategy. The primary outcome measure was the proportion of women with an optimal number of retrieved oocytes defined as 8-14. At their first IVF/ICSI cycle, 191 patients underwent a long gonadotrophin-releasing hormone agonist protocol and were randomized to receive a starting dose of recombinant (human) FSH, based on their age (150 IU if ≤35 years, 225 IU if >35 years) or based on the nomogram. Optimal response was observed in 58/92 patients (63%) in the nomogram group and in 42/99 (42%) in the control group (+21%, 95% CI = 0.07 to 0.35, P = 0.0037). No significant differences were found in the clinical pregnancy rate or the number of embryos cryopreserved per patient. The study showed that the FSH starting dose selected according to ovarian reserve is associated with an increase in the proportion of patients with an optimal response: large trials are recommended to investigate any possible effect on the live-birth rate. Copyright © 2017 Reproductive Healthcare Ltd. Published by Elsevier Ltd. All rights reserved.

Grey matter, an endophenotype for schizophrenia? A voxel-based morphometry study in siblings of patients with schizophrenia

PubMed Central

van der Velde, Jorien; Gromann, Paula M.; Swart, Marte; de Haan, Lieuwe; Wiersma, Durk; Bruggeman, Richard; Krabbendam, Lydia; Aleman, André

2015-01-01

Background Grey matter, both volume and concentration, has been proposed as an endophenotype for schizophrenia given a number of reports of grey matter abnormalities in relatives of patients with schizophrenia. However, previous studies on grey matter abnormalities in relatives have produced inconsistent results. The aim of the present study was to examine grey matter differences between controls and siblings of patients with schizophrenia and to examine whether the age, genetic loading or subclinical psychotic symptoms of selected individuals could explain the previously reported inconsistencies. Methods We compared the grey matter volume and grey matter concentration of healthy siblings of patients with schizophrenia and healthy controls matched for age, sex and education using voxel-based morphometry (VBM). Furthermore, we selected subsamples based on age (< 30 yr), genetic loading and subclinical psychotic symptoms to examine whether this would lead to different results. Results We included 89 siblings and 69 controls in our study. The results showed that siblings and controls did not differ significantly on grey matter volume or concentration. Furthermore, specifically selecting participants based on age, genetic loading or subclinical psychotic symptoms did not alter these findings. Limitations The main limitation was that subdividing the sample resulted in smaller samples for the subanalyses. Furthermore, we used MRI data from 2 different scanner sites. Conclusion These results indicate that grey matter measured through VBM might not be a suitable endophenotype for schizophrenia. PMID:25768029

How Sensor, Signal, and Imaging Informatics May Impact Patient Centered Care and Care Coordination

PubMed Central

Moreau-Gaudry, A.

2015-01-01

Summary Objective This synopsis presents a selection for the IMIA (International Medical Informatics Association) Yearbook 2015 of excellent research in the broad field of Sensor, Signal, and Imaging Informatics published in the year 2014, with a focus on patient centered care coordination. Methods The two section editors performed a systematic initial selection and a double blind peer review process to select a list of candidate best papers in the domain published in 2014, from the PubMed and Web of Science databases. A set of MeSH keywords provided by experts was used. This selection was peer-reviewed by external reviewers. Results The review process highlighted articles illustrating two current trends related to care coordination and patient centered care: the enhanced capacity to predict the evolution of a disease based on patient-specific information can impact care coordination; similarly, better perception of the patient and his treatment could lead to enhanced personalized care with a potential impact on care coordination. Conclusions This review shows the multiplicity of angles from which the question of patient-centered care can be addressed, with consequences on care coordination that will need to be confirmed and demonstrated in the future. PMID:26293856

Wide-undermining neck liposuction: tips and tricks for good results.

PubMed

Innocenti, Alessandro; Andretto Amodeo, Chiara; Ciancio, Francesco

2014-08-01

Neck rejuvenation is one of the most sought after procedures in the restoration of the facial contour. Numerous techniques to improve the aesthetic outcome and reduce downtime have been described. In our experience, wide undermining and local anesthesia are key to obtaining good results in selected patients who want a quick recovery. This article presents our experience with liposuction of the neck and proposes some tips and tricks to master wide-undermining neck liposuction. From January 2005 to September 2012, a total of 118 patients (34 males, 84 females) underwent neck liposuction. Patient selection was based mainly on age and neck-aging features. The procedure was performed with the patients under local anesthesia. A wide rhomboid-shaped skin undermining of the submandibular and neck area was performed and a very thin fat layer was preserved. Dressing was applied for 3 days. Improvement of the neck's contour was observed in all patients. Redefinition of the cervicomandibular angle and skin redraping of the cervical area occurred in all cases. No further touch-ups were needed. Edema and ecchymosis resolved in a few days. No major complications were observed. Our results show that wide-undermining neck liposuction performed under local anesthesia is an effective and safe procedure. Patient selection based on age and anatomical features was fundamental to obtain impressive improvement of neck contour. This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Hematopoietic stem cell transplantation. Indications, foundations and perspective].

PubMed

Buchholz, S; Ganser, A

2009-05-01

The hematopoietic stem cell transplantation (HSCT) has become a standard therapy for many inherited and acquired disorders of the bone marrow and immune system. Autologous HSCT is mainly done as part of the primary therapy in multiple myeloma and as part of relapse therapy in malignant lymphoma. In contrast, allogeneic HSCT is predominantly performed in patients with acute leukemias. The selection process for allogeneic HSCT takes disease-specific as well as patient-specific factors into account. Risk factors which can predict for poor response to chemotherapy can now be identified in acute myeloid as well as lymphoid leukemia, based on phenotype, cytogenetics, molecular genetics and response to therapy. In these patients allogeneic HSCT can improve overall survival from 0-20% to 30-60%. New conditioning protocols have now raised the upper age limit for transplantation to 70 years. In elderly patients the selection of patients based on absence of comorbidities becomes especially important. The increasing number of long-term survivors requires knowledge of organ-specific late toxicities including secondary malignancies.

An early examination of access to select orphan drugs treating rare diseases in health insurance exchange plans.

PubMed

Robinson, Sandy W; Brantley, Kelly; Liow, Christine; Teagarden, J Russell

2014-10-01

Patients with rare diseases often face significant health care access challenges, particularly since the number of available treatment options for rare diseases is limited. The implementation of health insurance exchanges promises improved access to health care. However, when purchasing a plan, patients with rare diseases need to consider multiple factors, such as insurance premium, access to providers, coverage of a specific medication or treatment, tier placement of drug, and out-of-pocket costs.  To provide an early snapshot of the exchange plan landscape from the perspective of patients with select rare diseases by evaluating the degree of access to medications in a subset of exchange plans based on coverage, tier placement, associated cost sharing, and utilization management (UM) applied.  The selection of drugs for this analysis began by identifying rare diseases with FDA-approved treatment options using the National Institutes of Health Office of Rare Diseases' webpage and further identification of a subset of drugs based on select criteria to ensure a varied sample, including the characteristics and prevalence of the condition. The medications were categorized based on whether alternative therapies have FDA approval for the same indication and whether there are comparators based on class or therapeutic area. The list was narrowed to 11 medications across 7 diseases, and the analysis was based on how these drugs are listed in exchange plan outpatient pharmacy benefit formularies. This analysis focused on 84 plans in 15 states with the highest expected exchange enrollment and included a variety of plan types to ensure that variability in the marketplace was represented. To best approximate plans that will have the greatest enrollment, the analysis focused on silver and bronze plan formularies because consumers in this market are expected to be sensitive to premiums. Data on drug coverage, tier placement, cost, and UM were collected from these plans beginning October 1, 2013, with the launch of the open enrollment period. Coverage and use of UM for selected medications vary within and across states. This study found that bronze plans were far less likely than silver plans to cover the 11 products included in this analysis. Results also showed that select drugs identified as the only FDA-approved product indicated for a certain rare disease experienced relatively robust coverage (at least 65% of plans) but often included some form of UM. However, coverage of selected rare disease therapies also is complicated by the fact that plans cover certain products under the medical benefit versus the pharmacy benefit. At the time of this analysis, transparency of medical benefit coverage for these products in exchange plans was limited.Selected medications are most likely to appear on the highest tiers of 4-tier formularies or are not covered at all. Although there are no requirements to designate certain tiers as "specialty tiers," more than 70% of plans in this study use coinsurance for the highest tiers of their formularies. Rates of coinsurance for medications on highest tiers range from 10% to 50% in silver plans and 15% to 50% in bronze plans. Among those plans utilizing copayments rather than coinsurance, ranges of copayments for these select products vary between $20 and $250 per prescription across both silver plans and bronze plans. This preliminary analysis of access to treatments for patients with select rare diseases revealed the complexities involved for patients with specific needs when selecting a plan with appropriate coverage. For patients with rare diseases, the process of identifying and selecting a plan centers on understanding if and how the plan covers a specific treatment or set of treatments. Access factors will likely vary substantially across plans, as demonstrated by the findings from this analysis. With limited treatment options and the potential for cost sharing and UM barriers, increased data transparency to assist patients in navigating formularies will be a critical step for patients to fully understand their access to needed therapies in each plan.

Expanding choices in intranasal steroid therapy: summary of a roundtable meeting.

PubMed

Blaiss, Michael S; Benninger, Michael S; Fromer, Len; Gross, Gary; Mabry, Richard; Mahr, Todd; Marple, Bradley; Stoloff, Stuart

2006-01-01

Intranasal steroids (INSs) are recommended as first-line treatment for allergic rhinitis (AR) and a wealth of data exist supporting them as safe and effective. Our goal was to develop a consensus to help physicians choose between INSs by focusing on clinical profiles and patient preferences and providing expert advice on choosing the appropriate INS for each patient. Experts from specialties that manage patients with AR attended a roundtable meeting to discuss INS therapy. Besides comparisons with other pharmacologic agents, they examined the effects of INS on nasal anatomy, patient preferences for INS, and benefits of product selection based on patient profile. The literature on INSs in AR was reviewed, examining properties of the various drugs, delivery devices, formulations, and patient preference data. Nasal anatomy and physiology must be considered to optimize INS deposition in the nose. Teaching patients proper technique for using INS devices is important to prevent nasal injury and may help concentrate drug effect on affected tissues. INS therapies differ somewhat in biological properties and specific formulation; however, all are considered safe and effective treatment for AR. Patients exhibit different clinical profiles, which play a role in INS selection. Patients can clearly identify sensory characteristics of INS and therefore establish product preference. Patient preference also can guide physicians in choosing the appropriate agent for each patient. Control of AR requires a systematic approach to treatment selection and follow-up. Treatment selection should be matched with clinical profile and patient preferences.

Molecular Classification Substitutes for the Prognostic Variables Stage, Age, and MYCN Status in Neuroblastoma Risk Assessment.

PubMed

Rosswog, Carolina; Schmidt, Rene; Oberthuer, André; Juraeva, Dilafruz; Brors, Benedikt; Engesser, Anne; Kahlert, Yvonne; Volland, Ruth; Bartenhagen, Christoph; Simon, Thorsten; Berthold, Frank; Hero, Barbara; Faldum, Andreas; Fischer, Matthias

2017-12-01

Current risk stratification systems for neuroblastoma patients consider clinical, histopathological, and genetic variables, and additional prognostic markers have been proposed in recent years. We here sought to select highly informative covariates in a multistep strategy based on consecutive Cox regression models, resulting in a risk score that integrates hazard ratios of prognostic variables. A cohort of 695 neuroblastoma patients was divided into a discovery set (n=75) for multigene predictor generation, a training set (n=411) for risk score development, and a validation set (n=209). Relevant prognostic variables were identified by stepwise multivariable L1-penalized least absolute shrinkage and selection operator (LASSO) Cox regression, followed by backward selection in multivariable Cox regression, and then integrated into a novel risk score. The variables stage, age, MYCN status, and two multigene predictors, NB-th24 and NB-th44, were selected as independent prognostic markers by LASSO Cox regression analysis. Following backward selection, only the multigene predictors were retained in the final model. Integration of these classifiers in a risk scoring system distinguished three patient subgroups that differed substantially in their outcome. The scoring system discriminated patients with diverging outcome in the validation cohort (5-year event-free survival, 84.9±3.4 vs 63.6±14.5 vs 31.0±5.4; P<.001), and its prognostic value was validated by multivariable analysis. We here propose a translational strategy for developing risk assessment systems based on hazard ratios of relevant prognostic variables. Our final neuroblastoma risk score comprised two multigene predictors only, supporting the notion that molecular properties of the tumor cells strongly impact clinical courses of neuroblastoma patients. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

The Adverse Drug Reactions from Patient Reports in Social Media Project: Five Major Challenges to Overcome to Operationalize Analysis and Efficiently Support Pharmacovigilance Process

PubMed Central

Dahamna, Badisse; Guillemin-Lanne, Sylvie; Darmoni, Stefan J; Faviez, Carole; Huot, Charles; Katsahian, Sandrine; Leroux, Vincent; Pereira, Suzanne; Richard, Christophe; Schück, Stéphane; Souvignet, Julien; Lillo-Le Louët, Agnès; Texier, Nathalie

2017-01-01

Background Adverse drug reactions (ADRs) are an important cause of morbidity and mortality. Classical Pharmacovigilance process is limited by underreporting which justifies the current interest in new knowledge sources such as social media. The Adverse Drug Reactions from Patient Reports in Social Media (ADR-PRISM) project aims to extract ADRs reported by patients in these media. We identified 5 major challenges to overcome to operationalize the analysis of patient posts: (1) variable quality of information on social media, (2) guarantee of data privacy, (3) response to pharmacovigilance expert expectations, (4) identification of relevant information within Web pages, and (5) robust and evolutive architecture. Objective This article aims to describe the current state of advancement of the ADR-PRISM project by focusing on the solutions we have chosen to address these 5 major challenges. Methods In this article, we propose methods and describe the advancement of this project on several aspects: (1) a quality driven approach for selecting relevant social media for the extraction of knowledge on potential ADRs, (2) an assessment of ethical issues and French regulation for the analysis of data on social media, (3) an analysis of pharmacovigilance expert requirements when reviewing patient posts on the Internet, (4) an extraction method based on natural language processing, pattern based matching, and selection of relevant medical concepts in reference terminologies, and (5) specifications of a component-based architecture for the monitoring system. Results Considering the 5 major challenges, we (1) selected a set of 21 validated criteria for selecting social media to support the extraction of potential ADRs, (2) proposed solutions to guarantee data privacy of patients posting on Internet, (3) took into account pharmacovigilance expert requirements with use case diagrams and scenarios, (4) built domain-specific knowledge resources embeding a lexicon, morphological rules, context rules, semantic rules, syntactic rules, and post-analysis processing, and (5) proposed a component-based architecture that allows storage of big data and accessibility to third-party applications through Web services. Conclusions We demonstrated the feasibility of implementing a component-based architecture that allows collection of patient posts on the Internet, near real-time processing of those posts including annotation, and storage in big data structures. In the next steps, we will evaluate the posts identified by the system in social media to clarify the interest and relevance of such approach to improve conventional pharmacovigilance processes based on spontaneous reporting. PMID:28935617

Feature Selection in Classification of Eye Movements Using Electrooculography for Activity Recognition

PubMed Central

Mala, S.; Latha, K.

2014-01-01

Activity recognition is needed in different requisition, for example, reconnaissance system, patient monitoring, and human-computer interfaces. Feature selection plays an important role in activity recognition, data mining, and machine learning. In selecting subset of features, an efficient evolutionary algorithm Differential Evolution (DE), a very efficient optimizer, is used for finding informative features from eye movements using electrooculography (EOG). Many researchers use EOG signals in human-computer interactions with various computational intelligence methods to analyze eye movements. The proposed system involves analysis of EOG signals using clearness based features, minimum redundancy maximum relevance features, and Differential Evolution based features. This work concentrates more on the feature selection algorithm based on DE in order to improve the classification for faultless activity recognition. PMID:25574185

Feature selection in classification of eye movements using electrooculography for activity recognition.

PubMed

Mala, S; Latha, K

2014-01-01

Activity recognition is needed in different requisition, for example, reconnaissance system, patient monitoring, and human-computer interfaces. Feature selection plays an important role in activity recognition, data mining, and machine learning. In selecting subset of features, an efficient evolutionary algorithm Differential Evolution (DE), a very efficient optimizer, is used for finding informative features from eye movements using electrooculography (EOG). Many researchers use EOG signals in human-computer interactions with various computational intelligence methods to analyze eye movements. The proposed system involves analysis of EOG signals using clearness based features, minimum redundancy maximum relevance features, and Differential Evolution based features. This work concentrates more on the feature selection algorithm based on DE in order to improve the classification for faultless activity recognition.

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

Heijkoop, Sabrina T., E-mail: s.heijkoop@erasmusmc.nl; Langerak, Thomas R.; Quint, Sandra

Purpose: To evaluate the clinical implementation of an online adaptive plan-of-the-day protocol for nonrigid target motion management in locally advanced cervical cancer intensity modulated radiation therapy (IMRT). Methods and Materials: Each of the 64 patients had four markers implanted in the vaginal fornix to verify the position of the cervix during treatment. Full and empty bladder computed tomography (CT) scans were acquired prior to treatment to build a bladder volume-dependent cervix-uterus motion model for establishment of the plan library. In the first phase of clinical implementation, the library consisted of one IMRT plan based on a single model-predicted internal targetmore » volume (mpITV), covering the target for the whole pretreatment observed bladder volume range, and a 3D conformal radiation therapy (3DCRT) motion-robust backup plan based on the same mpITV. The planning target volume (PTV) combined the ITV and nodal clinical target volume (CTV), expanded with a 1-cm margin. In the second phase, for patients showing >2.5-cm bladder-induced cervix-uterus motion during planning, two IMRT plans were constructed, based on mpITVs for empty-to-half-full and half-full-to-full bladder. In both phases, a daily cone beam CT (CBCT) scan was acquired to first position the patient based on bony anatomy and nodal targets and then select the appropriate plan. Daily post-treatment CBCT was used to verify plan selection. Results: Twenty-four and 40 patients were included in the first and second phase, respectively. In the second phase, 11 patients had two IMRT plans. Overall, an IMRT plan was used in 82.4% of fractions. The main reasons for selecting the motion-robust backup plan were uterus outside the PTV (27.5%) and markers outside their margin (21.3%). In patients with two IMRT plans, the half-full-to-full bladder plan was selected on average in 45% of the first 12 fractions, which was reduced to 35% in the last treatment fractions. Conclusions: The implemented online adaptive plan-of-the-day protocol for locally advanced cervical cancer enables (almost) daily tissue-sparing IMRT.« less

Mechanisms underlying selecting objects for action

PubMed Central

Wulff, Melanie; Laverick, Rosanna; Humphreys, Glyn W.; Wing, Alan M.; Rotshtein, Pia

2015-01-01

We assessed the factors which affect the selection of objects for action, focusing on the role of action knowledge and its modulation by distracters. Fourteen neuropsychological patients and 10 healthy aged-matched controls selected pairs of objects commonly used together among distracters in two contexts: with real objects and with pictures of the same objects presented sequentially on a computer screen. Across both tasks, semantically related distracters led to slower responses and more errors than unrelated distracters and the object actively used for action was selected prior to the object that would be passively held during the action. We identified a sub-group of patients (N = 6) whose accuracy was 2SDs below the controls performances in the real object task. Interestingly, these impaired patients were more affected by the presence of unrelated distracters during both tasks than intact patients and healthy controls. Note that the impaired patients had lesions to left parietal, right anterior temporal and bilateral pre-motor regions. We conclude that: (1) motor procedures guide object selection for action, (2) semantic knowledge affects action-based selection, (3) impaired action decision making is associated with the inability to ignore distracting information and (4) lesions to either the dorsal or ventral visual stream can lead to deficits in making action decisions. Overall, the data indicate that impairments in everyday tasks can be evaluated using a simulated computer task. The implications for rehabilitation are discussed. PMID:25954177

[Embryo selection in IVF/ICSI cycles using time-lapse microscopy and the clinical outcomes].

PubMed

Chen, Minghao; Huang, Jun; Zhong, Ying; Quan, Song

2015-12-01

To compare the clinical outcomes of embryos selected using time-lapse microscopy and traditional morphological method in IVF/ICSI cycles and evaluate the clinical value of time-lapse microscopy in early embryo monitoring and selection. e retrospectively analyzed the clinical data of 139 IVF/ICSI cycles with embryo selection based on time-lapse monitoring (TLM group, n=68) and traditional morphological method (control group, n=71). The βHCG-positive rate, clinical pregnancy rate and embryo implantation rate were compared between the 2 groups. Subgroup analysis was performed in view of female patients age and the fertilization type. The βHCG-positive rate, clinical pregnancy rate and implantation rate were 66.2%, 61.8% and 47.1% in TLM group, significantly higher than those in the control group (47.9%, 43.7% and 30.3%, respectively; P<0.05). Compared with patients below 30 years of age, patients aged between 31 and 35 years benefited more from time-lapse monitoring with improved clinical outcomes. time-lapse monitoring significantly increased the βHCG-positive rate, clinical pregnancy rate and implantation rate for patients undergoing IVF cycles, but not for those undergoing ICSI or TESA cycles. Compared with those selected using traditional morphological method, the embryos selected with time-lapse microscopy have better clinical outcomes, especially in older patients (31-35 years of age) and in IVF cycles.

Nerve monitoring-guided selective hypoglossal nerve stimulation in obstructive sleep apnea patients.

PubMed

Heiser, Clemens; Hofauer, Benedikt; Lozier, Luke; Woodson, B Tucker; Stark, Thomas

2016-12-01

Selective stimulation of the upper airway is a new therapy for obstructive sleep apnea. The aim of the study was to determine if a selective nerve integrity monitoring (NIM) system could aid in precise placement of the cuff electrode in selective upper-airway stimulation. Single-center, prospective clinical trial. Twenty patients who received a selective upper-airway stimulation system (Inspire Medical Systems, Maple Grove, MN) were implanted by using a NIM system. The tongue motions were recorded during surgery and 2 months postoperatively from the transoral view and by transnasal endoscopy. All patients exhibited consistent protrusion at tongue front and tongue base. The nerve monitoring system helped to place the cuff electrode around the protrusion and stiffening branches, while excluding the retractor branches of the hypoglossal nerve. This report demonstrated a novel use of a NIM system to identify the functional separation between inclusion and exclusion branches of the hypoglossal nerve for implantation of a selective upper-airway stimulation system. 4. Laryngoscope, 126:2852-2858, 2016. © 2016 The American Laryngological, Rhinological and Otological Society, Inc.

[Evidence-based medicine: an approach without any weakness?].

PubMed

Junod, A F

2000-04-06

Evidence-based medicine is a methodological approach giving access to the best information derived from clinical research for an individual patient. It requires the formulation of a question, a strategy to search for the best information, the selection of the latter, its critical appraisal and its application to the patient. The qualities, but also the limitations of this approach are discussed.

Comparison of Effectiveness of the Metacognition Treatment and the Mindfulness-Based Stress Reduction Treatment on Global and Specific Life Quality of Women with Breast Cancer

PubMed Central

Rahmani, Soheila; Talepasand, Siavash; Ghanbary-Motlagh, ALi

2014-01-01

Background This study is conducted to compare the metacognition treatment and the mindfulness-based stress reduction treatment on life quality of women with breast cancer. Methods In a quasi-experimental design, with pre-test, post-test and control group, 36 patients with diagnosis of breast cancer, among patients who referred to the Division of Oncology and Radiotherapy of Imam Hossein hospital in Tehran, were selected in accessible way and were assigned randomly to three experimental groups, the first group receiving meta-cognition treatment (n=12), the second one receiving mindfulness-based stress reduction program (n=12), and the other was the control group. Participants completed global life quality in cancer patient's questionnaire and specific quality of life in breast cancer patient's questionnaire in three stages: baseline, after intervention and two-month follow-up. Data were analyzed using the multivariate repeated measurement model. Results Findings showed both treatments were effective in improving global and specific quality of life in patients with breast cancer. The mindfulness -based stress reduction treatment excelled in functions and roles, fatigue, pain, future perspective and treatment side effects symptoms at the end of the treatment and follow-up in comparison to the metacognition treatment. Conclusion Results of this research showed the mindfulness-based stress reduction treatment can be effective in improving global and specific life quality of women with breast cancer and is a selective method for improving quality of life in patients. PMID:25628839

Selected correlates of white nursing students' attitudes toward black American patients.

PubMed

Morgan, B S

1983-01-01

Multivariate analyses were used to examine the relationships between white nursing students' attitudes toward black American patients and variables selected within a theoretical framework of prejudice which included socialization factors and personality-based factors. The variables selected were: authoritarianism and self-esteem (personality-based factors), parents' attitudes toward black Americans, peer attitudes toward black Americans, interracial contact and socioeconomic status (socialization factors). The study also examined the differences in the relationship among white nursing students enrolled in baccalaureate degree, associate degree and diploma nursing programs. Data were collected from 201 senior nursing students enrolled in the three types of nursing programs in Rhode Island during the late fall and winter of 1979-1980. Although baccalaureate degree, associate degree and diploma students were similar in terms of peer attitudes toward black Americans, fathers' attitudes toward black Americans, self-esteem and attitudes toward black American patients, they were significantly different in terms of age, socioeconomic status, mothers' attitudes toward black Americans, interracial contact and authoritarianism. The major findings of this study indicate that the socialization explanation of prejudice is more significant than the personality-based explanation. The variables socioeconomic status, interracial contact and peer attitudes toward black Americans (all socialization variables) accounted for 22.0% of the total variance in attitudes toward black American patients for the total sample of nursing students. However, this relationship was not generalizable across the three different types of nursing programs.

Effectiveness of a new health care organization model in primary care for chronic cardiovascular disease patients based on a multifactorial intervention: the PROPRESE randomized controlled trial.

PubMed

Orozco-Beltran, Domingo; Ruescas-Escolano, Esther; Navarro-Palazón, Ana Isabel; Cordero, Alberto; Gaubert-Tortosa, María; Navarro-Perez, Jorge; Carratalá-Munuera, Concepción; Pertusa-Martínez, Salvador; Soler-Bahilo, Enrique; Brotons-Muntó, Francisco; Bort-Cubero, Jose; Nuñez-Martinez, Miguel Angel; Bertomeu-Martinez, Vicente; Gil-Guillen, Vicente Francisco

2013-08-02

To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals. Experimental study. Randomized clinical trial. Follow-up period: one year. primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records. This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life, number of visits, and number of hospitalizations. NCT01826929.

Memory and selective attention in multiple sclerosis: cross-sectional computer-based assessment in a large outpatient sample.

PubMed

Adler, Georg; Lembach, Yvonne

2015-08-01

Cognitive impairments may have a severe impact on everyday functioning and quality of life of patients with multiple sclerosis (MS). However, there are some methodological problems in the assessment and only a few studies allow a representative estimate of the prevalence and severity of cognitive impairments in MS patients. We applied a computer-based method, the memory and attention test (MAT), in 531 outpatients with MS, who were assessed at nine neurological practices or specialized outpatient clinics. The findings were compared with those obtained in an age-, sex- and education-matched control group of 84 healthy subjects. Episodic short-term memory was substantially decreased in the MS patients. About 20% of them reached a score of only less than two standard deviations below the mean of the control group. The episodic short-term memory score was negatively correlated with the EDSS score. Minor but also significant impairments in the MS patients were found for verbal short-term memory, episodic working memory and selective attention. The computer-based MAT was found to be useful for a routine assessment of cognition in MS outpatients.

Model-based dose selection for phase III rivaroxaban study in Japanese patients with non-valvular atrial fibrillation.

PubMed

Tanigawa, Takahiko; Kaneko, Masato; Hashizume, Kensei; Kajikawa, Mariko; Ueda, Hitoshi; Tajiri, Masahiro; Paolini, John F; Mueck, Wolfgang

2013-01-01

The global ROCKET AF phase III trial evaluated rivaroxaban 20 mg once daily (o.d.) for stroke prevention in atrial fibrillation (AF). Based on rivaroxaban pharmacokinetics in Japanese subjects and lower anticoagulation preferences in Japan, particularly in elderly patients, the optimal dose regimen for Japanese AF patients was considered. The aim of this analysis was dose selection for Japanese patients from a pharmacokinetic aspect by comparison of simulated exposure in Japanese patients with those in Caucasian patients. As a result of population pharmacokinetics-pharmacodynamics analyses, a one-compartment pharmacokinetic model with first-order absorption and direct link pharmacokinetic-pharmacodynamic models optimally described the plasma concentration and pharmacodynamic models (Factor Xa activity, prothrombin time, activated partial thromboplastin time, and HepTest), which were also consistent with previous works. Steady-state simulations indicated 15 mg rivaroxaban o.d. doses in Japanese patients with AF would yield exposures comparable to the 20 mg o.d. dose in Caucasian patients with AF. In conclusion, in the context of the lower anticoagulation targets in Japanese practice, the population pharmacokinetic and pharmacodynamic modeling supports 15 mg o.d. as the principal rivaroxaban dose in J-ROCKET AF.

Evidence-based Practice. Findings from the Section on Education and Consumer Health Informatics.

PubMed

Staccini, P; Douali, N

2013-01-01

To provide an overview of outstanding current research conducted in Education and Consumer Informatics. Synopsis of the articles on education and consumer health informatics published in 2012 and selected for the IMIA Yearbook of Medical Informatics 2013. Architecture of monitoring or telehealth information systems for patients with chronic disease must include wireless devices to aid in the collection of personal data. Data acquisition technologies have an impact on patients' willingness to participate in telehealth programmes. Patients are more likely to prefer mobile applications over web-based applications. Social media is widely used by clinicians. Especially younger clinicians use it for personal purposes and for reference materials retrieval. Questions remain on optimal training requirements and on the effects on clinician behavior and on patient outcomes. A high level of e-Health literacy by patients will promote increased adoption and utilization of personal health records. The selected articles highlight the need for training of clinicians to become aware of existing telehealth systems, in order to correctly inform and guide patients to take part in telehealth systems and adopt personal healthcare records (PHR).

A Model to Predict the Use of Surgical Resection for Advanced-Stage Non-Small Cell Lung Cancer Patients.

PubMed

David, Elizabeth A; Andersen, Stina W; Beckett, Laurel A; Melnikow, Joy; Kelly, Karen; Cooke, David T; Brown, Lisa M; Canter, Robert J

2017-11-01

For advanced-stage non-small cell lung cancer, chemotherapy and chemoradiotherapy are the primary treatments. Although surgical intervention in these patients is associated with improved survival, the effect of selection bias is poorly defined. Our objective was to characterize selection bias and identify potential surgical candidates by constructing a Surgical Selection Score (SSS). Patients with clinical stage IIIA, IIIB, or IV non-small cell lung cancer were identified in the National Cancer Data Base from 1998 to 2012. Logistic regression was used to develop the SSS based on clinical characteristics. Estimated area under the receiver operating characteristic curve was used to assess discrimination performance of the SSS. Kaplan-Meier analysis was used to compare patients with similar SSSs. We identified 300,572 patients with stage IIIA, IIIB, or IV non-small cell lung cancer without missing data; 6% (18,701) underwent surgical intervention. The surgical cohort was 57% stage IIIA (n = 10,650), 19% stage IIIB (n = 3,483), and 24% stage IV (n = 4,568). The areas under the receiver operating characteristic curve from the best-fit logistic regression model in the training and validation sets were not significantly different, at 0.83 (95% confidence interval, 0.82 to 0.83) and 0.83 (95% confidence interval, 0.82 to 0.83). The range of SSS is 43 to 1,141. As expected, SSS was a good predictor of survival. Within each quartile of SSS, patients in the surgical group had significantly longer survival than nonsurgical patients (p < 0.001). A prediction model for selection of patients for surgical intervention was created. Once validated and prospectively tested, this model may be used to identify patients who may benefit from surgical intervention. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Does patient reporting lead to earlier detection of drug safety signals? A retrospective comparison of time to reporting between patients and healthcare professionals in a global database.

PubMed

Rolfes, Leàn; van Hunsel, Florence; Caster, Ola; Taavola, Henric; Taxis, Katja; van Puijenbroek, Eugène

2018-03-09

To explore if there is a difference between patients and healthcare professionals (HCPs) in time to reporting drug-adverse drug reaction (ADR) associations that led to drug safety signals. This was a retrospective comparison of time to reporting selected drug-ADR associations which led to drug safety signals between patients and HCPs. ADR reports were selected from the World Health Organization Global database of individual case safety reports, VigiBase. Reports were selected based on drug-ADR associations of actual drug safety signals. Primary outcome was the difference in time to reporting between patients and HCPs. The date of the first report for each individual signal was used as time zero. The difference in time between the date of the reports and time zero was calculated. Statistical differences in timing were analysed on the corresponding survival curves using a Mann-Whitney U test. In total, 2822 reports were included, of which 52.7% were patient reports, with a median of 25% for all included signals. For all signals, median time to signal detection was 10.4 years. Overall, HCPs reported earlier than patients: median 7.0 vs. 8.3 years (P < 0.001). Patients contributed a large proportion of reports on drug-ADR pairs that eventually became signals. HCPs reported 1.3 year earlier than patients. These findings strengthen the evidence on the value of patient reporting in signal detection and highlight an opportunity to encourage patients to report suspected ADRs even earlier in the future. © 2018 The Authors. British Journal of Clinical Pharmacology published by John Wiley & Sons Ltd on behalf of British Pharmacological Society.

Patient-based outcome analysis is important to determine the success of total knee arthroplasty: result of a focus group discussion.

PubMed

Zacharia, Balaji; Paul, Manu; Thanveeruddin Sherule, Mohammed

2016-01-01

Total knee replacement (TKR) results in an excellent outcome in terms of pain relief. The reporting of outcomes was traditionally focused on implant survivorship and objective outcomes such as range of motion, knee stability, and radiographic alignment. However, patients and doctors had differing perceptions of all domains of outcome, especially subjective quality of life domains such as emotions and social functioning. In this study, we tried to find out the expectations of Indian patients regarding TKR and assess the level of satisfaction among our patients from their view point using focus group discussion (FGD), and whether these expectations have an impact on outcomes and patient satisfaction. This study was conducted in the Department of Orthopedics, Government Medical College, Kozhikode, Kerala, India, in November 2014. Patients between the ages 60 and 65 years who met inclusion criteria were selected. A total of 50 patients were selected for FGDs. Among them, 42 patients participated in FGD. The remaining eight did not appear for the discussion. A total of four FGD sessions were conducted. It was found that there is a discrepancy between the satisfaction levels of patient and surgeon. There is a difference in satisfaction level achieved depending on socioeconomic, geographic, and cultural characteristics. Newer methods of TKR outcome assessment combining radiological outcome, surgeon-based assessment, and patient satisfaction based on their socioeconomic status and cultural characteristics should be developed for different populations.

Logistic-based patient grouping for multi-disciplinary treatment.

PubMed

Maruşter, Laura; Weijters, Ton; de Vries, Geerhard; van den Bosch, Antal; Daelemans, Walter

2002-01-01

Present-day healthcare witnesses a growing demand for coordination of patient care. Coordination is needed especially in those cases in which hospitals have structured healthcare into specialty-oriented units, while a substantial portion of patient care is not limited to single units. From a logistic point of view, this multi-disciplinary patient care creates a tension between controlling the hospital's units, and the need for a control of the patient flow between units. A possible solution is the creation of new units in which different specialties work together for specific groups of patients. A first step in this solution is to identify the salient patient groups in need of multi-disciplinary care. Grouping techniques seem to offer a solution. However, most grouping approaches in medicine are driven by a search for pathophysiological homogeneity. In this paper, we present an alternative logistic-driven grouping approach. The starting point of our approach is a database with medical cases for 3,603 patients with peripheral arterial vascular (PAV) diseases. For these medical cases, six basic logistic variables (such as the number of visits to different specialist) are selected. Using these logistic variables, clustering techniques are used to group the medical cases in logistically homogeneous groups. In our approach, the quality of the resulting grouping is not measured by statistical significance, but by (i) the usefulness of the grouping for the creation of new multi-disciplinary units; (ii) how well patients can be selected for treatment in the new units. Given a priori knowledge of a patient (e.g. age, diagnosis), machine learning techniques are employed to induce rules that can be used for the selection of the patients eligible for treatment in the new units. In the paper, we describe the results of the above-proposed methodology for patients with PAV diseases. Two groupings and the accompanied classification rule sets are presented. One grouping is based on all the logistic variables, and another grouping is based on two latent factors found by applying factor analysis. On the basis of the experimental results, we can conclude that it is possible to search for medical logistic homogenous groups (i) that can be characterized by rules based on the aggregated logistic variables; (ii) for which we can formulate rules to predict to which cluster new patients belong.

Reconstruction of the Irradiated Breast: A National Claims-Based Assessment of Postoperative Morbidity.

PubMed

Chetta, Matthew D; Aliu, Oluseyi; Zhong, Lin; Sears, Erika D; Waljee, Jennifer F; Chung, Kevin C; Momoh, Adeyiza O

2017-04-01

Implant-based reconstruction rates have risen among irradiation-treated breast cancer patients in the United States. This study aims to assess the morbidity associated with various breast reconstruction techniques in irradiated patients. From the MarketScan Commercial Claims and Encounters database, the authors selected breast cancer patients who had undergone mastectomy, irradiation, and breast reconstruction from 2009 to 2012. Demographic and clinical treatment data, including data on the timing of irradiation relative to breast reconstruction were recorded. Complications and failures after implant and autologous reconstruction were also recorded. A multivariable logistic regression model was developed with postoperative complications as the dependent variable and patient demographic and clinical variables as independent variables. Four thousand seven hundred eighty-one irradiated patients who met the inclusion criteria were selected. A majority of the patients [n = 3846 (80 percent)] underwent reconstruction with implants. Overall complication rates were 45.3 percent and 30.8 percent for patients with implant and autologous reconstruction, respectively. Failure of reconstruction occurred in 29.4 percent of patients with implant reconstruction compared with 4.3 percent of patients with autologous reconstruction. In multivariable logistic regression, irradiated patients with implant reconstruction had two times the odds of having any complication and 11 times the odds of failure relative to patients with autologous reconstruction. Implant-based breast reconstruction in the irradiated patient, although popular, is associated with significant morbidity. Failures of reconstruction with implants in these patients approach 30 percent in the short term, suggesting a need for careful shared decision-making, with full disclosure of the potential morbidity. Therapeutic, III.

Patient prognosis based on feature extraction, selection and classification of EEG periodic activity.

PubMed

Sánchez-González, Alain; García-Zapirain, Begoña; Maestro Saiz, Iratxe; Yurrebaso Santamaría, Izaskun

2015-01-01

Periodic activity in electroencephalography (PA-EEG) is shown as comprising a series of repetitive wave patterns that may appear in different cerebral regions and are due to many different pathologies. The diagnosis based on PA-EEG is an arduous task for experts in Clinical Neurophysiology, being mainly based on other clinical features of patients. Considering this difficulty in the diagnosis it is also very complicated to establish the prognosis of patients who present PA-EEG. The goal of this paper is to propose a method capable of determining patient prognosis based on characteristics of the PA-EEG activity. The approach, based on a parallel classification architecture and a majority vote system has proven successful by obtaining a success rate of 81.94% in the classification of patient prognosis of our database.

Implications of prognostic factors and risk groups in the management of differentiated thyroid cancer.

PubMed

Shaha, Ashok R

2004-03-01

The outcome in differentiated thyroid cancer generally depends on the stage of the disease at the time of presentation; prognostic factors such as age, grade, size, extension, or distant metastasis; and risk groups (eg, low or high risk). The author has reviewed a large number of patients with differentiated thyroid cancer to analyze their hypothesis and to confirm that various risk groups have a major implication in relation to extent of the treatment and outcome. Differentiated thyroid cancers make up 90% of all thyroid tumors. The prognostic factors are well defined, such as age, size of the tumor, extrathyroidal extension, presence of distant metastasis, histological appearance, and grade of the tumor. The author has previously divided the risk groups into low-, intermediate-, and high-risk categories based on prognostic factors. The study describes the author's treatment approach related to the extent of thyroidectomy and adjuvant therapy based on various risk groups and the long-term survival. Retrospective. In a retrospective review of 1038 patients with differentiated thyroid carcinoma, various prognostic factors were studied by univariate and multivariate analysis. The significant prognostic factors were studied in detail and, based on these prognostic factors, the patients were divided into low-, intermediate- and high-risk groups. The survival curves were plotted by Kaplan-Meier method. The long-term survivals in low-, intermediate- and high-risk groups were 99%, 87%, and 57% respectively. Based on these risk groups, a decision tree was made regarding extent of thyroidectomy and adjuvant treatment. In the high-risk group and selected patients in the intermediate-risk group, aggressive surgery including removal of all gross disease and extrathyroidal extension with postoperative radioactive iodine ablation is recommended. In the low-risk group and selected patients in the intermediate-risk group, lobectomy appears to be satisfactory with excellent long-term outcome. The surgical treatment offers the best long-term results in low-risk patients, and the role of adjuvant treatment in this group is questionable. The decisions in the management of well-differentiated thyroid cancer should be based on various prognostic factors and risk groups. The long-term survival in the low-risk group is excellent, and consideration should be given to conservative surgical resection depending on the extent of the disease. In the high-risk group and selected patients in the intermediate-risk group, total thyroidectomy with radioactive ablation is warranted. A consideration may be given to external-beam radiation therapy in selected high-risk patients. It is apparent, based on the author's clinical experience and critical retrospective analysis, that the author's hypothesis that risk groups are extremely important in the long-term outcome of patients with differentiated thyroid cancer is correct. Based on various risk groups, the author currently is able to guide the treatment policies for thyroid cancer.

Predictors and subsequent decisions of physical therapy and nursing students to work with geriatric clients: an application of the theory of reasoned action.

PubMed

Dunkle, S E; Hyde, R S

1995-07-01

In this study, the theory-based model of Ajzen and Fishbein was used to identify factors that influence physical therapist and registered nurse (RN) students' intentions toward working with elderly individuals. A follow-up identified actual job selection. Accredited physical therapist and RN education programs in the Northwest and California were surveyed. Two hundred one students responded; 176 survey questionnaires were usable. A survey instrument was developed based on Ajzen and Fishbein's theory-based model to assess student intention to work with elderly individuals and factors influencing this intention. Graduates were later contacted to determine whether job selection matched intention. For all students, factors influencing intention were student attitudes and student perceptions regarding their families' expectations about the student working with elderly persons. Intention had a positive correlation with job selection. Important underlying beliefs influencing student attitudes, which could be emphasized in academia, include the advantages of getting to know elderly patients and their families and having pleasant patients to work with. Faculty are encouraged to positively reinforce these beliefs throughout the curricula. Results of this study support using a theory-based model to identify predictors of job selection among physical therapist and RN graduates.

Systematic Treatment Selection (STS): A Review and Future Directions

ERIC Educational Resources Information Center

Nguyen, Tam T.; Bertoni, Matteo; Charvat, Mylea; Gheytanchi, Anahita; Beutler, Larry E.

2007-01-01

Systematic Treatment Selection (STS) is a form of technical eclectism that develops and plans treatments using empirically founded principles of psychotherapy. It is a model that provides systematic guidelines for the utilization of different psychotherapeutic strategies based on patient qualities and problem characteristics. Historically, it…

The "SWOT" of BRAF inhibition in melanoma: RAF inhibitors, MEK inhibitors or both?

PubMed

Nissan, Moriah H; Solit, David B

2011-12-01

Activating mutations in the BRAF gene are among the most prevalent kinase mutations in human cancer. BRAF mutations are most frequent in patients with melanoma where they occur in approximately 50% of patients with advanced disease. Remarkable clinical activity has recently been reported with highly selective RAF inhibitors in melanoma patients whose tumors harbor V600E BRAF mutations. The response rates of RAF inhibitors in patients with BRAF-mutant melanomas far exceed the activity level of any prior therapy studied in this disease. The results suggest that we have entered an era of personalized therapy for patients with metastatic melanoma in which treatment selection will be guided by BRAF mutational status. This review will discuss the strengths, weaknesses, opportunities and threats ("SWOT") of developing RAF and MEK selective inhibitors as anti-cancer therapies, recent insights into the mechanisms of intrinsic and acquired resistance to these agents, and current efforts to develop mechanism-based combination therapies.

Why do adults entitled to free or highly subsidized dental services select fully out-of-pocket-paid care?

PubMed

Bayat, Fariborz; Vehkalahti, Miira M; Murtomaa, Heikki; Tala, Heikki

2010-02-01

To investigate patients' reasons for selecting a dental clinic given their choice of free or highly-subsidized dental services. The study was based on cross-sectional data obtained through phone interviews with adults in Tehran, Iran. The present study included those entitled to free or highly-subsidized dental services (n = 726). The data covered the patients' awareness of subsidized dental services and type of dental clinic for their most recent visit and their reasons for selecting that clinic. Awareness of subsidized dental services was dichotomized as being either aware or unaware of such subsidy. The type of clinic was dichotomized as providing either free or highly-subsidized (FHS) or fully out-of-pocket paid (FOP) services. Free format answers about the subjects' reasons for selecting a particular clinic were later sub-grouped as: convenient access, good technical aspects, good interpersonal aspects, low or reasonable fees, recommendation by a friend, and no reason. Socio-demographic status was based on background. Data analysis included the chi-square test and logistic regression model. Of the subjects (n = 726), 60% were women and 58% were under 35 years of age. The subjects' mean age was 33.5 years with no difference by gender (P = 0.24) and the majority had public insurance (91%). Of all the subjects, 60% selected FOP. Good interpersonal aspects were the strongest reason for selecting FOP (OR = 4.6), follow by good technical aspects (OR = 2.3). Those subjects who were unaware of their benefit had 4.6 times the odds of selecting FOP. Despite the opportunity to use highly-subsidized dental services, good interpersonal and good technical aspects lead patients to select private dentists and to pay fully out of pocket.

A bioinformatics approach for precision medicine off-label drug drug selection among triple negative breast cancer patients.

PubMed

Cheng, Lijun; Schneider, Bryan P; Li, Lang

2016-07-01

Cancer has been extensively characterized on the basis of genomics. The integration of genetic information about cancers with data on how the cancers respond to target based therapy to help to optimum cancer treatment. The increasing usage of sequencing technology in cancer research and clinical practice has enormously advanced our understanding of cancer mechanisms. The cancer precision medicine is becoming a reality. Although off-label drug usage is a common practice in treating cancer, it suffers from the lack of knowledge base for proper cancer drug selections. This eminent need has become even more apparent considering the upcoming genomics data. In this paper, a personalized medicine knowledge base is constructed by integrating various cancer drugs, drug-target database, and knowledge sources for the proper cancer drugs and their target selections. Based on the knowledge base, a bioinformatics approach for cancer drugs selection in precision medicine is developed. It integrates personal molecular profile data, including copy number variation, mutation, and gene expression. By analyzing the 85 triple negative breast cancer (TNBC) patient data in the Cancer Genome Altar, we have shown that 71.7% of the TNBC patients have FDA approved drug targets, and 51.7% of the patients have more than one drug target. Sixty-five drug targets are identified as TNBC treatment targets and 85 candidate drugs are recommended. Many existing TNBC candidate targets, such as Poly (ADP-Ribose) Polymerase 1 (PARP1), Cell division protein kinase 6 (CDK6), epidermal growth factor receptor, etc., were identified. On the other hand, we found some additional targets that are not yet fully investigated in the TNBC, such as Gamma-Glutamyl Hydrolase (GGH), Thymidylate Synthetase (TYMS), Protein Tyrosine Kinase 6 (PTK6), Topoisomerase (DNA) I, Mitochondrial (TOP1MT), Smoothened, Frizzled Class Receptor (SMO), etc. Our additional analysis of target and drug selection strategy is also fully supported by the drug screening data on TNBC cell lines in the Cancer Cell Line Encyclopedia. The proposed bioinformatics approach lays a foundation for cancer precision medicine. It supplies much needed knowledge base for the off-label cancer drug usage in clinics. © The Author 2016. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Incremental Learning With Selective Memory (ILSM): Towards Fast Prostate Localization for Image Guided Radiotherapy

PubMed Central

Gao, Yaozong; Zhan, Yiqiang

2015-01-01

Image-guided radiotherapy (IGRT) requires fast and accurate localization of the prostate in 3-D treatment-guided radiotherapy, which is challenging due to low tissue contrast and large anatomical variation across patients. On the other hand, the IGRT workflow involves collecting a series of computed tomography (CT) images from the same patient under treatment. These images contain valuable patient-specific information yet are often neglected by previous works. In this paper, we propose a novel learning framework, namely incremental learning with selective memory (ILSM), to effectively learn the patient-specific appearance characteristics from these patient-specific images. Specifically, starting with a population-based discriminative appearance model, ILSM aims to “personalize” the model to fit patient-specific appearance characteristics. The model is personalized with two steps: backward pruning that discards obsolete population-based knowledge and forward learning that incorporates patient-specific characteristics. By effectively combining the patient-specific characteristics with the general population statistics, the incrementally learned appearance model can localize the prostate of a specific patient much more accurately. This work has three contributions: 1) the proposed incremental learning framework can capture patient-specific characteristics more effectively, compared to traditional learning schemes, such as pure patient-specific learning, population-based learning, and mixture learning with patient-specific and population data; 2) this learning framework does not have any parametric model assumption, hence, allowing the adoption of any discriminative classifier; and 3) using ILSM, we can localize the prostate in treatment CTs accurately (DSC ∼0.89) and fast (∼4 s), which satisfies the real-world clinical requirements of IGRT. PMID:24495983

DisTeam: A decision support tool for surgical team selection

PubMed Central

Ebadi, Ashkan; Tighe, Patrick J.; Zhang, Lei; Rashidi, Parisa

2018-01-01

Objective Surgical service providers play a crucial role in the healthcare system. Amongst all the influencing factors, surgical team selection might affect the patients’ outcome significantly. The performance of a surgical team not only can depend on the individual members, but it can also depend on the synergy among team members, and could possibly influence patient outcome such as surgical complications. In this paper, we propose a tool for facilitating decision making in surgical team selection based on considering history of the surgical team, as well as the specific characteristics of each patient. Methods DisTeam (a decision support tool for surgical team selection) is a metaheuristic framework for objective evaluation of surgical teams and finding the optimal team for a given patient, in terms of number of complications. It identifies a ranked list of surgical teams personalized for each patient, based on prior performance of the surgical teams. DisTeam takes into account the surgical complications associated with teams and their members, their teamwork history, as well as patient’s specific characteristics such as age, body mass index (BMI) and Charlson comorbidity index score. Results We tested DisTeam using intra-operative data from 6065 unique orthopedic surgery cases. Our results suggest high effectiveness of the proposed system in a health-care setting. The proposed framework converges quickly to the optimal solution and provides two sets of answers: a) The best surgical team over all the generations, and b) The best population which consists of different teams that can be used as an alternative solution. This increases the flexibility of the system as a complementary decision support tool. Conclusion DisTeam is a decision support tool for assisting in surgical team selection. It can facilitate the job of scheduling personnel in the hospital which involves an overwhelming number of factors pertaining to patients, individual team members, and team dynamics and can be used to compose patient-personalized surgical teams with minimum (potential) surgical complications. PMID:28363285

Selective Perioperative Administration of Pasireotide is More Cost-Effective Than Routine Administration for Pancreatic Fistula Prophylaxis.

PubMed

Denbo, Jason W; Slack, Rebecca S; Bruno, Morgan; Cloyd, Jordan M; Prakash, Laura; Fleming, Jason B; Kim, Michael P; Aloia, Thomas A; Vauthey, Jean-Nicolas; Lee, Jeffrey E; Katz, Matthew H G

2017-04-01

In a randomized trial, pasireotide significantly decreased the incidence and severity of postoperative pancreatic fistula (POPF). Subsequent analyses concluded that its routine use is cost-effective. We hypothesized that selective administration of the drug to patients at high risk for POPF would be more cost-effective. Consecutive patients who did not receive pasireotide and underwent pancreatoduodenectomy (PD) or distal pancreatectomy (DP) between July 2011 and January 2014 were distributed into groups based on their risk of POPF using a multivariate recursive partitioning regression tree analysis (RPA) of preoperative clinical factors. The costs of treating hypothetical patients in each risk group were then computed based upon actual institutional hospital costs and previously published relative risk values associated with pasireotide. Among 315 patients who underwent pancreatectomy, grade B/C POPF occurred in 64 (20%). RPA allocated patients who underwent PD into four groups with a risk for grade B/C POPF of 0, 10, 29, or 60% (P < 0.001) on the basis of diagnosis, pancreatic duct diameter, and body mass index. Patients who underwent DP were allocated to three groups with a grade B/C POPF risk of 14, 26, or 44% (P = 0.05) on the basis of pancreatic duct diameter alone. Although the routine administration of pasireotide to all 315 patients would have theoretically saved $30,892 over standard care, restriction of pasireotide to only patients at high risk for POPF would have led to a cost savings of $831,916. Preoperative clinical characteristics can be used to characterize patients' risk for POPF following pancreatectomy. Selective administration of pasireotide only to patients at high risk for grade B/C POPF may maximize the cost-efficacy of prophylactic pasireotide.

A method and knowledge base for automated inference of patient problems from structured data in an electronic medical record

PubMed Central

Pang, Justine; Feblowitz, Joshua C; Maloney, Francine L; Wilcox, Allison R; Ramelson, Harley Z; Schneider, Louise I; Bates, David W

2011-01-01

Background Accurate knowledge of a patient's medical problems is critical for clinical decision making, quality measurement, research, billing and clinical decision support. Common structured sources of problem information include the patient problem list and billing data; however, these sources are often inaccurate or incomplete. Objective To develop and validate methods of automatically inferring patient problems from clinical and billing data, and to provide a knowledge base for inferring problems. Study design and methods We identified 17 target conditions and designed and validated a set of rules for identifying patient problems based on medications, laboratory results, billing codes, and vital signs. A panel of physicians provided input on a preliminary set of rules. Based on this input, we tested candidate rules on a sample of 100 000 patient records to assess their performance compared to gold standard manual chart review. The physician panel selected a final rule for each condition, which was validated on an independent sample of 100 000 records to assess its accuracy. Results Seventeen rules were developed for inferring patient problems. Analysis using a validation set of 100 000 randomly selected patients showed high sensitivity (range: 62.8–100.0%) and positive predictive value (range: 79.8–99.6%) for most rules. Overall, the inference rules performed better than using either the problem list or billing data alone. Conclusion We developed and validated a set of rules for inferring patient problems. These rules have a variety of applications, including clinical decision support, care improvement, augmentation of the problem list, and identification of patients for research cohorts. PMID:21613643

Smartphone apps for the self-management of low back pain: A systematic review.

PubMed

Machado, Gustavo C; Pinheiro, Marina B; Lee, Hopin; Ahmed, Osman H; Hendrick, Paul; Williams, Chris; Kamper, Steven J

2016-12-01

Guidelines for low back pain (LBP) often recommend the use of self-management such as unsupervised exercise, booklets, and online education. Another potentially useful way for patients to self-manage LBP is by using smartphone applications (apps). However, to date, there has been no rigorous evaluation of LBP apps and no guidance for consumers on how to select high-quality, evidence-based apps. This chapter reviews smartphone apps for the self-management of LBP and evaluates their content quality and whether they recommend evidence-based interventions. This chapter shows that generally app developers are selecting interventions that are endorsed by guidelines, although their quality is low. There are many apps available for the self-management of LBP, but their effectiveness in improving patient outcomes has not been rigorously assessed. App developers need to work closely with healthcare professionals, researchers, and patients to ensure app content is accurate, evidence based, and engaging. Copyright © 2017 Elsevier Ltd. All rights reserved.

Development of a POC Test for TB Based on Multiple Immunodominant Epitopes of M. tuberculosis Specific Cell-Wall Proteins

PubMed Central

Gonzalez, Jesus M.; Francis, Bryan; Burda, Sherri; Hess, Kaitlyn; Behera, Digamber; Gupta, Dheeraj; Agarwal, Ashutosh Nath; Verma, Indu; Verma, Ajoy; Myneedu, Vithal Prasad; Niedbala, Sam; Laal, Suman

2014-01-01

The need for an accurate, rapid, simple and affordable point-of-care (POC) test for Tuberculosis (TB) that can be implemented in microscopy centers and other peripheral health-care settings in the TB-endemic countries remains unmet. This manuscript describes preliminary results of a new prototype rapid lateral flow TB test based on detection of antibodies to immunodominant epitopes (peptides) derived from carefully selected, highly immunogenic M. tuberculosis cell-wall proteins. Peptide selection was initially based on recognition by antibodies in sera from TB patients but not in PPD-/PPD+/BCG-vaccinated individuals from TB-endemic settings. The peptides were conjugated to BSA; the purified peptide-BSA conjugates striped onto nitrocellulose membrane and adsorbed onto colloidal gold particles to devise the prototype test, and evaluated for reactivity with sera from 3 PPD-, 29 PPD+, 15 PPD-unknown healthy subjects, 10 patients with non-TB lung disease and 124 smear-positive TB patients. The assay parameters were adjusted to determine positive/negative status within 15 minutes via visual or instrumented assessment. There was minimal or no reactivity of sera from non-TB subjects with the striped BSA-peptides demonstrating the lack of anti-peptide antibodies in subjects with latent TB and/or BCG vaccination. Sera from most TB patients demonstrated reactivity with one or more peptides. The sensitivity of antibody detection ranged from 28–85% with the 9 BSA-peptides. Three peptides were further evaluated with sera from 400 subjects, including additional PPD-/PPD+/PPD-unknown healthy contacts, close hospital contacts and household contacts of untreated TB patients, patients with non-TB lung disease, and HIV+TB- patients. Combination of the 3 peptides provided sensitivity and specificity>90%. While the final fully optimized lateral flow POC test for TB is under development, these preliminary results demonstrate that an antibody-detection based rapid POC lateral flow test based on select combinations of immunodominant M. tb-specific epitopes may potentially replace microscopy for TB diagnosis in TB-endemic settings. PMID:25247820

New advances in hepatocellular carcinoma

PubMed Central

Pascual, Sonia; Herrera, Iván; Irurzun, Javier

2016-01-01

Hepatocellular carcinoma (HCC) is the leading cause of deaths in cirrhotic patients and the third cause of cancer related deaths. Most HCC are associated with well known underlying risk factors, in fact, HCC arise in cirrhotic patients in up to 90% of cases, mainly due to chronic viral hepatitis and alcohol abuse. The worldwide prevention strategies are conducted to avoid the infection of new subjects and to minimize the risk of liver disease progression in infected patients. HCC is a condition which lends itself to surveillance as at-risk individuals can readily be identified. The American and European guidelines recommended implementation of surveillance programs with ultrasound every six months in patient at-risk for developing HCC. The diagnosis of HCC can be based on non-invasive criteria (only in cirrhotic patient) or pathology. Accurately staging patients is essential to oncology practice. The ideal tumour staging system in HCC needs to account for both tumour characteristics and liver function. Treatment allocation is based on several factors: Liver function, size and number of tumours, macrovascular invasion or extrahepatic spread. The recommendations in terms of selection for different treatment strategies must be based on evidence-based data. Resection, liver transplant and interventional radiology treatment are mainstays of HCC therapy and achieve the best outcomes in well-selected candidates. Chemoembolization is the most widely used treatment for unresectable HCC or progression after curative treatment. Finally, in patients with advanced HCC with preserved liver function, sorafenib is the only approved systemic drug that has demonstrated a survival benefit and is the standard of care in this group of patients. PMID:27028578

Discrimination of inflammatory bowel disease using Raman spectroscopy and linear discriminant analysis methods

NASA Astrophysics Data System (ADS)

Ding, Hao; Cao, Ming; DuPont, Andrew W.; Scott, Larry D.; Guha, Sushovan; Singhal, Shashideep; Younes, Mamoun; Pence, Isaac; Herline, Alan; Schwartz, David; Xu, Hua; Mahadevan-Jansen, Anita; Bi, Xiaohong

2016-03-01

Inflammatory bowel disease (IBD) is an idiopathic disease that is typically characterized by chronic inflammation of the gastrointestinal tract. Recently much effort has been devoted to the development of novel diagnostic tools that can assist physicians for fast, accurate, and automated diagnosis of the disease. Previous research based on Raman spectroscopy has shown promising results in differentiating IBD patients from normal screening cases. In the current study, we examined IBD patients in vivo through a colonoscope-coupled Raman system. Optical diagnosis for IBD discrimination was conducted based on full-range spectra using multivariate statistical methods. Further, we incorporated several feature selection methods in machine learning into the classification model. The diagnostic performance for disease differentiation was significantly improved after feature selection. Our results showed that improved IBD diagnosis can be achieved using Raman spectroscopy in combination with multivariate analysis and feature selection.

Gastrostomy Tube Weaning and Treatment of Severe Selective Eating in Childhood: Experience in Israel Using an Intensive Three Week Program.

PubMed

Shalem, Tzippora; Fradkin, Akiva; Dunitz-Scheer, Marguerite; Sadeh-Kon, Tal; Goz-Gulik, Tali; Fishler, Yael; Weiss, Batia

2016-06-01

Children dependent on gastrostomy tube feeding and those with extremely selective eating comprise the most challenging groups of early childhood eating disorders. We established, for the first time in Israel, a 3 week intensive weaning and treatment program for these patients based on the "Graz model." To investigate the Graz model for tube weaning and for treating severe selective eating disorders in one center in Israel. Pre-program assessment of patients' suitability to participate was performed 3 months prior to the study, and a treatment goal was set for each patient. The program included a multidisciplinary outpatient or inpatient 3 week treatment course. The major outcome measures were achievement of the target goal of complete or partial tube weaning for those with tube dependency, and expansion of the child's nutritional diversity for those with selective eating. Thirty-four children, 28 with tube dependency and 6 with selective eating, participated in four programs conducted over 24 months. Their mean age was 4.3 ± 0.37 years. Of all patients, 29 (85%) achieved the target goal (24 who were tube-dependent and 5 selective eaters). One patient was excluded due to aspiration pneumonia. After 6 months follow-up, 24 of 26 available patients (92%) maintained their target or improved. This intensive 3 week program was highly effective in weaning children with gastrostomy tube dependency and ameliorating severe selective eating. Preliminary evaluation of the family is necessary for completion of the program and achieving the child's personal goal, as are an experienced multidisciplinary team and the appropriate hospital setup, i.e., inpatient or outpatient.

Failure of physicians to recognize functional disability in ambulatory patients.

PubMed

Calkins, D R; Rubenstein, L V; Cleary, P D; Davies, A R; Jette, A M; Fink, A; Kosecoff, J; Young, R T; Brook, R H; Delbanco, T L

1991-03-15

To assess the ability of internists to identify functional disabilities reported by their patients. Comparison of responses by physicians and a random sample of their patients to a 12-item questionnaire about physical and social function. A hospital-based internal medicine group practice in Boston, Massachusetts, and selected office-based internal medicine practices in Los Angeles, California. Five staff physicians, three general internal medicine fellows, and 34 internal medicine residents in the hospital-based practice and 178 of their patients. Seventy-six physicians in the office-based practices and 230 of their patients. Physicians underestimated or failed to recognize 66% of disabilities reported by patients. Patient-reported disabilities were underestimated or unrecognized more often in the hospital-based practice than in the office-based practices (75% compared with 60%, P less than 0.05). Physicians overstated functional impairment in 21% of paired responses in which patients reported no disability. Physicians often underestimate or fail to recognize functional disabilities that are reported by their patients. They overstate functional impairment to a lesser degree. Because these discrepancies may adversely affect patient care and well-being, medical educators and clinicians should pay more attention to the assessment of patient function.

Selective versus routine patch metal allergy testing to select bar material for the Nuss procedure in 932 patients over 10years.

PubMed

Obermeyer, Robert J; Gaffar, Sheema; Kelly, Robert E; Kuhn, M Ann; Frantz, Frazier W; McGuire, Margaret M; Paulson, James F; Kelly, Cynthia S

2018-02-01

The aim of the study was to determine the role of patch metal allergy testing to select bar material for the Nuss procedure. An IRB-approved (11-04-WC-0098) single institution retrospective, cohort study comparing selective versus routine patch metal allergy testing to select stainless steel or titanium bars for Nuss repair was performed. In Cohort A (9/2004-1/2011), selective patch testing was performed based on clinical risk factors. In Cohort B (2/2011-9/2014), all patients were patch tested. The cohorts were compared for incidence of bar allergy and resultant premature bar loss. Risk factors for stainless steel allergy or positive patch test were evaluated. Cohort A had 628 patients with 63 (10.0%) selected for patch testing, while all 304 patients in Cohort B were tested. Over 10years, 15 (1.8%) of the 842 stainless steel Nuss repairs resulted in a bar allergy, and 5 had a negative preoperative patch test. The incidence of stainless steel bar allergy (1.8% vs 1.7%, p=0.57) and resultant bar loss (0.5% vs 1.3%, p=0.23) was not statistically different between cohorts. An allergic reaction to a stainless steel bar or a positive patch test was more common in females (OR=2.3, p<0.001) and patients with a personal (OR=24.8, p<0.001) or family history (OR=3.1, p<0.001) of metal sensitivity. Stainless steel bar allergies occur at a low incidence with either routine or selective patch metal allergy testing. If selective testing is performed, it is advisable in females and patients with a personal or family history of metal sensitivity. A negative preoperative patch metal allergy test does not preclude the possibility of a postoperative stainless steel bar allergy. Level III Treatment Study and Study of Diagnostic Test. Copyright © 2017 Elsevier Inc. All rights reserved.

A new functional method to choose the target lobe for lung volume reduction in emphysema - comparison with the conventional densitometric method.

PubMed

Hetzel, Juergen; Boeckeler, Michael; Horger, Marius; Ehab, Ahmed; Kloth, Christopher; Wagner, Robert; Freitag, Lutz; Slebos, Dirk-Jan; Lewis, Richard Alexander; Haentschel, Maik

2017-01-01

Lung volume reduction (LVR) improves breathing mechanics by reducing hyperinflation. Lobar selection usually focuses on choosing the most destroyed emphysematous lobes as seen on an inspiratory CT scan. However, it has never been shown to what extent these densitometric CT parameters predict the least deflation of an individual lobe during expiration. The addition of expiratory CT analysis allows measurement of the extent of lobar air trapping and could therefore provide additional functional information for choice of potential treatment targets. To determine lobar vital capacity/lobar total capacity (LVC/LTC) as a functional parameter for lobar air trapping using on an inspiratory and expiratory CT scan. To compare lobar selection by LVC/LTC with the established morphological CT density parameters. 36 patients referred for endoscopic LVR were studied. LVC/LTC, defined as delta volume over maximum volume of a lobe, was calculated using inspiratory and expiratory CT scans. The CT morphological parameters of mean lung density (MLD), low attenuation volume (LAV), and 15th percentile of Hounsfield units (15%P) were determined on an inspiratory CT scan for each lobe. We compared and correlated LVC/LTC with MLD, LAV, and 15%P. There was a weak correlation between the functional parameter LVC/LTC and all inspiratory densitometric parameters. Target lobe selection using lowest lobar deflation (lowest LVC/LTC) correlated with target lobe selection based on lowest MLD in 18 patients (50.0%), with the highest LAV in 13 patients (36.1%), and with the lowest 15%P in 12 patients (33.3%). CT-based measurement of deflation (LVC/LTC) as a functional parameter correlates weakly with all densitometric CT parameters on a lobar level. Therefore, morphological criteria based on inspiratory CT densitometry partially reflect the deflation of particular lung lobes, and may be of limited value as a sole predictor for target lobe selection in LVR.

Bacterial clonal diagnostics as a tool for evidence-based empiric antibiotic selection.

PubMed

Tchesnokova, Veronika; Avagyan, Hovhannes; Rechkina, Elena; Chan, Diana; Muradova, Mariya; Haile, Helen Ghirmai; Radey, Matthew; Weissman, Scott; Riddell, Kim; Scholes, Delia; Johnson, James R; Sokurenko, Evgeni V

2017-01-01

Despite the known clonal distribution of antibiotic resistance in many bacteria, empiric (pre-culture) antibiotic selection still relies heavily on species-level cumulative antibiograms, resulting in overuse of broad-spectrum agents and excessive antibiotic/pathogen mismatch. Urinary tract infections (UTIs), which account for a large share of antibiotic use, are caused predominantly by Escherichia coli, a highly clonal pathogen. In an observational clinical cohort study of urgent care patients with suspected UTI, we assessed the potential for E. coli clonal-level antibiograms to improve empiric antibiotic selection. A novel PCR-based clonotyping assay was applied to fresh urine samples to rapidly detect E. coli and the urine strain's clonotype. Based on a database of clonotype-specific antibiograms, the acceptability of various antibiotics for empiric therapy was inferred using a 20%, 10%, and 30% allowed resistance threshold. The test's performance characteristics and possible effects on prescribing were assessed. The rapid test identified E. coli clonotypes directly in patients' urine within 25-35 minutes, with high specificity and sensitivity compared to culture. Antibiotic selection based on a clonotype-specific antibiogram could reduce the relative likelihood of antibiotic/pathogen mismatch by ≥ 60%. Compared to observed prescribing patterns, clonal diagnostics-guided antibiotic selection could safely double the use of trimethoprim/sulfamethoxazole and minimize fluoroquinolone use. In summary, a rapid clonotyping test showed promise for improving empiric antibiotic prescribing for E. coli UTI, including reversing preferential use of fluoroquinolones over trimethoprim/sulfamethoxazole. The clonal diagnostics approach merges epidemiologic surveillance, antimicrobial stewardship, and molecular diagnostics to bring evidence-based medicine directly to the point of care.

Spatial enhancement of ECG using diagnostic similarity score based lead selective multi-scale linear model.

PubMed

Nallikuzhy, Jiss J; Dandapat, S

2017-06-01

In this work, a new patient-specific approach to enhance the spatial resolution of ECG is proposed and evaluated. The proposed model transforms a three-lead ECG into a standard twelve-lead ECG thereby enhancing its spatial resolution. The three leads used for prediction are obtained from the standard twelve-lead ECG. The proposed model takes advantage of the improved inter-lead correlation in wavelet domain. Since the model is patient-specific, it also selects the optimal predictor leads for a given patient using a lead selection algorithm. The lead selection algorithm is based on a new diagnostic similarity score which computes the diagnostic closeness between the original and the spatially enhanced leads. Standard closeness measures are used to assess the performance of the model. The similarity in diagnostic information between the original and the spatially enhanced leads are evaluated using various diagnostic measures. Repeatability and diagnosability are performed to quantify the applicability of the model. A comparison of the proposed model is performed with existing models that transform a subset of standard twelve-lead ECG into the standard twelve-lead ECG. From the analysis of the results, it is evident that the proposed model preserves diagnostic information better compared to other models. Copyright © 2017 Elsevier Ltd. All rights reserved.

Data integration to prioritize drugs using genomics and curated data.

PubMed

Louhimo, Riku; Laakso, Marko; Belitskin, Denis; Klefström, Juha; Lehtonen, Rainer; Hautaniemi, Sampsa

2016-01-01

Genomic alterations affecting drug target proteins occur in several tumor types and are prime candidates for patient-specific tailored treatments. Increasingly, patients likely to benefit from targeted cancer therapy are selected based on molecular alterations. The selection of a precision therapy benefiting most patients is challenging but can be enhanced with integration of multiple types of molecular data. Data integration approaches for drug prioritization have successfully integrated diverse molecular data but do not take full advantage of existing data and literature. We have built a knowledge-base which connects data from public databases with molecular results from over 2200 tumors, signaling pathways and drug-target databases. Moreover, we have developed a data mining algorithm to effectively utilize this heterogeneous knowledge-base. Our algorithm is designed to facilitate retargeting of existing drugs by stratifying samples and prioritizing drug targets. We analyzed 797 primary tumors from The Cancer Genome Atlas breast and ovarian cancer cohorts using our framework. FGFR, CDK and HER2 inhibitors were prioritized in breast and ovarian data sets. Estrogen receptor positive breast tumors showed potential sensitivity to targeted inhibitors of FGFR due to activation of FGFR3. Our results suggest that computational sample stratification selects potentially sensitive samples for targeted therapies and can aid in precision medicine drug repositioning. Source code is available from http://csblcanges.fimm.fi/GOPredict/.

Prevention of 3 "never events" in the operating room: fires, gossypiboma, and wrong-site surgery.

PubMed

Zahiri, Hamid R; Stromberg, Jeffrey; Skupsky, Hadas; Knepp, Erin K; Folstein, Matthew; Silverman, Ronald; Singh, Devinder

2011-03-01

This study sought to identify and provide preventative recommendations for potentially devastating safety violations in the operating room. A Medline database search from 1950 to current using the terms patient safety and operating room was conducted. All topics identified were reviewed. Three patient safety violations with potential for immediate and devastating outcomes were selected for discussion using evidence-based literature. The search identified 2851 articles, 807 of which were directly related to patient safety in the operating room. Topics addressed by these 807 included infectious complications (26%), fires (11%), communication/teamwork (6%), retained foreign objects (3%), safety checklists (1%), and wrong-site surgery (1%). Fires, gossypiboma, and wrong-site surgery were selected for discussion. Although fire, gossypiboma, and wrong-site surgery should be "never events" in the operating room, they continue to persist as 3 common patient safety violations. This study provides the epidemiology, common etiologies, and evidence-based preventative recommendations for each.

Factors influencing patient interest in plastic surgery and the process of selecting a surgeon.

PubMed

Galanis, Charles; Sanchez, Ivan S; Roostaeian, Jason; Crisera, Christopher

2013-05-01

Understanding patient interest in cosmetic surgery is an important tool in delineating the current market for aesthetic surgeons. Similarly, defining those factors that most influence surgeon selection is vital for optimizing marketing strategies. The authors evaluate a general population sample's interest in cosmetic surgery and investigate which factors patients value when selecting their surgeon. An anonymous questionnaire was distributed to 96 individuals in waiting rooms in nonsurgical clinics. Respondents were questioned on their ability to differentiate between a "plastic" surgeon and a "cosmetic" surgeon, their interest in having plastic surgery, and factors affecting surgeon and practice selection. Univariate and multivariate analyses were conducted to define any significant correlative relationships. Respondents consisted of 15 men and 81 women. Median age was 34.5 (range, 18-67) years. Overall, 20% were currently considering plastic surgery and 78% stated they would consider it in the future. The most common area of interest was a procedure for the face. The most important factors in selecting a surgeon were surgeon reputation and board certification. The least important were quality of advertising and surgeon age. The most cited factor preventing individuals from pursuing plastic surgery was fear of a poor result. Most (60%) patients would choose a private surgicenter-based practice. The level of importance for each studied attribute can help plastic surgeons understand the market for cosmetic surgery as well as what patients look for when selecting their surgeon. This study helps to define those attributes in a sample population.

Automated Surgical Approach Planning for Complex Skull Base Targets: Development and Validation of a Cost Function and Semantic At-las.

PubMed

Aghdasi, Nava; Whipple, Mark; Humphreys, Ian M; Moe, Kris S; Hannaford, Blake; Bly, Randall A

2018-06-01

Successful multidisciplinary treatment of skull base pathology requires precise preoperative planning. Current surgical approach (pathway) selection for these complex procedures depends on an individual surgeon's experiences and background training. Because of anatomical variation in both normal tissue and pathology (eg, tumor), a successful surgical pathway used on one patient is not necessarily the best approach on another patient. The question is how to define and obtain optimized patient-specific surgical approach pathways? In this article, we demonstrate that the surgeon's knowledge and decision making in preoperative planning can be modeled by a multiobjective cost function in a retrospective analysis of actual complex skull base cases. Two different approaches- weighted-sum approach and Pareto optimality-were used with a defined cost function to derive optimized surgical pathways based on preoperative computed tomography (CT) scans and manually designated pathology. With the first method, surgeon's preferences were input as a set of weights for each objective before the search. In the second approach, the surgeon's preferences were used to select a surgical pathway from the computed Pareto optimal set. Using preoperative CT and magnetic resonance imaging, the patient-specific surgical pathways derived by these methods were similar (85% agreement) to the actual approaches performed on patients. In one case where the actual surgical approach was different, revision surgery was required and was performed utilizing the computationally derived approach pathway.

Use of glucocorticoids in rheumatoid arthritis - pratical modalities of glucocorticoid therapy: recommendations for clinical practice based on data from the literature and expert opinion.

PubMed

Dernis, Emmanuelle; Ruyssen-Witrand, Adeline; Mouterde, Gaël; Maillefert, Jean-Francis; Tebib, Jacques; Cantagrel, Alain; Claudepierre, Pascal; Fautrel, Bruno; Gaudin, Philippe; Pham, Thao; Schaeverbeke, Thierry; Wendling, Daniel; Saraux, Alain; Loët, Xavier Le

2010-10-01

To develop recommendations about the use of glucocorticoids in patients with established rheumatoid arthritis (RA) managed in everyday practice, using the evidence-based approach and expert opinion. A three-step procedure was used: a scientific committee used a Delphi procedure to select five questions, which formed the basis for developing the recommendations; a systematic literature review was conducted by searching the Medline and Embase databases and the abstracts of meetings held by the Société Française de Rhumatologie (SFR), American College of Rheumatology (ACR), and European League Against Rheumatism (EULAR); and recommendations were developed and validated by a panel of experts based on the data from the literature review and on their experience. For each recommendation, the level of evidence and extent of agreement among experts were determined. The five questions pertained to the use of glucocorticoids in RA patients: role for intravenous glucocorticoid bolus therapy, role for intraarticular injections, and practical modalities of glucocorticoid administration and discontinuation. From the literature search, 93 articles were selected based on their titles and abstracts. Of these, 50 were selected for the literature review. Eight recommendations about the use of glucocorticoid therapy in everyday practice in patients with established RA were validated by a vote among all participating experts: bolus glucocorticoid therapy should be reserved for highly selected situations; triamcinolone hexacetonide is the preferred glucocorticoid for intraarticular therapy, and the joint should be rested for about 24h after the injection; for oral glucocorticoid therapy, agents with a short half-life taken once daily should be preferred; and when discontinuing glucocorticoid therapy, the patient and usual physician should be informed of the risk of adrenal insufficiency. Copyright © 2010 Société française de rhumatologie. Published by Elsevier SAS. All rights reserved.

How are patients influenced when counseled for minimally invasive lumbar spine surgeries? A stepwise model assessing pivotal information for decision-making.

PubMed

Hey, Hwee Weng Dennis; Kumar, Nishant; Teo, Alex Quok An; Tan, Kimberly-Anne; Kumar, Naresh; Liu, Ka-Po Gabriel; Wong, Hee-Kit

2017-08-01

Although minimally invasive surgery (MIS)-transforaminal lumbar interbody fusion (TLIF) has many evidence-based short-term benefits over open TLIF, both procedures have similar long-term outcomes. Patients' preference for MIS over open TLIF may be confounded by a lack of understanding of what each approach entails. The study aimed to identify the various factors influencing patients' choice between MIS and open TLIF. This is a cross-sectional study conducted at a tertiary health-care institution. Patients, for whom TLIF procedures were indicated, were recruited over a 3-month period from specialist outpatient clinics. The outcome measure was patients' choice of surgical approach (MIS or open). All patients were subjected to a stepwise interviewing process and were asked to select between open and MIS approaches at each step. Further subgroup analysis stratifying subjects based on stages of decision-making was performed to identify key predictors of selection changes. No sources of funding were required for this study and there are no conflicts of interests. Fifty-four patients with a mean age of 55.8 years participated in the study. Thirteen (24.1%) consistently selected a single approach, whereas 31 (57.4%) changed their selection more than once during the interviewing process. Overall, 12 patients (22.2%) had a final decision different from their initial choice, and 15 patients (27.8%) were unable to decide. A large proportion of patients (65.0%) initially favored the open approach's midline incision. This proportion dropped to 16.7% (p<.001) upon mention of the term MIS. The proportion of patients favoring MIS dropped significantly following discussion on the pros and cons (p=.002) of each approach, as well as conversion or revision surgery (p=.017). Radiation and cosmesis were identified as the two most important factors influencing patients' final decisions. The longer midline incision of the open approach is cosmetically more appealing to patients than the paramedian stab wounds of MIS. The advantages of the MIS approach may not be as valued by patients as they are by surgeons. Given the equivalent long-term outcomes of both approaches, it is crucial that patients are adequately informed during preoperative counseling to achieve the best consensus decision. Copyright © 2017 Elsevier Inc. All rights reserved.

Embryo selection using time-lapse analysis (Early Embryo Viability Assessment) in conjunction with standard morphology: a prospective two-center pilot study.

PubMed

Kieslinger, Dorit C; De Gheselle, Stefanie; Lambalk, Cornelis B; De Sutter, Petra; Kostelijk, E Hanna; Twisk, Jos W R; van Rijswijk, Joukje; Van den Abbeel, Etienne; Vergouw, Carlijn G

2016-11-01

Does prospective embryo selection using the results from the Eava Test (Early Embryo Viability Assessment) in combination with standard morphology increase the pregnancy rate of IVF and ICSI patients compared to embryo selection based on morphology only? Embryo selection using the Eeva Test plus standard morphology on Day 3 results in comparable pregnancy rates as conventional morphological embryo selection. Time-lapse monitoring of embryo development may represent a superior way to culture and select embryos in vitro. The Eeva Test records the development of each embryo with a cell-tracking system and predicts the likelihood (High, Medium or Low) that an embryo will form a blastocyst based on an automated analysis of early cell division timings. This trial was designed as a prospective, observational, two-center pilot study with a propensity matched control group. The analysis involved 280 of 302 enrolled patients who were included in the Eeva Test group in 2013 and 560 control patients who were treated in the years 2011-2013. The majority of transfers (98%) were single embryo transfers. Two academic hospitals (VUmc Amsterdam and UZ Gent) enrolled patients <41 years old, with <3 previous attempts and ≥5 normally fertilized eggs. Propensity matching was used to identify a propensity matched control group from a cohort of 1777 patients based on age, cycle number, oocyte number and number of fertilized oocytes. There was no difference in patient baseline characteristics between the two groups. The ongoing pregnancy rate (OPR) of patients enrolled in the Eeva Test group (34.3%; 96/280) did not differ significantly from the OPR in the propensity matched control group (34.6%, 194/560; P = 0.92). However, significantly less top quality embryos (eight-cell embryos with ≤25% fragmentation) were transferred in the Eeva Test group compared to the propensity matched control group (70.4% vs. 82.3%; P < 0.001). The transfer of Eeva High and Medium embryos resulted in a significantly higher OPR of 36.8% (89/242) compared to 18.4% (7/38) for Eeva Low embryos (P = 0.02). This pilot study is limited by its nonrandomized design with a concurrent and historical control. Our pilot data did not reveal significant differences between time-lapse based and conventional embryo selection. Interestingly, the pregnancy rates were comparable in both groups even though the morphological quality of the transferred embryos was significantly lower in the Eeva Test group compared to the propensity matched control group. A sufficiently powered three-armed randomized controlled trial (RCT) with a solid design should be performed to generate decisive evidence in the future. Progyny Inc., formerly Auxogyn provided the Eeva scopes, software and technical support for this study. The funding sources did neither influence data collection, management, analysis and interpretation of the data, nor the preparation of the manuscript. ClinicalTrials.gov: NCT01671644. © The Author 2016. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

Adjustable small-incision selective tenotomy and plication for correction of incomitant vertical strabismus and torsion

PubMed Central

Chang, Melinda Y.; Pineles, Stacy L.; Velez, Federico G.

2015-01-01

PURPOSE To evaluate the effectiveness of adjustable small-incision selective tenotomy and plication of vertical rectus muscles in correcting vertical strabismus incomitant in horizontal gaze positions and cyclotorsion. METHODS The medical records of all patients who underwent adjustable small-incision selective tenotomy or plication of a vertical rectus muscle for correction of horizontally incomitant vertical strabismus or cyclotorsion by a single surgeon at a single eye institute from July 2013 to September 2014 were retrospectively reviewed. Selective tenotomy and plication were performed on either the nasal or temporal side of vertical rectus muscles, based on the direction of cyclotorsion and incomitance of vertical strabismus. RESULTS Of 9 patients identified, 8 (89%) had successful correction of horizontally incomitant vertical strabismus, with postoperative vertical alignment within 4Δ of orthotropia in primary position, lateral gazes, and downgaze. Of the 8 patients with preoperative cyclotorsion, 4 (50%) were successfully corrected, with <5° of cyclotorsion postoperatively. Of the 4 patients in whom cyclotorsion did not improve, 3 had undergone prior strabismus surgery, and 2 had restrictive strabismus. Eight of the 9 patients (89%) reported postoperative resolution of diplopia. CONCLUSIONS Adjustable small-incision selective tenotomy and plication effectively treat horizontally incomitant vertical strabismus. These surgeries may be less effective for correcting cyclotorsion in patients with restriction or prior strabismus surgery. Advantages are that they may be performed in an adjustable manner and, in some cases, under topical anesthesia. PMID:26486021

Making effective referrals: a knowledge-management approach.

PubMed Central

Einbinder, J. S.; Klein, D. A.; Safran, C. S.

1997-01-01

Patients and physicians often choose specially consultants with only limited knowledge of the available options. Access to information about specialists that was directly relevant to patient and clinician preferences could improve the effectiveness of the referral process. We have developed a prescriptive representation of the process of selecting consultants. This "referral map," based on decision theory, uses patient and provider preferences elicited through a literature review and interviews with physicians and provides a formal framework for representing referral knowledge and for evaluating referral options. Our method suggests that the goals and processes of selecting consultants can be managed more systematically using explicit repositories. Such systematic management promises to have a beneficial impact on the delivery of health care, as well as on patient satisfaction. PMID:9357642

Recurrence predictive models for patients with hepatocellular carcinoma after radiofrequency ablation using support vector machines with feature selection methods.

PubMed

Liang, Ja-Der; Ping, Xiao-Ou; Tseng, Yi-Ju; Huang, Guan-Tarn; Lai, Feipei; Yang, Pei-Ming

2014-12-01

Recurrence of hepatocellular carcinoma (HCC) is an important issue despite effective treatments with tumor eradication. Identification of patients who are at high risk for recurrence may provide more efficacious screening and detection of tumor recurrence. The aim of this study was to develop recurrence predictive models for HCC patients who received radiofrequency ablation (RFA) treatment. From January 2007 to December 2009, 83 newly diagnosed HCC patients receiving RFA as their first treatment were enrolled. Five feature selection methods including genetic algorithm (GA), simulated annealing (SA) algorithm, random forests (RF) and hybrid methods (GA+RF and SA+RF) were utilized for selecting an important subset of features from a total of 16 clinical features. These feature selection methods were combined with support vector machine (SVM) for developing predictive models with better performance. Five-fold cross-validation was used to train and test SVM models. The developed SVM-based predictive models with hybrid feature selection methods and 5-fold cross-validation had averages of the sensitivity, specificity, accuracy, positive predictive value, negative predictive value, and area under the ROC curve as 67%, 86%, 82%, 69%, 90%, and 0.69, respectively. The SVM derived predictive model can provide suggestive high-risk recurrent patients, who should be closely followed up after complete RFA treatment. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Rational use of analgesic combinations.

PubMed

Phero, James C; Becker, Daniel

2002-10-01

Careful selection of an effective analgesic regimen based on the amount and type of pain the patient is expected to have can prevent the stress and anxiety associated with breakthrough pain. When analgesics fail, it is not unusual for patients to go to desperate lengths to seek relief. The clinician can and should develop a variety of effective, safe analgesic regimens based on estimates of anticipated pain intensity that apply sound pharmacologic principles.

Factors associated with a primary surgical approach for sinonasal squamous cell carcinoma.

PubMed

Cracchiolo, Jennifer R; Patel, Krupa; Migliacci, Jocelyn C; Morris, Luc T; Ganly, Ian; Roman, Benjamin R; McBride, Sean M; Tabar, Viviane S; Cohen, Marc A

2018-03-01

Primary surgery is the preferred treatment of T1-T4a sinonasal squamous cell carcinoma (SNSCC). Patients with SNSCC in the National Cancer Data Base (NCDB) were analyzed. Factors that contributed to selecting primary surgical treatment were examined. Overall survival (OS) in surgical patients was analyzed. Four-thousand seven hundred and seventy patients with SNSCC were included. In T1-T4a tumors, lymph node metastases, maxillary sinus location, and treatment at high-volume centers were associated with selecting primary surgery. When primary surgery was utilized, tumor factors and positive margin guided worse OS. Adjuvant therapy improved OS in positive margin resection and advanced T stage cases. Tumor and non-tumor factors are associated with selecting surgery for the treatment of SNSCC. When surgery is selected, tumor factors drive OS. Negative margin resection should be the goal of a primary surgical approach. When a positive margin resection ensues, adjuvant therapy may improve OS. © 2017 Wiley Periodicals, Inc.

Quality of life in thyroid cancer patients: a literature review

PubMed Central

BÃRBUŞ, ELENA; PEŞTEAN, CLAUDIU; LARG, MARIA IULIA; PICIU, DOINA

2017-01-01

Introduction Quality of life (QoL) has received increasing interest in the last years, especially in patients with cancer. This article aims to analyze a selection of medical research papers regarding the quality of life in patients with thyroid carcinoma. We overviewed the main QoL aspects derived from several studies and highlighted those less researched issues, which could represent a solid base for future clinical studies. Method We used an integrative selection method of medical literature, choosing mostly “free access” studies, as it was considered that they could be easily viewed, searched and researched including by patients. Results After an integrative literature review, we selected 16 relevant studies. Patients with thyroid cancer have several factors influencing their QoL, with both physical and psychological impact. The decisive factors are the quality of the surgical act, radioiodine therapy, follow-up using rh-TSH vs. hormonal withdrawal, access to behavioral help and the relationship with their physician. Conclusion We must understand the emotional impact of the cancer diagnosis on the patient and we must collaborate in order to help the patient restore the psychosomatic balance and to recover the quality of life PMID:28559697

Neuronal effects of nicotine during auditory selective attention in schizophrenia.

PubMed

Smucny, Jason; Olincy, Ann; Rojas, Donald C; Tregellas, Jason R

2016-01-01

Although nicotine has been shown to improve attention deficits in schizophrenia, the neurobiological mechanisms underlying this effect are poorly understood. We hypothesized that nicotine would modulate attention-associated neuronal response in schizophrenia patients in the ventral parietal cortex (VPC), hippocampus, and anterior cingulate based on previous findings in control subjects. To test this hypothesis, the present study examined response in these regions in a cohort of nonsmoking patients and healthy control subjects using an auditory selective attention task with environmental noise distractors during placebo and nicotine administration. In agreement with our hypothesis, significant diagnosis (Control vs. Patient) X drug (Placebo vs. Nicotine) interactions were observed in the VPC and hippocampus. The interaction was driven by task-associated hyperactivity in patients (relative to healthy controls) during placebo administration, and decreased hyperactivity in patients after nicotine administration (relative to placebo). No significant interaction was observed in the anterior cingulate. Task-associated hyperactivity of the VPC predicted poor task performance in patients during placebo. Poor task performance also predicted symptoms in patients as measured by the Brief Psychiatric Rating Scale. These results are the first to suggest that nicotine may modulate brain activity in a selective attention-dependent manner in schizophrenia. © 2015 Wiley Periodicals, Inc.

Use of the ‘Accountability for Reasonableness’ Approach to Improve Fairness in Accessing Dialysis in a Middle-Income Country

PubMed Central

Maree, Jonathan David; Chirehwa, Maxwell T.; Benatar, Solomon R.

2016-01-01

Universal access to renal replacement therapy is beyond the economic capability of most low and middle-income countries due to large patient numbers and the high recurrent cost of treating end stage kidney disease. In countries where limited access is available, no systems exist that allow for optimal use of the scarce dialysis facilities. We previously reported that using national guidelines to select patients for renal replacement therapy resulted in biased allocation. We reengineered selection guidelines using the ‘Accountability for Reasonableness’ (procedural fairness) framework in collaboration with relevant stakeholders, applying these in a novel way to categorize and prioritize patients in a unique hierarchical fashion. The guidelines were primarily premised on patients being transplantable. We examined whether the revised guidelines enhanced fairness of dialysis resource allocation. This is a descriptive study of 1101 end stage kidney failure patients presenting to a tertiary renal unit in a middle-income country, evaluated for dialysis treatment over a seven-year period. The Assessment Committee used the accountability for reasonableness-based guidelines to allocate patients to one of three assessment groups. Category 1 patients were guaranteed renal replacement therapy, Category 3 patients were palliated, and Category 2 were offered treatment if resources allowed. Only 25.2% of all end stage kidney disease patients assessed were accepted for renal replacement treatment. The majority of patients (48%) were allocated to Category 2. Of 134 Category 1 patients, 98% were accepted for treatment while 438 (99.5%) Category 3 patients were excluded. Compared with those palliated, patients accepted for dialysis treatment were almost 10 years younger, employed, married with children and not diabetic. Compared with our previous selection process our current method of priority setting based on procedural fairness arguably resulted in more equitable allocation of treatment but, more importantly, it is a model that is morally, legally and ethically more defensible. PMID:27701466

Preoperative [18F]-fluorodeoxyglucose positron emission tomography standardized uptake value of neck lymph nodes may aid in selecting patients with oral cavity squamous cell carcinoma for salvage therapy after relapse.

PubMed

Liao, Chun-Ta; Chang, Joseph Tung-Chieh; Wang, Hung-Ming; Ng, Shu-Hang; Huang, Shiang-Fu; Chen, I-How; Hsueh, Chuen; Lee, Li-Yu; Lin, Chih-Hung; Cheng, Ann-Joy; Yen, Tzu-Chen

2009-11-01

Relapse of tumours in patients with oral cavity squamous cell carcinoma (OSCC) is associated with a dismal outcome. In this prospective study, we sought to investigate the clinical significance of the preoperative maximal standardized uptake value (SUVmax) at the neck lymph nodes in selecting patients with OSCC for salvage therapy after relapse. Between 2002 and 2007, 108 patients with early relapse of OSCC (n=75) or late relapse of OSCC (n=33) were identified. Salvage therapy was performed in 47 patients. All patients underwent 2-deoxy-2[(18)F]-fluoro-D: -glucose positron emission tomography during the 2 weeks before surgery and neck dissection. All patients were followed for 12 months or more after surgery or until death. The optimal cut-off value for the neck lymph node SUVmax (SUVnodal-max) was selected according to the 5-year disease-specific survival (DSS) rate. Independent risk factors were identified by Cox regression analysis. The mean follow-up for all patients was 20.3 months (41.1 months for surviving patients). In the early relapse group, several prognostic factors were identified in univariate and multivariate analyses, including a SUVnodal-max value of >or=4.2. A scoring system based on univariate analysis was formulated. Patients with a score of 0 had a better 5-year DSS than those with scores of 1 or higher (58% vs. 5%, p=0.0003). In patients with late relapse, a SUVnodal-max value of >or=4.2 had the highest prognostic value for predicting the 5-year DSS (45% vs. 0%, p=0.0005). Among patients with relapsed OSCC, the SUVnodal-max value may aid in selecting patients for salvage therapy.

The Adverse Drug Reactions from Patient Reports in Social Media Project: Five Major Challenges to Overcome to Operationalize Analysis and Efficiently Support Pharmacovigilance Process.

PubMed

Bousquet, Cedric; Dahamna, Badisse; Guillemin-Lanne, Sylvie; Darmoni, Stefan J; Faviez, Carole; Huot, Charles; Katsahian, Sandrine; Leroux, Vincent; Pereira, Suzanne; Richard, Christophe; Schück, Stéphane; Souvignet, Julien; Lillo-Le Louët, Agnès; Texier, Nathalie

2017-09-21

Adverse drug reactions (ADRs) are an important cause of morbidity and mortality. Classical Pharmacovigilance process is limited by underreporting which justifies the current interest in new knowledge sources such as social media. The Adverse Drug Reactions from Patient Reports in Social Media (ADR-PRISM) project aims to extract ADRs reported by patients in these media. We identified 5 major challenges to overcome to operationalize the analysis of patient posts: (1) variable quality of information on social media, (2) guarantee of data privacy, (3) response to pharmacovigilance expert expectations, (4) identification of relevant information within Web pages, and (5) robust and evolutive architecture. This article aims to describe the current state of advancement of the ADR-PRISM project by focusing on the solutions we have chosen to address these 5 major challenges. In this article, we propose methods and describe the advancement of this project on several aspects: (1) a quality driven approach for selecting relevant social media for the extraction of knowledge on potential ADRs, (2) an assessment of ethical issues and French regulation for the analysis of data on social media, (3) an analysis of pharmacovigilance expert requirements when reviewing patient posts on the Internet, (4) an extraction method based on natural language processing, pattern based matching, and selection of relevant medical concepts in reference terminologies, and (5) specifications of a component-based architecture for the monitoring system. Considering the 5 major challenges, we (1) selected a set of 21 validated criteria for selecting social media to support the extraction of potential ADRs, (2) proposed solutions to guarantee data privacy of patients posting on Internet, (3) took into account pharmacovigilance expert requirements with use case diagrams and scenarios, (4) built domain-specific knowledge resources embeding a lexicon, morphological rules, context rules, semantic rules, syntactic rules, and post-analysis processing, and (5) proposed a component-based architecture that allows storage of big data and accessibility to third-party applications through Web services. We demonstrated the feasibility of implementing a component-based architecture that allows collection of patient posts on the Internet, near real-time processing of those posts including annotation, and storage in big data structures. In the next steps, we will evaluate the posts identified by the system in social media to clarify the interest and relevance of such approach to improve conventional pharmacovigilance processes based on spontaneous reporting. ©Cedric Bousquet, Badisse Dahamna, Sylvie Guillemin-Lanne, Stefan J Darmoni, Carole Faviez, Charles Huot, Sandrine Katsahian, Vincent Leroux, Suzanne Pereira, Christophe Richard, Stéphane Schück, Julien Souvignet, Agnès Lillo-Le Louët, Nathalie Texier. Originally published in JMIR Research Protocols (http://www.researchprotocols.org), 21.09.2017.

Tissue Reinforcement in Implant-based Breast Reconstruction

PubMed Central

Scheflan, Michael

2014-01-01

Background: Tissue reinforcement with allogeneic or xenogeneic acellular dermal matrices (ADMs) is increasingly used in single-stage (direct-to-implant) and 2-stage implant-based breast reconstruction following mastectomy. ADMs allow surgeons to control implant position and obviate the need for submuscular implant placement. Here, we review the benefits and risks of using ADMs in implant-based breast reconstruction based on available data. Methods: A comprehensive analysis of the literature with focus on recent publications was performed. Additional information regarding the proper use of ADMs was based on our institutional experience. Results: ADM use may improve definition of the lateral confines of the breast and lower pole projection. It may facilitate direct-to-implant procedures and improve aesthetic outcomes. The effect of ADMs on complication rates remains controversial. Known patient risk factors such as obesity, smoking, and radiotherapy should be considered during patient selection. For patients with healthy, well-vascularized skin envelopes, ADM-assisted direct-to- implant reconstruction is a safe and cost-effective alternative to 2-stage implant reconstruction, with low complication rates. ADMs may be used to treat capsular contracture, and limited available data further suggest the possibility that ADMs may reduce the risk of capsular contracture. Novel synthetic or biosynthetic tissue reinforcement devices with different physical and ease-of-use properties than ADMs are emerging options for reconstructive surgeons and patients who seek to avoid tissue products from human or mammalian cadavers. Conclusions: ADM-assisted implant-based breast reconstruction may improve aesthetic outcomes. However, appropriate patient selection, surgical technique, and postoperative management are critical for its success, including minimizing the risk of complications. PMID:25426375

A conceptual-practice model for occupational therapy to facilitate return to work in breast cancer patients.

PubMed

Désiron, Huguette A M; Donceel, Peter; de Rijk, Angelique; Van Hoof, Elke

2013-12-01

Improved therapies and early detection have significantly increased the number of breast cancers survivors, leading to increasing needs regarding return to work (RTW). Occupational therapy (OT) interventions provide successful RTW assistance for other conditions, but are not validated in breast cancer. This paper aims to identify a theoretical framework for OT intervention by questioning how OT models can be used in OT interventions in RTW of breast cancer patients; criteria to be used to select these models and adaptations that would be necessary to match the OT model(s) to breast cancer patients' needs? Using research specific criteria derived from OT literature (conceptual OT-model, multidisciplinary, referring to the International Classification of functioning (ICF), RTW in breast cancer) a search in 9 electronic databases was conducted to select articles that describe conceptual OT models. A content analysis of those models complying to at least two of the selection criteria was realised. Checking for breast cancer specific issues, results were matched with literature of care-models regarding RTW in breast cancer. From the nine models initially identified, three [Canadian Model of Occupational Performance, Model of Human Occupation (MOHO), Person-Environment-Occupation-Performance model] were selected based on the selection criteria. The MOHO had the highest compliance rate with the criteria. To enhance usability in breast cancer, some adaptations are needed. No OT model to facilitate RTW in breast cancer could be identified, indicating a need to fill this gap. Individual and societal needs of breast cancer patients can be answered by using a MOHO-based OT model, extended with indications for better treatment, work-outcomes and longitudinal process factors.

Screening for thrombophilia in high-risk situations: a meta-analysis and cost-effectiveness analysis.

PubMed

Wu, Olivia; Robertson, Lindsay; Twaddle, Sara; Lowe, Gordon; Clark, Peter; Walker, Isobel; Brenkel, Ivan; Greaves, Mike; Langhorne, Peter; Regan, Lesley; Greer, Ian

2005-10-01

Laboratory testing for the identification of heritable thrombophilia in high-risk patient groups have become common practice; however, indiscriminate testing of all patients is unjustified. The objective of this study was to evaluate the cost-effectiveness of universal and selective history-based thrombophilia screening relative to no screening, from the perspective of the UK National Health Service, in women prior to prescribing combined oral contraceptives and hormone replacement therapy, women during pregnancy and patients prior to major orthopaedic surgery. A decision analysis model was developed, and data from meta-analysis, the literature and two Delphi studies were incorporated in the model. Incremental cost-effectiveness ratios (ICERs) for screening compared with no screening was calculated for each patient group. Of all the patient groups evaluated, universal screening of women prior to prescribing hormone replacement therapy was the most cost-effective (ICER 6824 pounds). In contrast, universal screening of women prior to prescribing combined oral contraceptives was the least cost-effective strategy (ICER 202,402 pounds). Selective thrombophilia screening based on previous personal and/or family history of venous thromboembolism was more cost-effective than universal screening in all the patient groups evaluated.

Behavioral Interviewing: Integrating ACGME Competency-Based Questions Into the Radiology Resident Selection Process.

PubMed

McArthur, Tatum A; Flug, Jonathan A; Restauri, Nicole

The practice of radiology is continually evolving with external pressures increasing the involvement of the radiologist as an integrated member of the multidisciplinary care delivery team and not just image interpreters working in isolation. Radiologists need to be comfortable interacting directly with patients and practicing "patient and family-centered care" and "value-based medicine." Despite this evolving role of the radiologist, medical training and the residency selection process have not significantly adapted to accommodate these new demands. In order to develop and hire radiologists who can excel in this role, the selection and interview process must be adapted to prospectively identify those candidates who can thrive in this changing role. Behavior-based interviewing is a tool that can help identify those candidates who may excel in the future. 1-3 Though there are reports of it being used in the United States medical schools and residency programs across the nation, it has not become a mainstay for medical residency and professional medical interviewing. Copyright © 2017 Elsevier Inc. All rights reserved.

Advanced Cancer and End-of-Life Preferences: Curative Intent Surgery Versus Noncurative Intent Treatment.

PubMed

Schubart, Jane R; Green, Michael J; Van Scoy, Lauren J; Lehman, Erik; Farace, Elana; Gusani, Niraj J; Levi, Benjamin H

2015-12-01

People with cancer face complex medical decisions, including whether to receive life-sustaining treatments at the end of life. It is not unusual for clinicians to make assumptions about patients' wishes based on whether they had previously chosen to pursue curative treatment. We hypothesized that cancer patients who initially underwent curative intent surgery (CIS) would prefer more aggressive end-of-life treatments compared to patients whose treatment was noncurative intent (non-CIT). This study was a retrospective review of data from a large, randomized controlled trial examining the use of an online decision aid for advance care planning, "Making Your Wishes Known" (MYWK), with patients who had advanced cancer. We reviewed patients' medical records to determine which patients underwent CIS versus non-CIT. In the parent trial, conducted at an academic medical center (2007-2012), 200 patients were enrolled with stage IV malignancy or other poor prognosis cancer. Patients' preferences for aggressive treatment were measured in two ways: using patient-selected General Wishes statements generated by the decision aid and patient-selected wishes for specific treatments under various hypothetical clinical scenarios (Specific Wishes). We evaluated 79 patients. Of these, 48 had undergone initial CIS and 31 had non-CIT. Cancer patients who initially underwent CIS did not prefer more aggressive end-of-life treatments compared to patients whose treatment was non-CIT. Clinicians should avoid assumptions about patients' preferences for life-sustaining treatment based on their prior choices for aggressive treatment.

Office-based surgery: embracing patient safety strategies.

PubMed

Shapiro, Fred E; Punwani, Nathan; Urman, Richard D

2013-01-01

Office-based surgery continues to grow as more procedures are being performed in the outpatient setting. With this exponential growth, there is an increasing emphasis on safe and effective patient care. Current research shows both gaps in safety and opportunities for improvement. Practice managers, clinicians, and other personnel should be cognizant that office procedures are coming under intense regulatory scrutiny. Effective strategies to maintain quality and patient safety include the use of checklists, obtaining office accreditation, encouraging board-certification and proper credentialing of proceduralists, and appropriate patient and procedure selection. There is increasing regulation of ambulatory surgery on state and national levels that will likely affect the financial and care quality aspects of office-based practice. Socioeconomic and political forces will continue to shape the future of office-based surgery.

JCDSA: a joint covariate detection tool for survival analysis on tumor expression profiles.

PubMed

Wu, Yiming; Liu, Yanan; Wang, Yueming; Shi, Yan; Zhao, Xudong

2018-05-29

Survival analysis on tumor expression profiles has always been a key issue for subsequent biological experimental validation. It is crucial how to select features which closely correspond to survival time. Furthermore, it is important how to select features which best discriminate between low-risk and high-risk group of patients. Common features derived from the two aspects may provide variable candidates for prognosis of cancer. Based on the provided two-step feature selection strategy, we develop a joint covariate detection tool for survival analysis on tumor expression profiles. Significant features, which are not only consistent with survival time but also associated with the categories of patients with different survival risks, are chosen. Using the miRNA expression data (Level 3) of 548 patients with glioblastoma multiforme (GBM) as an example, miRNA candidates for prognosis of cancer are selected. The reliability of selected miRNAs using this tool is demonstrated by 100 simulations. Furthermore, It is discovered that significant covariates are not directly composed of individually significant variables. Joint covariate detection provides a viewpoint for selecting variables which are not individually but jointly significant. Besides, it helps to select features which are not only consistent with survival time but also associated with prognosis risk. The software is available at http://bio-nefu.com/resource/jcdsa .

2013 AAHA/AAFP fluid therapy guidelines for dogs and cats.

PubMed

Davis, Harold; Jensen, Tracey; Johnson, Anthony; Knowles, Pamela; Meyer, Robert; Rucinsky, Renee; Shafford, Heidi

2013-01-01

Fluid therapy is important for many medical conditions in veterinary patients. The assessment of patient history, chief complaint, physical exam findings, and indicated additional testing will determine the need for fluid therapy. Fluid selection is dictated by the patient's needs, including volume, rate, fluid composition required, and location the fluid is needed (e.g., interstitial versus intravascular). Therapy must be individualized, tailored to each patient, and constantly re-evaluated and reformulated according to changes in status. Needs may vary according to the existence of either acute or chronic conditions, patient pathology (e.g., acid-base, oncotic, electrolyte abnormalities), and comorbid conditions. All patients should be assessed for three types of fluid disturbances: changes in volume, changes in content, and/or changes in distribution. The goals of these guidelines are to assist the clinician in prioritizing goals, selecting appropriate fluids and rates of administration, and assessing patient response to therapy. These guidelines provide recommendations for fluid administration for anesthetized patients and patients with fluid disturbances.

Prospective study of swallowing function in patients with cervical dystonia undergoing selective peripheral denervation

PubMed Central

Munchau, A; Good, C; McGowan, S; Quinn, N; Palmer, J; Bhatia, K

2001-01-01

OBJECTIVE—To characterise swallowing function in patients with cervical dystonia with botulinum toxin treatment failure, before and after selective peripheral denervation surgery.
METHODS—Twelve patients with cervical dystonia had a thorough examination including standardised assessment for cervical dystonia, scoring of subjective dysphagia, and videofluoroscopic swallow. Videofluoroscopy was scored by consensus opinion between a speech and language therapist and an independent blinded radiologist using a validated scoring system.
RESULTS—Seven patients with cervical dystonia experienced no subjective dysphagia either before or after surgery, although in all these patients there was objective videofluoroscopic evidence of underlying mild to moderate oropharyngeal dysphagia preoperatively and postoperatively. The most common finding was delayed initiation of swallow. Three other patients, also without subjective dysphagia before surgery, developed postoperative dysphagia. In these patients, videofluoroscopy showed a delayed swallow reflex before surgery, which was worse postoperatively in two. The remaining two patients had mild subjective dysphagia before surgery that improved postoperatively in one and deteriorated in the other. In the first, videofluoroscopy was normal preoperatively and postoperatively, and in the second, oral bolus preparation was moderately abnormal preoperatively and swallow initiation was delayed postoperatively. Mean subjective dysphagia scores did not change significantly. Apart from a significant improvement of tongue base retraction, videofluoroscopic scores were not significantly different after surgery. Postoperatively there was significant improvement of overall cervical dystonia severity and abnormal head rotation in the group as a whole. There was no correlation between age, duration of symptoms of cervical dystonia, preoperative or postoperative cervical dystonia severity, subjective dysphagia scores, or videofluoroscopic scores. However, in the five patients with persisting anterior sagittal head shift as part of the torticollis, tongue base retraction was less likely to improve after surgery compared with those without head shift.
CONCLUSION—Surgical denervation of dystonic neck muscles, leading to improved neck posture, can also improve tongue base retraction, which is a key component of normal bolus propagation. However, delayed swallow initiation, a common feature in patients with cervical dystonia, can be further compromised by surgery, leading to subjective dysphagia. In general, selective peripheral denervation seems to be a safe procedure with no major compromise of swallowing function.

 PMID:11413266

Effectiveness of a new health care organization model in primary care for chronic cardiovascular disease patients based on a multifactorial intervention: the PROPRESE randomized controlled trial

PubMed Central

2013-01-01

Background To evaluate the effectiveness of a new multifactorial intervention to improve health care for chronic ischemic heart disease patients in primary care. The strategy has two components: a) organizational for the patient/professional relationship and b) training for professionals. Methods/design Experimental study. Randomized clinical trial. Follow-up period: one year. Study setting: primary care, multicenter (15 health centers). For the intervention group 15 health centers are selected from those participating in ESCARVAL study. Once the center agreed to participate patients are randomly selected from the total amount of patients with ischemic heart disease registered in the electronic health records. For the control group a random sample of patients with ischemic heart disease is selected from all 72 health centers electronic records. Intervention components: a) Organizational intervention on the patient/professional relationship. Centered on the Chronic Care Model, the Stanford Expert Patient Program and the Kaiser Permanente model: Teamwork, informed and active patient, decision making shared with the patient, recommendations based on clinical guidelines, single electronic medical history per patient that allows the use of indicators for risk monitoring and stratification. b) Formative strategy for professionals: 4 face-to-face training workshops (one every 3 months), monthly update clinical sessions, online tutorial by a cardiologist, availability through the intranet of the action protocol and related documents. Measurements: Blood pressure, blood glucose, HbA1c, lipid profile and smoking. Frequent health care visits. Number of hospitalizations related to vascular disease. Therapeutic compliance. Drug use. Discussion This study aims to evaluate the efficacy of a multifactorial intervention strategy involving patients with ischemic heart disease for the improvement of the degree of control of the cardiovascular risk factors and of the quality of life, number of visits, and number of hospitalizations. Trial registration NCT01826929 PMID:23915267

Selection of patients for sublingual versus subcutaneous immunotherapy.

PubMed

Larenas Linnemann, Désirée E S; Blaiss, Michael S

2014-01-01

Allergen immunotherapy is the sole treatment for IgE-mediated allergic diseases directed at the underlying mechanism. The two widely accepted administration routes are sublingual (SLIT) and subcutaneous (SCIT). We reviewed how patients should best be selected for immunotherapy and how the optimal administration route can be defined. Before deciding SCIT or SLIT, appropriate selection of patients for allergen immunotherapy (AIT) is mandatory. To be eligible for AIT, subjects must have a clear medical history of allergic disease, with exacerbation of symptoms on exposure to one or more allergens and a corresponding positive skin or in vitro test. Then the route of administration should be based on: published evidence of clinical and immunologic efficacy (which varies per allergic disease and per allergen); mono- or multi-allergen immunotherapy, for SLIT multi-allergen immunotherapy was not effective; safety: adverse events with SLIT are more frequent, but less severe; and, costs and patient preferences, closely related to adherence issues. All these are discussed in the article.

Five Antiretroviral Drug Class-Resistant HIV-1 in a Treatment-Naïve Patient Successfully Suppressed with Optimized Antiretroviral Drug Selection.

PubMed

Volpe, Joseph M; Ward, Douglas J; Napolitano, Laura; Phung, Pham; Toma, Jonathan; Solberg, Owen; Petropoulos, Christos J; Walworth, Charles M

2015-01-01

Transmitted HIV-1 exhibiting reduced susceptibility to protease and reverse transcriptase inhibitors is well documented but limited for integrase inhibitors and enfuvirtide. We describe here a case of transmitted 5 drug class-resistance in an antiretroviral (ARV)-naïve patient who was successfully treated based on the optimized selection of an active ARV drug regimen. The value of baseline resistance testing to determine an optimal ARV treatment regimen is highlighted in this case report. © The Author(s) 2015.

Prospective Bundled Payments in a Changing Environment: The Experience of a Self-Funded, State-Sponsored Plan.

PubMed

Lawler, Frank H; Wilson, Frank R; Smith, G Keith; Mitchell, Lynn V

2017-12-01

Healthcare reimbursement, which has traditionally been based on the quantity of services delivered, is currently moving toward value-based reimbursement-a system that addresses the quantity, quality, and cost of services. One such arrangement has been the evolution of bundled payments for a specific procedure or for an episode of care, paid prospectively or through post-hoc reconciliation. To evaluate the impact of instituting bundled payments that incorporate facility charges, physician fees, and all ancillary charges by the State of Oklahoma HealthChoice public employee insurance plan. From January 1 through December 31, 2016, HealthChoice, a large, government-sponsored Oklahoma health plan, implemented a voluntary, prospective, bundled payment system with network facilities, called Select. The Select program allows members at the time of certification of the services to opt to use participating facilities for specified services at a bundled rate, with deductible and coinsurance covered by the health plan. That is, the program allows any plan member to choose either a participating Select facility with no out-of-pocket costs or standard benefits at a participating network facility. During 2016, more than 7900 procedures were performed for 5907 patients who chose the Select arrangement (also designated as the intervention group). The most common outpatient Select procedures were for cardiology, colonoscopy, and magnetic resonance imaging scans. The most common inpatient procedures for Select-covered patients were in 6 diagnosis-related groups covering spinal fusions, joint replacement surgeries, and percutaneous coronary artery stenting. The allowable costs were similar for bundled procedures at ambulatory surgery centers and at outpatient hospital facilities; the allowable costs for patients not in the Select program (mean, $813) were lower at ambulatory surgery centers than at outpatient hospital departments (mean, $3086) because of differences in case mix. Patients in the Select system who had outpatient procedures had significantly fewer subsequent claims than those who were not in Select for hospitalization (1.7% vs 2.5%, respectively) and emergency department visits (4.4% vs 11.5%, respectively) in the 30 days postprocedure. Quality measures (eg, wound infection and reoperation) were similar for patients who were and were not in the Select group and had procedures. Surgical complication (ie, return to surgery) rates were higher for the Select group. The Select program demonstrated promising results during its first year of operation, suggesting that prospective bundled payment arrangements can be implemented successfully. Further research on reimbursement mechanisms, that is, how to pay physicians and facilities, and quality of outcomes is needed, especially with respect to which procedures are most suitable for this payment arrangement.

Prospective Bundled Payments in a Changing Environment: The Experience of a Self-Funded, State-Sponsored Plan

PubMed Central

Lawler, Frank H.; Wilson, Frank R.; Smith, G. Keith; Mitchell, Lynn V.

2017-01-01

Background Healthcare reimbursement, which has traditionally been based on the quantity of services delivered, is currently moving toward value-based reimbursement—a system that addresses the quantity, quality, and cost of services. One such arrangement has been the evolution of bundled payments for a specific procedure or for an episode of care, paid prospectively or through post-hoc reconciliation. Objective To evaluate the impact of instituting bundled payments that incorporate facility charges, physician fees, and all ancillary charges by the State of Oklahoma HealthChoice public employee insurance plan. Method From January 1 through December 31, 2016, HealthChoice, a large, government-sponsored Oklahoma health plan, implemented a voluntary, prospective, bundled payment system with network facilities, called Select. The Select program allows members at the time of certification of the services to opt to use participating facilities for specified services at a bundled rate, with deductible and coinsurance covered by the health plan. That is, the program allows any plan member to choose either a participating Select facility with no out-of-pocket costs or standard benefits at a participating network facility. Results During 2016, more than 7900 procedures were performed for 5907 patients who chose the Select arrangement (also designated as the intervention group). The most common outpatient Select procedures were for cardiology, colonoscopy, and magnetic resonance imaging scans. The most common inpatient procedures for Select-covered patients were in 6 diagnosis-related groups covering spinal fusions, joint replacement surgeries, and percutaneous coronary artery stenting. The allowable costs were similar for bundled procedures at ambulatory surgery centers and at outpatient hospital facilities; the allowable costs for patients not in the Select program (mean, $813) were lower at ambulatory surgery centers than at outpatient hospital departments (mean, $3086) because of differences in case mix. Patients in the Select system who had outpatient procedures had significantly fewer subsequent claims than those who were not in Select for hospitalization (1.7% vs 2.5%, respectively) and emergency department visits (4.4% vs 11.5%, respectively) in the 30 days postprocedure. Quality measures (eg, wound infection and reoperation) were similar for patients who were and were not in the Select group and had procedures. Surgical complication (ie, return to surgery) rates were higher for the Select group. Conclusion The Select program demonstrated promising results during its first year of operation, suggesting that prospective bundled payment arrangements can be implemented successfully. Further research on reimbursement mechanisms, that is, how to pay physicians and facilities, and quality of outcomes is needed, especially with respect to which procedures are most suitable for this payment arrangement. PMID:29403570

Addressing the selective role of distinct prefrontal areas in response suppression: A study with brain tumor patients.

PubMed

Arbula, Sandra; Pacella, Valentina; De Pellegrin, Serena; Rossetto, Marta; Denaro, Luca; D'Avella, Domenico; Della Puppa, Alessandro; Vallesi, Antonino

2017-06-01

The diverging evidence for functional localization of response inhibition within the prefrontal cortex might be justified by the still unclear involvement of other intrinsically related cognitive processes like response selection and sustained attention. In this study, the main aim was to understand whether inhibitory impairments, previously found in patients with both left and right frontal lesions, could be better accounted for by assessing these potentially related cognitive processes. We tested 37 brain tumor patients with left prefrontal, right prefrontal and non-prefrontal lesions and a healthy control group on Go/No-Go and Foreperiod tasks. In both types of tasks inhibitory impairments are likely to cause false alarms, although additionally the former task requires response selection and the latter target detection abilities. Irrespective of the task context, patients with right prefrontal damage showed frequent Go and target omissions, probably due to sustained attention lapses. Left prefrontal patients, on the other hand, showed both Go and target omissions and high false alarm rates to No-Go and warning stimuli, suggesting a decisional rather than an inhibitory impairment. An exploratory whole-brain voxel-based lesion-symptom mapping analysis confirmed the association of left ventrolateral and dorsolateral prefrontal lesions with target discrimination failure, and right ventrolateral and medial prefrontal lesions with target detection failure. Results from this study show how left and right prefrontal areas, which previous research has linked to response inhibition, underlie broader cognitive control processes, particularly involved in response selection and target detection. Based on these findings, we suggest that successful inhibitory control relies on more than one functionally distinct process which, if assessed appropriately, might help us to better understand inhibitory impairments across different pathologies. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

SU-F-R-14: PET Based Radiomics to Predict Outcomes in Patients with Hodgkin Lymphoma

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

Lee, J; Aristophanous, M; Akhtari, M

Purpose: To identify PET-based radiomics features associated with high refractory/relapsed disease risk for Hodgkin lymphoma patients. Methods: A total of 251 Hodgkin lymphoma patients including 19 primary refractory and 9 relapsed patients were investigated. All patients underwent an initial pre-treatment diagnostic FDG PET/CT scan. All cancerous lymph node regions (ROIs) were delineated by an experienced physician based on thresholding each volume of disease in the anatomical regions to SUV>2.5. We extracted 122 image features and evaluated the effect of ROI selection (the largest ROI, the ROI with highest mean SUV, merged ROI, and a single anatomic region [e.g. mediastinum]) onmore » classification accuracy. Random forest was used as a classifier and ROC analysis was used to assess the relationship between selected features and patient’s outcome status. Results: Each patient had between 1 and 9 separate ROIs, with much intra-patient variability in PET features. The best model, which used features from a single anatomic region (the mediastinal ROI, only volumes>5cc: 169 patients with 12 primary refractory) had a classification accuracy of 80.5% for primary refractory disease. The top five features, based on Gini index, consist of shape features (max 3D-diameter and volume) and texture features (correlation and information measure of correlation1&2). In the ROC analysis, sensitivity and specificity of the best model were 0.92 and 0.80, respectively. The area under the ROC (AUC) and the accuracy were 0.86 and 0.86, respectively. The classification accuracy was less than 60% for other ROI models or when ROIs less than 5cc were included. Conclusion: This study showed that PET-based radiomics features from the mediastinal lymph region are associated with primary refractory disease and therefore may play an important role in predicting outcomes in Hodgkin lymphoma patients. These features could be additive beyond baseline tumor and clinical characteristics, and may warrant more aggressive treatment.« less

Investigation of the optimum location of external markers for patient setup accuracy enhancement at external beam radiotherapy

PubMed Central

Torshabi, Ahmad Esmaili; Nankali, Saber

2016-01-01

In external beam radiotherapy, one of the most common and reliable methods for patient geometrical setup and/or predicting the tumor location is use of external markers. In this study, the main challenging issue is increasing the accuracy of patient setup by investigating external markers location. Since the location of each external marker may yield different patient setup accuracy, it is important to assess different locations of external markers using appropriate selective algorithms. To do this, two commercially available algorithms entitled a) canonical correlation analysis (CCA) and b) principal component analysis (PCA) were proposed as input selection algorithms. They work on the basis of maximum correlation coefficient and minimum variance between given datasets. The proposed input selection algorithms work in combination with an adaptive neuro‐fuzzy inference system (ANFIS) as a correlation model to give patient positioning information as output. Our proposed algorithms provide input file of ANFIS correlation model accurately. The required dataset for this study was prepared by means of a NURBS‐based 4D XCAT anthropomorphic phantom that can model the shape and structure of complex organs in human body along with motion information of dynamic organs. Moreover, a database of four real patients undergoing radiation therapy for lung cancers was utilized in this study for validation of proposed strategy. Final analyzed results demonstrate that input selection algorithms can reasonably select specific external markers from those areas of the thorax region where root mean square error (RMSE) of ANFIS model has minimum values at that given area. It is also found that the selected marker locations lie closely in those areas where surface point motion has a large amplitude and a high correlation. PACS number(s): 87.55.km, 87.55.N PMID:27929479

ASTRAL-R score predicts non-recanalisation after intravenous thrombolysis in acute ischaemic stroke.

PubMed

Vanacker, Peter; Heldner, Mirjam R; Seiffge, David; Mueller, Hubertus; Eskandari, Ashraf; Traenka, Christopher; Ntaios, George; Mosimann, Pascal J; Sztajzel, Roman; Mendes Pereira, Vitor; Cras, Patrick; Engelter, Stefan; Lyrer, Philippe; Fischer, Urs; Lambrou, Dimitris; Arnold, Marcel; Michel, Patrik

2015-05-01

Intravenous thrombolysis (IVT) as treatment in acute ischaemic strokes may be insufficient to achieve recanalisation in certain patients. Predicting probability of non-recanalisation after IVT may have the potential to influence patient selection to more aggressive management strategies. We aimed at deriving and internally validating a predictive score for post-thrombolytic non-recanalisation, using clinical and radiological variables. In thrombolysis registries from four Swiss academic stroke centres (Lausanne, Bern, Basel and Geneva), patients were selected with large arterial occlusion on acute imaging and with repeated arterial assessment at 24 hours. Based on a logistic regression analysis, an integer-based score for each covariate of the fitted multivariate model was generated. Performance of integer-based predictive model was assessed by bootstrapping available data and cross validation (delete-d method). In 599 thrombolysed strokes, five variables were identified as independent predictors of absence of recanalisation: Acute glucose > 7 mmol/l (A), significant extracranial vessel STenosis (ST), decreased Range of visual fields (R), large Arterial occlusion (A) and decreased Level of consciousness (L). All variables were weighted 1, except for (L) which obtained 2 points based on β-coefficients on the logistic scale. ASTRAL-R scores 0, 3 and 6 corresponded to non-recanalisation probabilities of 18, 44 and 74 % respectively. Predictive ability showed AUC of 0.66 (95 %CI, 0.61-0.70) when using bootstrap and 0.66 (0.63-0.68) when using delete-d cross validation. In conclusion, the 5-item ASTRAL-R score moderately predicts non-recanalisation at 24 hours in thrombolysed ischaemic strokes. If its performance can be confirmed by external validation and its clinical usefulness can be proven, the score may influence patient selection for more aggressive revascularisation strategies in routine clinical practice.

Development of an evidence-based decision pathway for vestibular schwannoma treatment options.

PubMed

Linkov, Faina; Valappil, Benita; McAfee, Jacob; Goughnour, Sharon L; Hildrew, Douglas M; McCall, Andrew A; Linkov, Igor; Hirsch, Barry; Snyderman, Carl

To integrate multiple sources of clinical information with patient feedback to build evidence-based decision support model to facilitate treatment selection for patients suffering from vestibular schwannomas (VS). This was a mixed methods study utilizing focus group and survey methodology to solicit feedback on factors important for making treatment decisions among patients. Two 90-minute focus groups were conducted by an experienced facilitator. Previously diagnosed VS patients were recruited by clinical investigators at the University of Pittsburgh Medical Center (UPMC). Classical content analysis was used for focus group data analysis. Providers were recruited from practices within the UPMC system and were surveyed using Delphi methods. This information can provide a basis for multi-criteria decision analysis (MCDA) framework to develop a treatment decision support system for patients with VS. Eight themes were derived from these data (focus group + surveys): doctor/health care system, side effects, effectiveness of treatment, anxiety, mortality, family/other people, quality of life, and post-operative symptoms. These data, as well as feedback from physicians were utilized in building a multi-criteria decision model. The study illustrated steps involved in the development of a decision support model that integrates evidence-based data and patient values to select treatment alternatives. Studies focusing on the actual development of the decision support technology for this group of patients are needed, as decisions are highly multifactorial. Such tools have the potential to improve decision making for complex medical problems with alternate treatment pathways. Copyright © 2016 Elsevier Inc. All rights reserved.

Association Between Carotid Bulb Diaphragm and Ischemic Stroke in Young Afro-Caribbean Patients: A Population-Based Case-Control Study.

PubMed

Joux, Julien; Boulanger, Marion; Jeannin, Severine; Chausson, Nicolas; Hennequin, Jean-Luc; Molinié, Vincent; Smadja, Didier; Touzé, Emmanuel; Olindo, Stephane

2016-10-01

Carotid bulb diaphragm (CBD) has been described in young carotid ischemic stroke (CIS) patients, especially in blacks. However, the prevalence of CBD in CIS patients is unknown, and whether CBD is a risk factor for CIS remains unclear. We assessed the association between CBD and incident CIS in a population-based study. We selected all young (<55 years) CIS patients from a 1-year population-based cohort study in the Afro-Caribbean population of Martinique in 2012. All patients had a comprehensive work-up including a computed tomographic angiography. We calculated CIS associated with ipsilateral CBD incidence with 95% confidence intervals using Poisson distribution. We then selected age- and sex-matched controls among young (<55 years) Afro-Caribbean stroke-free patients admitted for a road crash who routinely had computed tomographic angiography. Odds ratio (ORs) were calculated by conditional logistic regression adjusted for hypertension, dyslipidemia, diabetes and smoking. CIS associated with ipsilateral CBD incidence was 3.8 per 100 000 person-years (95% confidence interval, 1.4-6.1). Prevalence of ipsilateral CBD was 23% in all CIS and 37% in undetermined CIS patients. When restricted to undetermined CIS, CBD prevalence was 24 times higher than that in controls (adjusted OR, 24.1; 95% confidence interval, 1.8-325.6). CBD is associated with an increased risk of ipsilateral CIS in young Afro-Caribbean population. © 2016 American Heart Association, Inc.

A wavelet-based technique to predict treatment outcome for Major Depressive Disorder.

PubMed

Mumtaz, Wajid; Xia, Likun; Mohd Yasin, Mohd Azhar; Azhar Ali, Syed Saad; Malik, Aamir Saeed

2017-01-01

Treatment management for Major Depressive Disorder (MDD) has been challenging. However, electroencephalogram (EEG)-based predictions of antidepressant's treatment outcome may help during antidepressant's selection and ultimately improve the quality of life for MDD patients. In this study, a machine learning (ML) method involving pretreatment EEG data was proposed to perform such predictions for Selective Serotonin Reuptake Inhibitor (SSRIs). For this purpose, the acquisition of experimental data involved 34 MDD patients and 30 healthy controls. Consequently, a feature matrix was constructed involving time-frequency decomposition of EEG data based on wavelet transform (WT) analysis, termed as EEG data matrix. However, the resultant EEG data matrix had high dimensionality. Therefore, dimension reduction was performed based on a rank-based feature selection method according to a criterion, i.e., receiver operating characteristic (ROC). As a result, the most significant features were identified and further be utilized during the training and testing of a classification model, i.e., the logistic regression (LR) classifier. Finally, the LR model was validated with 100 iterations of 10-fold cross-validation (10-CV). The classification results were compared with short-time Fourier transform (STFT) analysis, and empirical mode decompositions (EMD). The wavelet features extracted from frontal and temporal EEG data were found statistically significant. In comparison with other time-frequency approaches such as the STFT and EMD, the WT analysis has shown highest classification accuracy, i.e., accuracy = 87.5%, sensitivity = 95%, and specificity = 80%. In conclusion, significant wavelet coefficients extracted from frontal and temporal pre-treatment EEG data involving delta and theta frequency bands may predict antidepressant's treatment outcome for the MDD patients.

Do Hospital-Owned Skilled Nursing Facilities Provide Better Post-Acute Care Quality?

PubMed Central

Norton, Edward C.; Grabowski, David C.

2016-01-01

As hospitals are increasingly held accountable for patients' post-discharge outcomes under new payment models, hospitals may choose to acquire skilled nursing facilities (SNFs) to better manage these outcomes. This raises the question of whether patients discharged to hospital-based SNFs have better outcomes. In unadjusted comparisons, hospital-based SNF patients have much lower Medicare utilization in the 180 days following discharge relative to freestanding SNF patients. We solved the problem of differential selection into hospital-based and freestanding SNFs by using differential distance from home to the nearest hospital with a SNF relative to the distance from home to the nearest hospital without a SNF as an instrument. We found that hospital-based SNF patients spent roughly 5 more days in the community and 6 fewer days in the SNF in the 180 days following their original hospital discharge with no significant effect on mortality or hospital readmission. PMID:27661738

Value of Computed Tomographic Perfusion-Based Patient Selection for Intra-Arterial Acute Ischemic Stroke Treatment.

PubMed

Borst, Jordi; Berkhemer, Olvert A; Roos, Yvo B W E M; van Bavel, Ed; van Zwam, Wim H; van Oostenbrugge, Robert J; van Walderveen, Marianne A A; Lingsma, Hester F; van der Lugt, Aad; Dippel, Diederik W J; Yoo, Albert J; Marquering, Henk A; Majoie, Charles B L M

2015-12-01

The utility of computed tomographic perfusion (CTP)-based patient selection for intra-arterial treatment of acute ischemic stroke has not been proven in randomized trials and requires further study in a cohort that was not selected based on CTP. Our objective was to study the relationship between CTP-derived parameters and outcome and treatment effect in patients with acute ischemic stroke because of a proximal intracranial arterial occlusion. We included 175 patients who underwent CTP in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in The Netherlands (MR CLEAN). Association of CTP-derived parameters (ischemic-core volume, penumbra volume, and percentage ischemic core) with outcome was estimated with multivariable ordinal logistic regression as an adjusted odds ratio for a shift in the direction of a better outcome on the modified Rankin Scale. Interaction between CTP-derived parameters and treatment effect was determined using multivariable ordinal logistic regression. Interaction with treatment effect was also tested for mismatch (core <70 mL; penumbra core >1.2; penumbra core >10 mL). The adjusted odds ratio for improved functional outcome for ischemic core, percentage ischemic core, and penumbra were 0.79 per 10 mL (95% confidence interval: 0.71-0.89; P<0.001), 0.82 per 10% (95% confidence interval: 0.66-0.90; P=0.002), and 0.97 per 10 mL (96% confidence interval: 0.92-1.01; P=0.15), respectively. No significant interaction between any of the CTP-derived parameters and treatment effect was observed. We observed no significant interaction between mismatch and treatment effect. CTP seems useful for predicting functional outcome, but cannot reliably identify patients who will not benefit from intra-arterial therapy. © 2015 American Heart Association, Inc.

A prediction model to select PCOS patients suitable for IVM treatment based on anti-Mullerian hormone and antral follicle count.

PubMed

Guzman, L; Ortega-Hrepich, C; Polyzos, N P; Anckaert, E; Verheyen, G; Coucke, W; Devroey, P; Tournaye, H; Smitz, J; De Vos, M

2013-05-01

Which baseline patient characteristics can help assisted reproductive technology practitioners to identify patients who are suitable for in-vitro maturation (IVM) treatment? In patients with polycystic ovary syndrome (PCOS) who undergo oocyte IVM in a non-hCG-triggered system, circulating anti-Müllerian hormone (AMH), antral follicle count (AFC) and total testosterone are independently related to the number of immature oocytes and hold promise as outcome predictors to guide the patient selection process for IVM. Patient selection criteria for IVM treatment have been described in normo-ovulatory patients, although patients with PCOS constitute the major target population for IVM. With this study, we assessed the independent predictive value of clinical and endocrine parameters that are related to oocyte yield in patients with PCOS undergoing IVM. Cohort study involving 124 consecutive patients with PCOS undergoing IVM whose data were prospectively collected. Enrolment took place between January 2010 and January 2012. Only data relating to the first IVM cycle of each patient were included. Patients with PCOS underwent oocyte retrieval for IVM after minimal gonadotrophin stimulation and no hCG trigger. Correlation coefficients were calculated to investigate which parameters are related to immature oocyte yield (patient's age, BMI, baseline hormonal profile and AMH, AFC). The independence of predictive parameters was tested using multivariate linear regression analysis. Finally, multivariate receiver operating characteristic (ROC) analyses for cumulus oocyte complexes (COC) yield were performed to assess the efficiency of the prediction model to select suitable candidates for IVM. Using multivariate regression analysis, circulating baseline AMH, AFC and baseline total testosterone serum concentration were incorporated into a model to predict the number of COC retrieved in an IVM cycle, with unstandardized coefficients [95% confidence interval (CI)] of 0.03 (0.02-0.03) (P < 0.001), 0.012 (0.008-0.017) (P < 0.001) and 0.37 (0.18-0.57) (P < 0.001), respectively. Logistic regression analysis shows that a prediction model based on AMH and AFC, with unstandardized coefficients (95% CI) of 0.148 (0.03-0.25) (P < 0.001) and 0.034 (-0.003-0.07) (P = 0.025), respectively, is a useful patient selection tool to predict the probability to yield at least eight COCs for IVM in patients with PCOS. In this population, patients with at least eight COC available for IVM have a statistically higher number of embryos of good morphological quality (2.9 ± 2.3; 0.9 ± 0.9; P < 0.001) and cumulative ongoing pregnancy rate [30.4% (24 out of 79); 11% (5 out of 45); P = 0.01] when compared with patients with less than eight COC. ROC curve analysis showed that this prediction model has an area under the curve of 0.7864 (95% CI = 0.6997-0.8732) for the prediction of oocyte yield in IVM. The proposed model has been constructed based on a genuine IVM system, i.e. no hCG trigger was given and none of the oocytes matured in vivo. However, other variables, such as needle type, aspiration technique and whether or not hCG-triggering is used, should be considered as confounding factors. The results of this study have to be confirmed using a second independent validation sample. The proposed model could be applied to patients with PCOS after confirmation through a further validation study. This study was supported by a research grant by the Institute for the Promotion of Innovation by Science and Technology in Flanders, Project number IWT 070719.

ANTONIA perfusion and stroke. A software tool for the multi-purpose analysis of MR perfusion-weighted datasets and quantitative ischemic stroke assessment.

PubMed

Forkert, N D; Cheng, B; Kemmling, A; Thomalla, G; Fiehler, J

2014-01-01

The objective of this work is to present the software tool ANTONIA, which has been developed to facilitate a quantitative analysis of perfusion-weighted MRI (PWI) datasets in general as well as the subsequent multi-parametric analysis of additional datasets for the specific purpose of acute ischemic stroke patient dataset evaluation. Three different methods for the analysis of DSC or DCE PWI datasets are currently implemented in ANTONIA, which can be case-specifically selected based on the study protocol. These methods comprise a curve fitting method as well as a deconvolution-based and deconvolution-free method integrating a previously defined arterial input function. The perfusion analysis is extended for the purpose of acute ischemic stroke analysis by additional methods that enable an automatic atlas-based selection of the arterial input function, an analysis of the perfusion-diffusion and DWI-FLAIR mismatch as well as segmentation-based volumetric analyses. For reliability evaluation, the described software tool was used by two observers for quantitative analysis of 15 datasets from acute ischemic stroke patients to extract the acute lesion core volume, FLAIR ratio, perfusion-diffusion mismatch volume with manually as well as automatically selected arterial input functions, and follow-up lesion volume. The results of this evaluation revealed that the described software tool leads to highly reproducible results for all parameters if the automatic arterial input function selection method is used. Due to the broad selection of processing methods that are available in the software tool, ANTONIA is especially helpful to support image-based perfusion and acute ischemic stroke research projects.

Which family physician should I choose? The analytic hierarchy process approach for ranking of criteria in the selection of a family physician.

PubMed

Kuruoglu, Emel; Guldal, Dilek; Mevsim, Vildan; Gunvar, Tolga

2015-08-05

Choosing the most appropriate family physician (FP) for the individual, plays a fundamental role in primary care. The aim of this study is to determine the selection criteria for the patients in choosing their family doctors and priority ranking of these criteria by using the multi-criteria decision-making method of the Analytic Hierarchy Process (AHP) model. The study was planned and conducted in two phases. In the first phase, factors affecting the patients' decisions were revealed with a qualitative research. In the next phase, the priorities of FP selection criteria were determined by using AHP model. Criteria were compared in pairs. 96 patient were asked to fill the information forms which contains comparison scores in the Family Health Centres. According to the analysis of focus group discussions FP selection criteria were congregated in to five groups: Individual Characteristics, Patient-Doctor relationship, Professional characteristics, the Setting, and Ethical Characteristics. For each of the 96 participants, comparison matrixes were formed based on the scores of their information forms. Of these, models of only 5 (5.2 %) of the participants were consistent, in other words, they have been able to score consistent ranking. The consistency ratios (CR) were found to be smaller than 0.10. Therefore the comparison matrix of this new model, which was formed based on the medians of scores only given by these 5 participants, was consistent (CR = 0.06 < 0.10). According to comparison results; with a 0.467 value-weight, the most important criterion for choosing a family physician is his/her 'Professional characteristics'. Selection criteria for choosing a FP were put in a priority order by using AHP model. These criteria can be used as measures for selecting alternative FPs in further researches.

Clinical decision-making about inpatient violence risk at admission to a public-sector acute psychiatric hospital.

PubMed

Newton, Virginia M; Elbogen, Eric B; Brown, Carrie L; Snyder, Jennifer; Barrick, Ann Louise

2012-01-01

This is an examination of the extent to which patients who are violent in the hospital can be distinguished from nonviolent patients, based on information that is readily available at the time of admission to a state acute psychiatric hospital. The charts of 235 inpatients were examined retrospectively, by selecting 103 patients who had engaged in inpatient violence and comparing them with 132 randomly selected patients who had not during the same period. Data were gathered from initial psychiatric assessment and admissions face sheets in patients' charts, reflecting information available to a mental health professional within the first 24 hours of a patient's admission. Multivariate analysis showed that violent and nonviolent patients were distinguished by diagnosis, age, gender, estimated intelligence, psychiatric history, employment history, living situation, and agitated behavior. These factors led to an 80 percent correct classification of violent patients and thus may assist clinicians to structure decision-making about the risk of inpatient violence.

Quantitative proteomic profiling of paired cancerous and normal colon epithelial cells isolated freshly from colorectal cancer patients.

PubMed

Tu, Chengjian; Mojica, Wilfrido; Straubinger, Robert M; Li, Jun; Shen, Shichen; Qu, Miao; Nie, Lei; Roberts, Rick; An, Bo; Qu, Jun

2017-05-01

The heterogeneous structure in tumor tissues from colorectal cancer (CRC) patients excludes an informative comparison between tumors and adjacent normal tissues. Here, we develop and apply a strategy to compare paired cancerous (CEC) versus normal (NEC) epithelial cells enriched from patients and discover potential biomarkers and therapeutic targets for CRC. CEC and NEC cells are respectively isolated from five different tumor and normal locations in the resected colon tissue from each patient (N = 12 patients) using an optimized epithelial cell adhesion molecule (EpCAM)-based enrichment approach. An ion current-based quantitative method is employed to perform comparative proteomic analysis for each patient. A total of 458 altered proteins that are common among >75% of patients are observed and selected for further investigation. Besides known findings such as deregulation of mitochondrial function, tricarboxylic acid cycle, and RNA post-transcriptional modification, functional analysis further revealed RAN signaling pathway, small nucleolar ribonucleoproteins (snoRNPs), and infection by RNA viruses are altered in CEC cells. A selection of the altered proteins of interest is validated by immunohistochemistry analyses. The informative comparison between matched CEC and NEC enhances our understanding of molecular mechanisms of CRC development and provides biomarker candidates and new pathways for therapeutic intervention. © 2016 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Making every word count for nonresponsive patients.

PubMed

Naci, Lorina; Owen, Adrian M

2013-10-01

Despite the apparent absence of external signs of consciousness, a significant small proportion of patients with disorders of consciousness can respond to commands by willfully modulating their brain activity, even respond to yes or no questions, by performing mental imagery tasks. However, little is known about the mental life of such responsive patients, for example, with regard to whether they can have coherent thoughts or selectively maintain attention to specific events in their environment. The ability to selectively pay attention would provide evidence of a patient's preserved cognition and a method for brain-based communication, thus far untested with functional magnetic resonance imaging in this patient group. To test whether selective auditory attention can be used to detect conscious awareness and communicate with behaviorally nonresponsive patients. Case study performed in 3 patients with severe brain injury, 2 diagnosed as being in a minimally conscious state and 1 as being in a vegetative state. The patients constituted a convenience sample. Functional magnetic resonance imaging data were acquired as the patients were asked to selectively attend to auditory stimuli, thereby conveying their ability to follow commands and communicate. All patients demonstrated command following according to instructions. Two patients (1 in a minimally conscious state and 1 in a vegetative state) were also able to guide their attention to repeatedly communicate correct answers to binary (yes or no) questions. To our knowledge, we show for the first time with functional magnetic resonance imaging that behaviorally nonresponsive patients can use selective auditory attention to convey their ability to follow commands and communicate. One patient in a minimally conscious state was able to use attention to establish functional communication in the scanner, despite his inability to produce any communication responses in repeated bedside examinations. More important, 1 patient, who had been in a vegetative state for 12 years before the scanning and subsequent to it, was able to use attention to correctly communicate answers to several binary questions. The technique may be useful in establishing basic communication with patients who appear unresponsive to bedside examinations and cannot respond with existing neuroimaging methods.

Axillary Ultrasound After Neoadjuvant Chemotherapy and Its Impact on Sentinel Lymph Node Surgery: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance)

PubMed Central

Boughey, Judy C.; Ballman, Karla V.; Hunt, Kelly K.; McCall, Linda M.; Mittendorf, Elizabeth A.; Ahrendt, Gretchen M.; Wilke, Lee G.; Le-Petross, Huong T.

2015-01-01

Purpose The American College of Surgeons Oncology Group Z1071 trial reported a 12.6% false-negative rate (FNR) for sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) in cN1 disease. Patients were not selected for surgery based on response, but a secondary end point was to determine whether axillary ultrasound (AUS) after NAC after fine-needle aspiration cytology can identify abnormal nodes and guide patient selection for SLN surgery. Patients and Methods Patients with T0-4, N1-2, M0 breast cancer underwent AUS after neoadjuvant chemotherapy. AUS images were centrally reviewed and classified as normal or suspicious lymph nodes. AUS findings were tested for association with pathologic nodal status and SLN FNR. The impact of AUS results to select patients for SLN surgery to reduce the FNR was assessed. Results Postchemotherapy AUS images were reviewed for 611 patients. One hundred thirty (71.8%) of 181 AUS-suspicious patients were node positive at surgery compared with 243 (56.5%) of 430 AUS-normal patients (P < .001). Patients with AUS-suspicious nodes had a greater number of positive nodes and greater metastasis size (P < .001). The SLN FNR was not different based on AUS results; however, using a strategy where only patients with normal AUS undergo SLN surgery would potentially reduce the FNR in Z1071 patients with ≥ two SLNs removed from 12.6% to 9.8% when preoperative AUS results are considered as part of SLN surgery. Conclusion AUS is recommended after chemotherapy to guide axillary surgery. An FNR of 9.8% with the combination of AUS and SLN surgery would be acceptable for the adoption of SLN surgery for women with node-positive breast cancer treated with neoadjuvant chemotherapy. PMID:25646192

Deficits of spatial and task-related attentional selection in mild cognitive impairment and Alzheimer's disease.

PubMed

Redel, P; Bublak, P; Sorg, C; Kurz, A; Förstl, H; Müller, H J; Schneider, W X; Perneczky, R; Finke, K

2012-01-01

Visual selective attention was assessed with a partial-report task in patients with probable Alzheimer's disease (AD), amnestic mild cognitive impairment (MCI), and healthy elderly controls. Based on Bundesen's "theory of visual attention" (TVA), two parameters were derived: top-down control of attentional selection, representing task-related attentional weighting for prioritizing relevant visual objects, and spatial distribution of attentional weights across the left and the right hemifield. Compared with controls, MCI patients showed significantly reduced top-down controlled selection, which was further deteriorated in AD subjects. Moreover, attentional weighting was significantly unbalanced across hemifields in MCI and tended to be more lateralized in AD. Across MCI and AD patients, carriers of the apolipoprotein E ε4 allele (ApoE4) displayed a leftward spatial bias, which was the more pronounced the younger the ApoE4-positive patients and the earlier disease onset. These results indicate that impaired top-down control may be linked to early dysfunction of fronto-parietal networks. An early temporo-parietal interhemispheric asymmetry might cause a pathological spatial bias which is associated with ApoE4 genotype and may therefore function as early cognitive marker of upcoming AD. Copyright © 2012 Elsevier Inc. All rights reserved.

How evidence-based medicine is failing due to biased trials and selective publication.

PubMed

Every-Palmer, Susanna; Howick, Jeremy

2014-12-01

Evidence-based medicine (EBM) was announced in the early 1990s as a 'new paradigm' for improving patient care. Yet there is currently little evidence that EBM has achieved its aim. Since its introduction, health care costs have increased while there remains a lack of high-quality evidence suggesting EBM has resulted in substantial population-level health gains. In this paper we suggest that EBM's potential for improving patients' health care has been thwarted by bias in the choice of hypotheses tested, manipulation of study design and selective publication. Evidence for these flaws is clearest in industry-funded studies. We argue EBM's indiscriminate acceptance of industry-generated 'evidence' is akin to letting politicians count their own votes. Given that most intervention studies are industry funded, this is a serious problem for the overall evidence base. Clinical decisions based on such evidence are likely to be misinformed, with patients given less effective, harmful or more expensive treatments. More investment in independent research is urgently required. Independent bodies, informed democratically, need to set research priorities. We also propose that evidence rating schemes are formally modified so research with conflict of interest bias is explicitly downgraded in value. © 2014 John Wiley & Sons, Ltd.

Treatment Selection in Depression.

PubMed

Cohen, Zachary D; DeRubeis, Robert J

2018-05-07

Mental health researchers and clinicians have long sought answers to the question "What works for whom?" The goal of precision medicine is to provide evidence-based answers to this question. Treatment selection in depression aims to help each individual receive the treatment, among the available options, that is most likely to lead to a positive outcome for them. Although patient variables that are predictive of response to treatment have been identified, this knowledge has not yet translated into real-world treatment recommendations. The Personalized Advantage Index (PAI) and related approaches combine information obtained prior to the initiation of treatment into multivariable prediction models that can generate individualized predictions to help clinicians and patients select the right treatment. With increasing availability of advanced statistical modeling approaches, as well as novel predictive variables and big data, treatment selection models promise to contribute to improved outcomes in depression.

Psychological interventions for delayed ejaculation/orgasm.

PubMed

Althof, S E

2012-01-01

Of all the male sexual dysfunctions, delayed ejaculation (DE) is the least understood, least common and least studied. This paper aims to review and integrate the diverse psychological theories and proposed psychological interventions for DE. Clinicians will then be able to more clearly discern the relevant psychological/interpersonal issues of the patient/couple and implement systematically based effective interventions. After reviewing the literature, it is clear that no one theory accounts for all the varied presentations of DE, and no theory by itself has strong empirical support. However, awareness of the diverse points of view helps clinicians conduct better assessments and broaden their understanding of the patient's ejaculatory dysfunction. Similarly, no one psychological intervention works for all patients, nor will unsystematic random selection of interventions. This paper stresses on the need to clearly identify the source of the dysfunction and select treatments based upon the precipitating and maintaining factors. Much work remains to be done with regard to our understanding and treatment of DE. Specifically, we need to craft an evidence-based definition, assess the true prevalence of the dysfunction, demonstrate the efficacy of psychological interventions and design validated outcome measures.

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

Shen, Z; Greskovich, J; Xia, P

Purpose: To generate virtual phantoms with clinically relevant deformation and use them to objectively evaluate geometric and dosimetric uncertainties of deformable image registration (DIR) algorithms. Methods: Ten lung cancer patients undergoing adaptive 3DCRT planning were selected. For each patient, a pair of planning CT (pCT) and replanning CT (rCT) were used as the basis for virtual phantom generation. Manually adjusted meshes were created for selected ROIs (e.g. PTV, lungs, spinal cord, esophagus, and heart) on pCT and rCT. The mesh vertices were input into a thin-plate spline algorithm to generate a reference displacement vector field (DVF). The reference DVF wasmore » used to deform pCT to generate a simulated replanning CT (srCT) that was closely matched to rCT. Three DIR algorithms (Demons, B-Spline, and intensity-based) were applied to these ten virtual phantoms. The images, ROIs, and doses were mapped from pCT to srCT using the DVFs computed by these three DIRs and compared to those mapped using the reference DVF. Results: The average Dice coefficients for selected ROIs were from 0.85 to 0.96 for Demons, from 0.86 to 0.97 for intensity-based, and from 0.76 to 0.95 for B-Spline. The average Hausdorff distances for selected ROIs were from 2.2 to 5.4 mm for Demons, from 2.3 to 6.8 mm for intensity-based, and from 2.4 to 11.4 mm for B-Spline. The average absolute dose errors for selected ROIs were from 0.2 to 0.6 Gy for Demons, from 0.1 to 0.5 Gy for intensity-based, and from 0.5 to 1.5 Gy for B-Spline. Conclusion: Virtual phantoms were modeled after patients with lung cancer and were clinically relevant for adaptive radiotherapy treatment replanning. Virtual phantoms with known DVFs serve as references and can provide a fair comparison when evaluating different DIRs. Demons and intensity-based DIRs were shown to have smaller geometric and dosimetric uncertainties than B-Spline. Z Shen: None; K Bzdusek: an employee of Philips Healthcare; J Greskovich: None; P Xia: received research grants from Philips Healthcare and Siemens Healthcare.« less

3D patient-specific models for left atrium characterization to support ablation in atrial fibrillation patients.

PubMed

Valinoti, Maddalena; Fabbri, Claudio; Turco, Dario; Mantovan, Roberto; Pasini, Antonio; Corsi, Cristiana

2018-01-01

Radiofrequency ablation (RFA) is an important and promising therapy for atrial fibrillation (AF) patients. Optimization of patient selection and the availability of an accurate anatomical guide could improve RFA success rate. In this study we propose a unified, fully automated approach to build a 3D patient-specific left atrium (LA) model including pulmonary veins (PVs) in order to provide an accurate anatomical guide during RFA and without PVs in order to characterize LA volumetry and support patient selection for AF ablation. Magnetic resonance data from twenty-six patients referred for AF RFA were processed applying an edge-based level set approach guided by a phase-based edge detector to obtain the 3D LA model with PVs. An automated technique based on the shape diameter function was designed and applied to remove PVs and compute LA volume. 3D LA models were qualitatively compared with 3D LA surfaces acquired during the ablation procedure. An expert radiologist manually traced the LA on MR images twice. LA surfaces from the automatic approach and manual tracing were compared by mean surface-to-surface distance. In addition, LA volumes were compared with volumes from manual segmentation by linear and Bland-Altman analyses. Qualitative comparison of 3D LA models showed several inaccuracies, in particular PVs reconstruction was not accurate and left atrial appendage was missing in the model obtained during RFA procedure. LA surfaces were very similar (mean surface-to-surface distance: 2.3±0.7mm). LA volumes were in excellent agreement (y=1.03x-1.4, r=0.99, bias=-1.37ml (-1.43%) SD=2.16ml (2.3%), mean percentage difference=1.3%±2.1%). Results showed the proposed 3D patient-specific LA model with PVs is able to better describe LA anatomy compared to models derived from the navigation system, thus potentially improving electrograms and voltage information location and reducing fluoroscopic time during RFA. Quantitative assessment of LA volume derived from our 3D LA model without PVs is also accurate and may provide important information for patient selection for RFA. Copyright © 2017 Elsevier Inc. All rights reserved.

Universal antifungal therapy is not needed in persistent febrile neutropenia: a tailored diagnostic and therapeutic approach

PubMed Central

Aguilar-Guisado, Manuela; Martín-Peña, Almudena; Espigado, Ildefonso; Ruiz Pérez de Pipaon, Maite; Falantes, José; de la Cruz, Fátima; Cisneros, José M.

2012-01-01

Background Giving antifungal therapy exclusively to selected patients with persistent febrile neutropenia may avoid over-treatment without increasing mortality. The aim of this study was to validate an innovative diagnostic and therapeutic approach based on assessing patients’ risk profile and clinical criteria in order to select those patients requiring antifungal therapy. The efficacy of this approach was compared to that of universal empirical antifungal therapy. Design and Methods This was a prospective study which included all consecutive adult hematology patients with neutropenia and fever refractory to 5 days of empirical antibacterial therapy admitted to a teaching hospital in Spain over a 2-year period. A diagnostic and therapeutic approach based on clinical criteria and risk profile was applied in order to select patients for antifungal therapy. The sensitivity, specificity and negative predictive value of this approach and also the overall success rate, according to the same criteria of efficacy described in classical clinical trials, were analyzed. Results Eighty-five episodes were included, 35 of them (41.2%) in patients at high risk of invasive fungal infections. Antifungal therapy was not indicated in 33 episodes (38.8%). The overall incidence of proven and probable invasive fungal infections was 14.1%, all of which occurred in patients who had received empirical antifungal therapy. The 30-day crude mortality rate was 15.3% and the invasive fungal infection-related mortality rate was 2.8% (2/72). The overall success rate following the diagnostic and therapeutic approach was 36.5% compared with 33.9% and 33.7% obtained in the trial by Walsh et al. The sensitivity, specificity and negative predictive value of the study approach were 100%, 52.4% and 100%, respectively. Conclusions Based on the high negative predictive value of this diagnostic and therapeutic approach in persistent febrile neutropenia patients with hematologic malignancies or patients who have received a hematopoietic stem cell transplant, the approach is useful for identifying patients who are not likely to develop invasive fungal infection and do not, therefore, require antifungal therapy. The effectiveness of the strategy is similar to that of universal empirical antifungal therapy reported in controlled trials. PMID:22058202

Preoperative Evaluation and Patient Selection for Office-Based Oral Surgery Anesthesia.

PubMed

Lieblich, Stuart

2018-05-01

Provision of an outpatient anesthetic requires careful review of the patient's medical history along with salient aspects of the physical examination. The oral and maxillofacial surgeon may need to consult with the patient's medical providers to gain an understanding of the patient's potential risks for an adverse event. This article reviews key aspects of the patient evaluation so that an informed determination of suitability for an office anesthetic can be made. Copyright © 2018 Elsevier Inc. All rights reserved.

Identifying prognostic signature in ovarian cancer using DirGenerank

PubMed Central

Wang, Jian-Yong; Chen, Ling-Ling; Zhou, Xiong-Hui

2017-01-01

Identifying the prognostic genes in cancer is essential not only for the treatment of cancer patients, but also for drug discovery. However, it's still a big challenge to select the prognostic genes that can distinguish the risk of cancer patients across various data sets because of tumor heterogeneity. In this situation, the selected genes whose expression levels are statistically related to prognostic risks may be passengers. In this paper, based on gene expression data and prognostic data of ovarian cancer patients, we used conditional mutual information to construct gene dependency network in which the nodes (genes) with more out-degrees have more chances to be the modulators of cancer prognosis. After that, we proposed DirGenerank (Generank in direct netowrk) algorithm, which concerns both the gene dependency network and genes’ correlations to prognostic risks, to identify the gene signature that can predict the prognostic risks of ovarian cancer patients. Using ovarian cancer data set from TCGA (The Cancer Genome Atlas) as training data set, 40 genes with the highest importance were selected as prognostic signature. Survival analysis of these patients divided by the prognostic signature in testing data set and four independent data sets showed the signature can distinguish the prognostic risks of cancer patients significantly. Enrichment analysis of the signature with curated cancer genes and the drugs selected by CMAP showed the genes in the signature may be drug targets for therapy. In summary, we have proposed a useful pipeline to identify prognostic genes of cancer patients. PMID:28615526

78 FR 15559 - Patient Protection and Affordable Care Act; Establishment of the Multi-State Plan Program for the...

Federal Register 2010, 2011, 2012, 2013, 2014

2013-03-11

.... Based on initial comparative research, it appears that the proposed OPM-selected EHB-benchmark plans are... include any discriminatory benefit design elements as defined under 45 CFR 156.125. Response: In response... OPM-selected benchmarks and substitutions not be allowed in States having standard benefit designs...

Selection of Optimal Adjuvant Chemotherapy and Targeted Therapy for Early Breast Cancer: ASCO Clinical Practice Guideline Focused Update.

PubMed

Denduluri, Neelima; Chavez-MacGregor, Mariana; Telli, Melinda L; Eisen, Andrea; Graff, Stephanie L; Hassett, Michael J; Holloway, Jamie N; Hurria, Arti; King, Tari A; Lyman, Gary H; Partridge, Ann H; Somerfield, Mark R; Trudeau, Maureen E; Wolff, Antonio C; Giordano, Sharon H

2018-05-22

Purpose To update key recommendations of the ASCO guideline adaptation of the Cancer Care Ontario guideline on the selection of optimal adjuvant chemotherapy regimens for early breast cancer and adjuvant targeted therapy for breast cancer. Methods An Expert Panel conducted targeted systematic literature reviews guided by a signals approach to identify new, potentially practice-changing data that might translate to revised practice recommendations. Results The Expert Panel reviewed phase III trials that evaluated adjuvant capecitabine after completion of standard preoperative anthracycline- and taxane-based combination chemotherapy by patients with early-stage breast cancer HER2-negative breast cancer with residual invasive disease at surgery; the addition of 1 year of adjuvant pertuzumab to combination chemotherapy and trastuzumab for patients with early-stage, HER2-positive breast cancer; and the use of neratinib as extended adjuvant therapy for patients after combination chemotherapy and trastuzumab-based adjuvant therapy with early-stage, HER2-positive breast cancer. Recommendations Patients with early-stage HER2-negative breast cancer with pathologic, invasive residual disease at surgery following standard anthracycline- and taxane-based preoperative therapy may be offered up to six to eight cycles of adjuvant capecitabine. Clinicians may add 1 year of adjuvant pertuzumab to trastuzumab-based combination chemotherapy in patients with high-risk, early-stage, HER2-positive breast cancer. Clinicians may use extended adjuvant therapy with neratinib to follow trastuzumab in patients with early-stage, HER2-positive breast cancer. Neratinib causes substantial diarrhea, and diarrhea prophylaxis must be used. Additional information can be found at www.asco.org/breast-cancer-guidelines .

Classification of Alzheimer's disease patients with hippocampal shape wrapper-based feature selection and support vector machine

NASA Astrophysics Data System (ADS)

Young, Jonathan; Ridgway, Gerard; Leung, Kelvin; Ourselin, Sebastien

2012-02-01

It is well known that hippocampal atrophy is a marker of the onset of Alzheimer's disease (AD) and as a result hippocampal volumetry has been used in a number of studies to provide early diagnosis of AD and predict conversion of mild cognitive impairment patients to AD. However, rates of atrophy are not uniform across the hippocampus making shape analysis a potentially more accurate biomarker. This study studies the hippocampi from 226 healthy controls, 148 AD patients and 330 MCI patients obtained from T1 weighted structural MRI images from the ADNI database. The hippocampi are anatomically segmented using the MAPS multi-atlas segmentation method, and the resulting binary images are then processed with SPHARM software to decompose their shapes as a weighted sum of spherical harmonic basis functions. The resulting parameterizations are then used as feature vectors in Support Vector Machine (SVM) classification. A wrapper based feature selection method was used as this considers the utility of features in discriminating classes in combination, fully exploiting the multivariate nature of the data and optimizing the selected set of features for the type of classifier that is used. The leave-one-out cross validated accuracy obtained on training data is 88.6% for classifying AD vs controls and 74% for classifying MCI-converters vs MCI-stable with very compact feature sets, showing that this is a highly promising method. There is currently a considerable fall in accuracy on unseen data indicating that the feature selection is sensitive to the data used, however feature ensemble methods may overcome this.

Selected HIV-1 Env trimeric formulations act as potent immunogens in a rabbit vaccination model.

PubMed

Heyndrickx, Leo; Stewart-Jones, Guillaume; Jansson, Marianne; Schuitemaker, Hanneke; Bowles, Emma; Buonaguro, Luigi; Grevstad, Berit; Vinner, Lasse; Vereecken, Katleen; Parker, Joe; Ramaswamy, Meghna; Biswas, Priscilla; Vanham, Guido; Scarlatti, Gabriella; Fomsgaard, Anders

2013-01-01

Ten to 30% of HIV-1 infected subjects develop broadly neutralizing antibodies (bNAbs) during chronic infection. We hypothesized that immunizing rabbits with viral envelope glycoproteins (Envs) from these patients may induce bNAbs, when formulated as a trimeric protein and in the presence of an adjuvant. Based on in vitro neutralizing activity in serum, patients with bNAbs were selected for cloning of their HIV-1 Env. Seven stable soluble trimeric gp140 proteins were generated from sequences derived from four adults and two children infected with either clade A or B HIV-1. From one of the clade A Envs both the monomeric and trimeric Env were produced for comparison. Rabbits were immunized with soluble gp120 or trimeric gp140 proteins in combination with the adjuvant dimethyl dioctadecyl ammonium/trehalose dibehenate (CAF01). Env binding in rabbit immune serum was determined using ELISAs based on gp120-IIIB protein. Neutralizing activity of IgG purified from rabbit immune sera was measured with the pseudovirus-TZMbl assay and a PBMC-based neutralization assay for selected experiments. It was initially established that gp140 trimers induce better antibody responses over gp120 monomers and that the adjuvant CAF01 was necessary for such strong responses. Gp140 trimers, based on HIV-1 variants from patients with bNAbs, were able to elicit both gp120IIIB specific IgG and NAbs to Tier 1 viruses of different subtypes. Potency of NAbs closely correlated with titers, and an gp120-binding IgG titer above a threshold of 100,000 was predictive of neutralization capability. Finally, peptide inhibition experiments showed that a large fraction of the neutralizing IgG was directed against the gp120 V3 region. Our results indicate that the strategy of reverse immunology based on selected Env sequences is promising when immunogens are delivered as stabilized trimers in CAF01 adjuvant and that the rabbit is a valuable model for HIV vaccine studies.

Thoracoabdominal Computed Tomography in Trauma Patients: A Cost-Consequences Analysis

PubMed Central

van Vugt, Raoul; Kool, Digna R.; Brink, Monique; Dekker, Helena M.; Deunk, Jaap; Edwards, Michael J.

2014-01-01

Background: CT is increasingly used during the initial evaluation of blunt trauma patients. In this era of increasing cost-awareness, the pros and cons of CT have to be assessed. Objectives: This study was performed to evaluate cost-consequences of different diagnostic algorithms that use thoracoabdominal CT in primary evaluation of adult patients with high-energy blunt trauma. Materials and Methods: We compared three different algorithms in which CT was applied as an immediate diagnostic tool (rush CT), a diagnostic tool after limited conventional work-up (routine CT), and a selective tool (selective CT). Probabilities of detecting and missing clinically relevant injuries were retrospectively derived. We collected data on radiation exposure and performed a micro-cost analysis on a reference case-based approach. Results: Both rush and routine CT detected all thoracoabdominal injuries in 99.1% of the patients during primary evaluation (n = 1040). Selective CT missed one or more diagnoses in 11% of the patients in which a change of treatment was necessary in 4.8%. Rush CT algorithm costed € 2676 (US$ 3660) per patient with a mean radiation dose of 26.40 mSv per patient. Routine CT costed € 2815 (US$ 3850) and resulted in the same radiation exposure. Selective CT resulted in less radiation dose (23.23 mSv) and costed € 2771 (US$ 3790). Conclusions: Rush CT seems to result in the least costs and is comparable in terms of radiation dose exposure and diagnostic certainty with routine CT after a limited conventional work-up. However, selective CT results in less radiation dose exposure but a slightly higher cost and less certainty. PMID:25337521

Liver cirrhosis in selected autoimmune diseases: a nationwide cohort study in Taiwan.

PubMed

Tung, Chien-Hsueh; Lai, Ning-Seng; Lu, Ming-Chi; Lee, Ching-Chih

2016-02-01

The association between autoimmune diseases and liver cirrhosis has rarely been explored in Asian populations, an endemic area of viral hepatitis. The aim of this study was to investigate the comparative risk of liver cirrhosis among a group of selective autoimmune diseases in Taiwanese patients and to identify groups of high risk. This retrospective study was a nationwide, population-based study and used Taiwan's National Health Insurance Research Database. A total of 29,856 patients with definite diagnosis of selected autoimmune diseases (Registry of Taiwan Catastrophic Illness Database, ACR classification) at the starting time point of January 1, 2005, were enrolled in this study. After tracked for a 5-year period, the endpoints were diagnosis of liver cirrhosis (in accordance with International Classification of Diseases, Ninth Revision, Clinical Modification, ICD-9-CM codes 571). The control group was composed of other patients in the same database and consisted of randomly selected 753,495 sex- and age-matched non-autoimmune disease patients. The Cox proportional hazard regression model was used to calculate the risk of liver cirrhosis after adjusting for certain variables such as comorbidity, living area, and socioeconomic status. Among the patients with selected autoimmune diseases, 1987 liver cirrhosis were observed. Patients with psoriasis had a significantly increased risk of liver cirrhosis (HR 1.87, 95 % CI 1.25-2.81) than control group without psoriasis. The risk of liver cirrhosis was significantly lower in patients with rheumatoid arthritis (HR 0.29, 95 % CI 0.19-0.44). There is a gradient of risk of liver cirrhosis among the autoimmune diseases; the specific risks need to be investigated on the basis of hypotheses. Conventional immunosuppressive drug administration should be carefully implemented by regular monitoring of liver condition in order to avoid causing an adverse effect of chronic liver fibrosis.

The feminist approach in the decision-making process for treatment of women with breast cancer.

PubMed

Szumacher, Ewa

2006-09-01

The principal aim of this review was to investigate a feminist approach to the decision-making process for women with breast cancer. Empirical research into patient preferences for being informed about and participating in healthcare decisions has some limitations because it is mostly quantitative and designed within the dominant medical culture. Indigenous medical knowledge and alternative medical treatments are not widely accepted because of the lack of confirmed efficacy of such treatments in evidence-based literature. While discussing their treatment options with oncologists, women with breast cancer frequently express many concerns regarding treatment side effects, and sometimes decline conventional treatment when the risks are too high. A search of all relevant literary sources, including Pub-Med, ERIC, Medline, and the Ontario Institute for Studies in Education at the University of Toronto was conducted. The key words for selection of the articles were "feminism," "decision-making," "patients preferences for treatment," and "breast cancer." Fifty-one literary sources were selected. The review was divided into the following themes: (1) limitations of the patient decision-making process in conventional medicine; (2) participation of native North American patients in healthcare decisions; (3) towards a feminist approach to breast cancer; and (4) towards a feminist theory of breast cancer. This article discusses the importance of a feminist approach to the decision-making process for treatment of patients with breast cancer. As the literature suggests, the needs of minority patients are not completely fulfilled in Western medical culture. Introducing feminist theory into evidence-based medicine will help patients to be better informed about treatment choices and will assist them to select treatment according to their own beliefs and values.

Cost-effectiveness of cell saver in short-segment lumbar laminectomy and fusion (≤3 levels).

PubMed

Kelly, Patrick D; Parker, Scott L; Mendenhall, Stephen K; Bible, Jesse E; Sivasubramaniam, Priya; Shau, David N; McGirt, Matthew J; Devin, Clinton J

2015-09-01

Mixed retrospective-prospective cohort study. To characterize practice patterns for the use of Cell Saver at our institution, investigate its cost-effectiveness, and propose a new tool for patient selection. Blood loss is an exceedingly common complication of spine surgery, and Cell Saver intraoperative cell salvage has been used to decrease reliance on allogeneic blood transfusions for blood volume replacement. The cost-effectiveness of Cell Saver has not been established for lumbar spinal surgery, and no universal guidelines exist for clinicians to decide when to utilize this tool. Other authors have proposed cutoffs for anticipated blood loss volumes which indicate that Cell Saver should be used. Five hundred and eight patients undergoing lumbar laminectomy in 3 or fewer levels were reviewed from our prospective spinal outcomes registry. Cost information for Cell Saver and allogeneic transfusions was collected from our institution's billing and collections department. Logistic regression was used to identify patient characteristics associated with use of Cell Saver. An incremental cost effectiveness ratio was calculated based on transfusion and cost data. A clinical prediction score was derived using logistic regression. Use of Cell Saver correlated with increased age, higher body mass index, diabetes, greater American Society of Anesthesiologists classification, and greater number of previous spine surgeries. Outcomes for patients who did and did not have Cell Saver set up intraoperatively were equivocal. Cell Saver was not cost effective based on current usage patterns, but may become cost effective if used for patients with high expected blood loss. A simple clinical prediction rule is proposed which may aid in selection of patients to have Cell Saver present intraoperatively. Cell Saver is not a cost-effective intervention but may become cost effective if a threshold of expected intraoperative blood loss is used to select patients more judiciously. 3.

Radiomics analysis of DWI data to identify the rectal cancer patients qualified for local excision after neoadjuvant chemoradiotherapy

NASA Astrophysics Data System (ADS)

Tang, Zhenchao; Liu, Zhenyu; Zhang, Xiaoyan; Shi, Yanjie; Wang, Shou; Fang, Mengjie; Sun, Yingshi; Dong, Enqing; Tian, Jie

2018-02-01

The Locally advanced rectal cancer (LARC) patients were routinely treated with neoadjuvant chemoradiotherapy (CRT) firstly and received total excision afterwards. While, the LARC patients might relieve to T1N0M0/T0N0M0 stage after the CRT, which would enable the patients be qualified for local excision. However, accurate pathological TNM stage could only be obtained by the pathological examination after surgery. We aimed to conduct a Radiomics analysis of Diffusion weighted Imaging (DWI) data to identify the patients in T1N0M0/T0N0M0 stages before surgery, in hope of providing clinical surgery decision support. 223 routinely treated LARC patients in Beijing Cancer Hospital were enrolled in current study. DWI data and clinical characteristics were collected after CRT. According to the pathological TNM stage, the patients of T1N0M0 and T0N0M0 stages were labelled as 1 and the other patients were labelled as 0. The first 123 patients in chronological order were used as training set, and the rest patients as validation set. 563 image features extracted from the DWI data and clinical characteristics were used as features. Two-sample T test was conducted to pre-select the top 50% discriminating features. Least absolute shrinkage and selection operator (Lasso)-Logistic regression model was conducted to further select features and construct the classification model. Based on the 14 selected image features, the area under the Receiver Operating Characteristic (ROC) curve (AUC) of 0.8781, classification Accuracy (ACC) of 0.8432 were achieved in the training set. In the validation set, AUC of 0.8707, ACC (ACC) of 0.84 were observed.

Clinical utility of routine pre-operative axillary ultrasound and fine needle aspiration cytology in patient selection for sentinel lymph node biopsy.

PubMed

Rattay, T; Muttalib, M; Khalifa, E; Duncan, A; Parker, S J

2012-04-01

In patients with operable breast cancer, pre-operative evaluation of the axilla may be of use in the selection of appropriate axillary surgery. Pre-operative axillary ultrasound (US) and fine needle aspiration cytology (FNAC) assessments have become routine practice in many breast units, although the evidence base is still gathering. This study assessed the clinical utility of US+/-FNAC in patient selection for either axillary node clearance (ANC) or sentinel lymph node biopsy (SLNB) in patients undergoing surgery for operable breast cancer. Over a two-year period, 348 patients with a clinically negative axilla underwent axillary US. 67 patients with suspicious nodes on US also underwent FNAC. The sensitivity and specificity of axillary investigations to determine nodal involvement were 56% (confidence interval: 47-64%) and 90% (84-93%) for US alone, and 76% (61-87%) and 100% (65-100%) for FNAC combined with US, respectively. With a positive US, the post-test probability was 78%. A negative US carried a post-test probability of 25%. When FNAC was positive, the post-test probability was greater than unity. A negative FNAC yielded a post-test probability of 52%. All patients with positive FNAC and most patients with suspicious US were listed for axillary node clearance (ANC) after consideration at the multi-disciplinary team (MDT) meeting. With pre-operative axillary US+/-FNAC, 20% of patients were saved a potential second axillary procedure, facilitating a reduction in the overall re-operation rate to 12%. In this study, a positive pre-operative US+/-FNAC directs patients towards ANC. When the result is negative, other clinico-pathological factors need to be taken into account in the selection of the appropriate axillary procedure. Copyright © 2011 Elsevier Ltd. All rights reserved.

Axillary Ultrasound After Neoadjuvant Chemotherapy and Its Impact on Sentinel Lymph Node Surgery: Results From the American College of Surgeons Oncology Group Z1071 Trial (Alliance).

PubMed

Boughey, Judy C; Ballman, Karla V; Hunt, Kelly K; McCall, Linda M; Mittendorf, Elizabeth A; Ahrendt, Gretchen M; Wilke, Lee G; Le-Petross, Huong T

2015-10-20

The American College of Surgeons Oncology Group Z1071 trial reported a 12.6% false-negative rate (FNR) for sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) in cN1 disease. Patients were not selected for surgery based on response, but a secondary end point was to determine whether axillary ultrasound (AUS) after NAC after fine-needle aspiration cytology can identify abnormal nodes and guide patient selection for SLN surgery. Patients with T0-4, N1-2, M0 breast cancer underwent AUS after neoadjuvant chemotherapy. AUS images were centrally reviewed and classified as normal or suspicious lymph nodes. AUS findings were tested for association with pathologic nodal status and SLN FNR. The impact of AUS results to select patients for SLN surgery to reduce the FNR was assessed. Postchemotherapy AUS images were reviewed for 611 patients. One hundred thirty (71.8%) of 181 AUS-suspicious patients were node positive at surgery compared with 243 (56.5%) of 430 AUS-normal patients (P < .001). Patients with AUS-suspicious nodes had a greater number of positive nodes and greater metastasis size (P < .001). The SLN FNR was not different based on AUS results; however, using a strategy where only patients with normal AUS undergo SLN surgery would potentially reduce the FNR in Z1071 patients with ≥ two SLNs removed from 12.6% to 9.8% when preoperative AUS results are considered as part of SLN surgery. AUS is recommended after chemotherapy to guide axillary surgery. An FNR of 9.8% with the combination of AUS and SLN surgery would be acceptable for the adoption of SLN surgery for women with node-positive breast cancer treated with neoadjuvant chemotherapy. © 2015 by American Society of Clinical Oncology.

Magnetic Resonance Imaging Targeted Biopsy Improves Selection of Patients Considered for Active Surveillance for Clinically Low Risk Prostate Cancer Based on Systematic Biopsies.

PubMed

Ouzzane, Adil; Renard-Penna, Raphaele; Marliere, François; Mozer, Pierre; Olivier, Jonathan; Barkatz, Johann; Puech, Philippe; Villers, Arnauld

2015-08-01

Current selection criteria for active surveillance based on systematic biopsy underestimate prostate cancer volume and grade. We investigated the role of additional magnetic resonance imaging targeted biopsy in reclassifying patients eligible for active surveillance based on systematic biopsy. We performed a study at 2 institutions in a total of 281 men with increased prostate specific antigen. All men met certain criteria, including 1) prebiopsy magnetic resonance imaging, 12-core transrectal systematic biopsy and 2 additional magnetic resonance imaging targeted biopsies of lesions suspicious for cancer during the same sequence as systematic biopsy, and 2) eligibility for active surveillance based on systematic biopsy results. Criteria for active surveillance were prostate specific antigen less than 10 ng/ml, no Gleason grade 4/5, 5 mm or less involvement of any biopsy core and 2 or fewer positive systematic biopsy cores. Patient characteristics were compared between reclassified and nonreclassified groups based on magnetic resonance imaging targeted biopsy results. On magnetic resonance imaging 58% of the 281 patients had suspicious lesions. Magnetic resonance imaging targeted biopsy was positive for cancer in 81 of 163 patients (50%). Of 281 patients 28 (10%) were reclassified by magnetic resonance imaging targeted biopsy as ineligible for active surveillance based on Gleason score in 8, cancer length in 20 and Gleason score plus cancer length in 9. Suspicious areas on magnetic resonance imaging were in the anterior part of the prostate in 15 of the 28 men (54%). Reclassified patients had a smaller prostate volume (37 vs 52 cc) and were older (66.5 vs 63 years) than those who were not reclassified (p < 0.05). Magnetic resonance imaging targeted biopsy reclassified 10% of patients who were eligible for active surveillance based on systematic biopsy. Its incorporation into the active surveillance eligibility criteria may decrease the risk of reclassification to higher stages during followup. Copyright © 2015 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.

Intramuscular injection technique: an evidence-based approach.

PubMed

Ogston-Tuck, Sherri

2014-09-30

Intramuscular injections require a thorough and meticulous approach to patient assessment and injection technique. This article, the second in a series of two, reviews the evidence base to inform safer practice and to consider the evidence for nursing practice in this area. A framework for safe practice is included, identifying important points for safe technique, patient care and clinical decision making. It also highlights the ongoing debate in selection of intramuscular injection sites, predominately the ventrogluteal and dorsogluteal muscles.

Improving strategies for syphilis control in China: selective testing of sexually transmitted disease patients--too little, too late?

PubMed

Yin, Y-P; Wong, S P Y; Liu, M-S; Wei, W-H; Yu, Y-H; Gao, X; Chen, Q; Fu, Z-Z; Cheng, F; Chen, X-S; Cohen, M S

2008-12-01

Syphilis testing guidelines in China are usually based on symptomatic criteria, overlooking risk assessment and ultimately opportunities for disease detection and control. We used data from 10,695 sexually transmitted disease (STD) clinic patients in Guangxi, China, to assess the efficacy of a potential screening tool inquiring about behavioural and health risk factors in identifying the STD patients who should not be triaged for syphilis testing under current guidelines, but on the contrary receive such testing. Validity testing of the screening tool was performed and receiver-operating characteristic curves were plotted to determine an optimal total risk score cut-off for testing. About 40.9% of patients with positive toluidine red unheated serum test and Treponema pallidum particle agglutination test did not show hallmark signs of syphilis. The screening tool was more sensitive in detecting infection in non-triaged male versus female patients (highest sensitivity = 90% vs. 55%) and the cut-off score to warrant testing was lower in non-triaged female patients than in non-triaged male patients (cut-off = 1 vs. 2). Most of the cases were missed among female STD patients. In spite of selective testing based on behavioural and health indicators that improve case detection, cases were still missed. Our study supports universal testing for syphilis in the STD population.

Targeted Screening With Combined Age- and Morphology-Based Criteria Enriches Detection of Lynch Syndrome in Endometrial Cancer.

PubMed

Lin, Douglas I; Hecht, Jonathan L

2016-06-01

Endometrial cancer is associated with Lynch syndrome in 2% to 6% of cases. Adequate screening may prevent of a second cancer and incident cancers in family members via risk-reducing strategies. The goal of the study was to evaluate the detection rate of Lynch syndrome via a targeted screening approach. In 2009, we incorporated targeted Lynch syndrome screening via immunohistochemistry for MLH1, PMS2, MSH2, and MSH6, followed by MLH1 promoter hypermethylation, in select cases of endometrial carcinoma. Criteria for patient selection included (1) all patients <50 years; (2) patients of any age with tumors showing features of microsatellite instability (lower uterine segment-centered tumors, hard to classify carcinomas, increased peritumoral or tumor infiltrating lymphocytes and cases with synchronous ovarian carcinomas); (3) clinician's request based on family or personal history; and (4) ad hoc retrospective testing based on the established criteria on patients discovered on follow-up visits. By using a targeted screening approach in a 4.5-year period, approximately 2.1% of endometrial cancers (7 of 328) were potentially associated with Lynch syndrome. Therefore, targeted screening with combined age and morphology based criteria enriches detection of Lynch syndrome in endometrial cancer. However, the detection rate is lower than the rates from published series that offer universal screening. © The Author(s) 2016.

A novel protein-based prognostic signature improves risk stratification to guide clinical management in early lung adenocarcinoma patients.

PubMed

Martínez-Terroba, Elena; Behrens, Carmen; de Miguel, Fernando J; Agorreta, Jackeline; Monsó, Eduard; Millares, Laura; Sainz, Cristina; Mesa-Guzman, Miguel; Pérez-Gracia, Jose Luis; Lozano, María Dolores; Zulueta, Javier J; Pio, Ruben; Wistuba, Ignacio I; Montuenga, Luis M; Pajares, María J

2018-05-13

Each of the pathological stages (I-IIIa) in which surgically resected non-small cell lung cancer patients are classified conceals hidden biological heterogeneity, manifested in heterogeneous outcomes within each stage. Thus, the finding of robust and precise molecular classifiers to assess individual patient risk is an unmet medical need. Here we identified and validated the clinical utility of a new prognostic signature based on three proteins (BRCA1, QKI and SLC2A1) to stratify early lung adenocarcinoma patients according to their risk of recurrence or death. Patients were staged following the new International Association for the Study of Lung Cancer (IASLC) staging criteria (8 th edition, 2018). A test cohort (n=239) was used to assess the value of this new prognostic index (PI) based on the three proteins. The prognostic signature was developed by Cox regression following stringent statistical criteria (TRIPOD: Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis). The model resulted in a highly significant predictor of five-year outcome for disease-free survival (P<0.001) and overall survival (P<0.001). The prognostic ability of the model was externally validated in an independent multi-institutional cohort of patients (n=114, P=0.021). We also demonstrated that this molecular classifier adds relevant information to the gold standard TNM-based pathological staging with a highly significant improvement of likelihood ratio. We subsequently developed a combined prognostic index (CPI) including both the molecular and the pathological data which improved the risk stratification in both cohorts (P≤0.001). Moreover, the signature may help to select stage I-IIA patients who might benefit from adjuvant chemotherapy. In summary, this protein-based signature accurately identifies those patients with high risk of recurrence and death, and adds further prognostic information to the TNM-based clinical staging, even applying the new IASLC 8 th edition staging criteria. More importantly, it may be a valuable tool for selecting patients for adjuvant therapy. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

A Mobile System for Music Anamnesis and Receptive Music Therapy in the Personal Home.

PubMed

Denecke, Kerstin

2017-01-01

Receptive music therapy is active hearing of music that is specifically selected to cause a certain effect on a person, such as pain reduction, mental opening, confrontation etc. This active, guided hearing could be helpful as a supporting ritual for patients at home and could extend traditional therapy. However, patients are often unable to select the music pieces that might be helpful for them in a current situation. We are suggesting a self-learning decision support system that allows a patient to answer questions on music anamnesis, is ready for inclusion into an electronic health record, and which enables a therapist to compile a therapeutic music program for the patient at home. Beyond this, the system also suggests appropriate music and duration of listening based on the patient's reported current mental state. In this paper, a concept for such a mobile system for receptive music therapy will be proposed.

Ergonomics and patient handling.

PubMed

McCoskey, Kelsey L

2007-11-01

This study aimed to describe patient-handling demands in inpatient units during a 24-hour period at a military health care facility. A 1-day total population survey described the diverse nature and impact of patient-handling tasks relative to a variety of nursing care units, patient characteristics, and transfer equipment. Productivity baselines were established based on patient dependency, physical exertion, type of transfer, and time spent performing the transfer. Descriptions of the physiological effect of transfers on staff based on patient, transfer, and staff characteristics were developed. Nursing staff response to surveys demonstrated how patient-handling demands are impacted by the staff's physical exertion and level of patient dependency. The findings of this study describe the types of transfers occurring in these inpatient units and the physical exertion and time requirements for these transfers. This description may guide selection of the most appropriate and cost-effective patient-handling equipment required for specific units and patients.

Application of Adaptive Design Methodology in Development of a Long-Acting Glucagon-Like Peptide-1 Analog (Dulaglutide): Statistical Design and Simulations

PubMed Central

Skrivanek, Zachary; Berry, Scott; Berry, Don; Chien, Jenny; Geiger, Mary Jane; Anderson, James H.; Gaydos, Brenda

2012-01-01

Background Dulaglutide (dula, LY2189265), a long-acting glucagon-like peptide-1 analog, is being developed to treat type 2 diabetes mellitus. Methods To foster the development of dula, we designed a two-stage adaptive, dose-finding, inferentially seamless phase 2/3 study. The Bayesian theoretical framework is used to adaptively randomize patients in stage 1 to 7 dula doses and, at the decision point, to either stop for futility or to select up to 2 dula doses for stage 2. After dose selection, patients continue to be randomized to the selected dula doses or comparator arms. Data from patients assigned the selected doses will be pooled across both stages and analyzed with an analysis of covariance model, using baseline hemoglobin A1c and country as covariates. The operating characteristics of the trial were assessed by extensive simulation studies. Results Simulations demonstrated that the adaptive design would identify the correct doses 88% of the time, compared to as low as 6% for a fixed-dose design (the latter value based on frequentist decision rules analogous to the Bayesian decision rules for adaptive design). Conclusions This article discusses the decision rules used to select the dula dose(s); the mathematical details of the adaptive algorithm—including a description of the clinical utility index used to mathematically quantify the desirability of a dose based on safety and efficacy measurements; and a description of the simulation process and results that quantify the operating characteristics of the design. PMID:23294775

SU-E-J-73: Extension of a Clinical OIS/EMR/R&V System to Deliver Safe and Efficient Adaptive Plan-Of-The-Day Treatments Using a Fully Customizable Plan-Library-Based Workflow

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

Akhiat, A.; Elekta, Sunnyvale, CA; Kanis, A.P.

Purpose: To extend a clinical Record and Verify (R&V) system to enable a safe and fast workflow for Plan-of-the-Day (PotD) adaptive treatments based on patient-specific plan libraries. Methods: Plan libraries for PotD adaptive treatments contain for each patient several pre-treatment generated treatment plans. They may be generated for various patient anatomies or CTV-PTV margins. For each fraction, a Cone Beam CT scan is acquired to support the selection of the plan that best fits the patient’s anatomy-of-the-day. To date, there are no commercial R&V systems that support PotD delivery strategies. Consequently, the clinical workflow requires many manual interventions. Moreover, multiplemore » scheduled plans have a high risk of excessive dose delivery. In this work we extended a commercial R&V system (MOSAIQ) to support PotD workflows using IQ-scripting. The PotD workflow was designed after extensive risk analysis of the manual procedure, and all identified risks were incorporated as logical checks. Results: All manual PotD activities were automated. The workflow first identifies if the patient is scheduled for PotD, then performs safety checks, and continues to treatment plan selection only if no issues were found. The user selects the plan to deliver from a list of candidate plans. After plan selection, the workflow makes the treatment fields of the selected plan available for delivery by adding them to the treatment calendar. Finally, control is returned to the R&V system to commence treatment. Additional logic was added to incorporate off-line changes such as updating the plan library. After extensive testing including treatment fraction interrupts and plan-library updates during the treatment course, the workflow is running successfully in a clinical pilot, in which 35 patients have been treated since October 2014. Conclusion: We have extended a commercial R&V system for improved safety and efficiency in library-based adaptive strategies enabling a wide-spread implementation of those strategies. This work was in part funded by a research grant of Elekta AB, Stockholm, Sweden.« less

Risk of Pathologic Upgrading or Locally Advanced Disease in Early Prostate Cancer Patients Based on Biopsy Gleason Score and PSA: A Population-Based Study of Modern Patients

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

Caster, Joseph M.; Falchook, Aaron D.; Hendrix, Laura H.

Purpose: Radiation oncologists rely on available clinical information (biopsy Gleason score and prostate-specific antigen [PSA]) to determine the optimal treatment regimen for each prostate cancer patient. Existing published nomograms correlating clinical to pathologic extent of disease were based on patients treated in the 1980s and 1990s at select academic institutions. We used the Surveillance, Epidemiology, and End Results (SEER) database to examine pathologic outcomes (Gleason score and cancer stage) in early prostate cancer patients based on biopsy Gleason score and PSA concentration. Methods and Materials: This analysis included 25,858 patients whose cancer was diagnosed between 2010 and 2011, with biopsymore » Gleason scores of 6 to 7 and clinical stage T1 to T2 disease, who underwent radical prostatectomy. In subgroups based on biopsy Gleason score and PSA level, we report the proportion of patients with pathologically advanced disease (positive surgical margin or pT3-T4 disease) or whose Gleason score was upgraded. Logistic regression was used to examine factors associated with pathologic outcomes. Results: For patients with biopsy Gleason score 6 cancers, 84% of those with PSA <10 ng/mL had surgical T2 disease with negative margins; this decreased to 61% in patients with PSA of 20 to 29.9 ng/mL. Gleason score upgrading was seen in 43% (PSA: <10 ng/mL) to 61% (PSA: 20-29.9 ng/mL) of biopsy Gleason 6 patients. Patients with biopsy Gleason 7 cancers had a one-third (Gleason 3 + 4; PSA: <10 ng/mL) to two-thirds (Gleason 4 + 3; PSA: 20-29.9 ng/mL) probability of having pathologically advanced disease. Gleason score upgrading was seen in 11% to 19% of patients with biopsy Gleason 4 + 3 cancers. Multivariable analysis showed that higher PSA and older age were associated with Gleason score upgrading and pathologically advanced disease. Conclusions: This is the first population-based study to examine pathologic extent of disease and pathologic Gleason score upgrading based on clinically available information in modern patients. These data inform the selection of radiation therapy strategies and an understanding of whether prostatectomy alone is likely to be curative for patients with early prostate cancers.« less

Morph-X-Select: Morphology-based tissue aptamer selection for ovarian cancer biomarker discovery

PubMed Central

Wang, Hongyu; Li, Xin; Volk, David E.; Lokesh, Ganesh L.-R.; Elizondo-Riojas, Miguel-Angel; Li, Li; Nick, Alpa M.; Sood, Anil K.; Rosenblatt, Kevin P.; Gorenstein, David G.

2016-01-01

High affinity aptamer-based biomarker discovery has the advantage of simultaneously discovering an aptamer affinity reagent and its target biomarker protein. Here, we demonstrate a morphology-based tissue aptamer selection method that enables us to use tissue sections from individual patients and identify high-affinity aptamers and their associated target proteins in a systematic and accurate way. We created a combinatorial DNA aptamer library that has been modified with thiophosphate substitutions of the phosphate ester backbone at selected 5′dA positions for enhanced nuclease resistance and targeting. Based on morphological assessment, we used image-directed laser microdissection (LMD) to dissect regions of interest bound with the thioaptamer (TA) library and further identified target proteins for the selected TAs. We have successfully identified and characterized the lead candidate TA, V5, as a vimentin-specific sequence that has shown specific binding to tumor vasculature of human ovarian tissue and human microvascular endothelial cells. This new Morph-X-Select method allows us to select high-affinity aptamers and their associated target proteins in a specific and accurate way, and could be used for personalized biomarker discovery to improve medical decision-making and to facilitate the development of targeted therapies to achieve more favorable outcomes. PMID:27839510

An Assessment in SpondyloArthritis International Society (ASAS)-endorsed definition of clinically important worsening in axial spondyloarthritis based on ASDAS.

PubMed

Molto, Anna; Gossec, Laure; Meghnathi, Bhowmik; Landewé, Robert B M; van der Heijde, Désirée; Atagunduz, Pamir; Elzorkany, Bassel Kamal; Akkoc, Nurullah; Kiltz, Uta; Gu, Jieruo; Wei, James Cheng Chung; Dougados, Maxime

2018-01-01

In a previous phase, 12 draft definitions for clinically important worsening in axial spondyloarthritis (axSpA) were selected, of which 3 were based on absolute changes in Ankylosing Spondylitis Disease Activity Score (ASDAS)-CRP (ASDAS). The objective here was to select the best cut-off for ASDAS for clinically important worsening in axSpA for use in clinical trials and observational studies. An international longitudinal prospective study evaluating stable patients with axSpA was conducted. Data necessary to calculate ASDAS were collected at two consecutive visits (spaced 7 days to 6 months). Sensitivity and specificity of the three cut-offs for change in ASDAS were tested against the patient's subjective assessment of worsening as the external standard (ie, the patient reporting that he had worsened and felt a need for treatment intensification). Final selection was made by a consensus and voting procedure among Assessment of SpondyloArthritis International Society (ASAS) members. In total, 1169 patients with axSpA were analysed: 64.8% were male and had a mean age of 41.7 (SD 12.4) years. At the second visit, 127 (10.9%) patients judged their situation as worsened.Sensitivity and specificity for an increase of at least 0.6, 0.9 and 1.1 ASDAS points to detect patient-reported worsening were 0.55 (Se) and 0.91 (Sp), 0.38 (Se) and 0.96 (Sp), and 0.33 (Se) and 0.98 (Sp), respectively. The ASAS consensus was to define clinically important worsening as an increase in ASDAS of at least 0.9 points. This data-driven ASAS consensus process resulted in an ASDAS-based cut-off value defining clinically important worsening in axSpA for use in trials. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

SMART: self-management of anticoagulation, a randomised trial [ISRCTN19313375].

PubMed

McCahon, Deborah; Fitzmaurice, David A; Murray, Ellen T; Fuller, Christopher J; Hobbs, Richard F D; Allan, Teresa F; Raftery, James P

2003-09-18

Oral anticoagulation monitoring has traditionally taken place in secondary care because of the need for a laboratory blood test, the international normalised ratio (INR). The development of reliable near patient testing (NPT) systems for INR estimation has facilitated devolution of testing to primary care. Patient self-management is a logical progression from the primary care model. This study will be the first to randomise non-selected patients in primary care, to either self-management or standard care. The study was a multi-centred randomised controlled trial with patients from 49 general practices recruited. Those suitable for inclusion were aged 18 or over, with a long term indication for oral anticoagulation, who had taken warfarin for at least six months. Patients randomised to the intervention arm attended at least two training sessions which were practice-based, 1 week apart. Each patient was assessed on their capability to undertake self management. If considered capable, they were given a near patient INR testing monitor, test strips and quality control material for home testing. Patients managed their own anticoagulation for a period of 12 months and performed their INR test every 2 weeks. Control patients continued with their pre-study care either attending hospital or practice based anticoagulant clinics. The methodology used in this trial will overcome concerns from previous trials of selection bias and relevance to the UK health service. The study will give a clearer understanding of the benefits of self-management in terms of clinical and cost effectiveness and patient preference.

Beyond xMOOCs in healthcare education: study of the feasibility in integrating virtual patient systems and MOOC platforms.

PubMed

Stathakarou, Natalia; Zary, Nabil; Kononowicz, Andrzej A

2014-01-01

Background. Massive Open Online Courses (MOOCs) are an emerging trend in online learning. However, their technology is not yet completely adjusted to the needs of healthcare education. Integration of Virtual Patients within MOOCs to increase interactivity and foster clinical reasoning skills training, has been discussed in the past, but not verified by a practical implementation. Objective. To investigate the technical feasibility of integrating MOOCs with Virtual Patients for the purpose of enabling further research into the potential pedagogical benefits of this approach. Methods. We selected OpenEdx and Open Labyrinth as representative constituents of a MOOC platform and Virtual Patient system integration. Based upon our prior experience we selected the most fundamental technical requirement to address. Grounded in the available literature we identified an e-learning standard to guide the integration. We attempted to demonstrate the feasibility of the integration by designing a "proof-of-concept" prototype. The resulting pilot implementation was subject of verification by two test cases. Results. A Single Sign-On mechanism connecting Open Labyrinth with OpenEdx and based on the IMS LTI standard was successfully implemented and verified. Conclusion. We investigated the technical perspective of integrating Virtual Patients with MOOCs. By addressing this crucial technical requirement we set a base for future research on the educational benefits of using virtual patients in MOOCs. This provides new opportunities for integrating specialized software in healthcare education at massive scale.

Beyond xMOOCs in healthcare education: study of the feasibility in integrating virtual patient systems and MOOC platforms

PubMed Central

Zary, Nabil; Kononowicz, Andrzej A.

2014-01-01

Background. Massive Open Online Courses (MOOCs) are an emerging trend in online learning. However, their technology is not yet completely adjusted to the needs of healthcare education. Integration of Virtual Patients within MOOCs to increase interactivity and foster clinical reasoning skills training, has been discussed in the past, but not verified by a practical implementation. Objective. To investigate the technical feasibility of integrating MOOCs with Virtual Patients for the purpose of enabling further research into the potential pedagogical benefits of this approach. Methods. We selected OpenEdx and Open Labyrinth as representative constituents of a MOOC platform and Virtual Patient system integration. Based upon our prior experience we selected the most fundamental technical requirement to address. Grounded in the available literature we identified an e-learning standard to guide the integration. We attempted to demonstrate the feasibility of the integration by designing a “proof-of-concept” prototype. The resulting pilot implementation was subject of verification by two test cases. Results. A Single Sign-On mechanism connecting Open Labyrinth with OpenEdx and based on the IMS LTI standard was successfully implemented and verified. Conclusion. We investigated the technical perspective of integrating Virtual Patients with MOOCs. By addressing this crucial technical requirement we set a base for future research on the educational benefits of using virtual patients in MOOCs. This provides new opportunities for integrating specialized software in healthcare education at massive scale. PMID:25405078

Effectiveness of chemotherapy counselling on self-esteem and psychological affects among cancer patients in Malaysia: Randomized controlled trial.

PubMed

Mohd-Sidik, Sherina; Akhtari-Zavare, Mehrnoosh; Periasamy, Ummavathy; Rampal, Lekhraj; Fadhilah, Siti Irma; Mahmud, Rozi

2018-05-01

The aim of this study was to implement and evaluate the outcomes of chemotherapy counselling based on the "Managing Patients on Chemotherapy" module on self-esteem and psychological affect (anxiety, depression) of cancer patients by pharmacists in ten selected government hospitals in Peninsular Malaysia. A randomized control trial was conducted among 2120 cancer patients from April 2016 to January 2017 in ten selected government hospitals in Peninsular Malaysia. Cancer patients were randomly assigned to intervention and control groups. The intervention group received chemotherapy counselling by pharmacists based on the "Managing Patients on Chemotherapy" module. The outcomes were assessed at baseline, 1st, 2nd and 3rd follow-ups after counselling. In the course of data analysis; independent sample t-test, chi-square and two-way repeated measures ANOVA were conducted. Mean scores of self-esteem in the intervention group had significant difference in comparison with those of the control group in the 1st, 2nd and 3rd follow-ups after counselling (P < 0.0001). Also, among those with depression and anxiety at baseline, there was reduction in depression and anxiety scores after the 1st, 2nd and 3rd follow-ups after counselling (p < 0.05). Repetitive counselling by pharmacists based on the "Managing Patients on Chemotherapy" module had positive effect on improving self-esteem and psychological affect of cancer patients undergoing chemotherapy in Peninsular Malaysia. This module can be used for all Malaysian cancer patients undergoing chemotherapy to improving self-esteem and psychological affect. Copyright © 2018 The Authors. Published by Elsevier B.V. All rights reserved.

Phase 2 Trial of Induction Gemcitabine, Oxaliplatin, and Cetuximab Followed by Selective Capecitabine-Based Chemoradiation in Patients With Borderline Resectable or Unresectable Locally Advanced Pancreatic Cancer

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

Esnaola, Nestor F.; Chaudhary, Uzair B.; O'Brien, Paul

Purpose: To evaluate, in a phase 2 study, the safety and efficacy of induction gemcitabine, oxaliplatin, and cetuximab followed by selective capecitabine-based chemoradiation in patients with borderline resectable or unresectable locally advanced pancreatic cancer (BRPC or LAPC, respectively). Methods and Materials: Patients received gemcitabine and oxaliplatin chemotherapy repeated every 14 days for 6 cycles, combined with weekly cetuximab. Patients were then restaged; “downstaged” patients with resectable disease underwent attempted resection. Remaining patients were treated with chemoradiation consisting of intensity modulated radiation therapy (54 Gy) and concurrent capecitabine; patients with borderline resectable disease or better at restaging underwent attempted resection. Results:more » A total of 39 patients were enrolled, of whom 37 were evaluable. Protocol treatment was generally well tolerated. Median follow-up for all patients was 11.9 months. Overall, 29.7% of patients underwent R0 surgical resection (69.2% of patients with BRPC; 8.3% of patients with LAPC). Overall 6-month progression-free survival (PFS) was 62%, and median PFS was 10.4 months. Median overall survival (OS) was 11.8 months. In patients with LAPC, median OS was 9.3 months; in patients with BRPC, median OS was 24.1 months. In the group of patients who underwent R0 resection (all of which were R0 resections), median survival had not yet been reached at the time of analysis. Conclusions: This regimen was well tolerated in patients with BRPC or LAPC, and almost one-third of patients underwent R0 resection. Although OS for the entire cohort was comparable to that in historical controls, PFS and OS in patients with BRPC and/or who underwent R0 resection was markedly improved.« less

Phase 2 Trial of Induction Gemcitabine, Oxaliplatin, and Cetuximab Followed by Selective Capecitabine Based Chemoradiation in Patients With Borderline Resectable or Unresectable Locally Advanced Pancreatic Cancer

PubMed Central

Esnaola, Nestor F.; Chaudhary, Uzair B.; O'Brien, Paul; Garrett-Mayer, Elizabeth; Camp, E. Ramsay; Thomas, Melanie B.; Cole, David J.; Montero, Alberto J.; Hoffman, Brenda J.; Romagnuolo, Joseph; Orwat, Kelly P.; Marshall, David T.

2014-01-01

Purpose To evaluate, in a phase 2 study, the safety and efficacy of induction gemcitabine, oxaliplatin, and cetuximab followed by selective capecitabine-based chemoradiation in patients with borderline resectable or unresectable locally advanced pancreatic cancer (BRPC or LAPC, respectively). Methods and Materials Patients received gemcitabine and oxaliplatin chemotherapy repeated every 14 days for 6 cycles, combined with weekly cetuximab. Patients were then restaged; “downstaged” patients with resectable disease underwent attempted resection. Remaining patients were treated with chemoradiation consisting of intensity modulated radiation therapy (54 Gy) and concurrent capecitabine; patients with borderline resectable disease or better at restaging underwent attempted resection. Results A total of 39 patients were enrolled, of whom 37 were evaluable. Protocol treatment was generally well tolerated. Median follow-up for all patients was 11.9 months. Overall, 29.7% of patients underwent R0 surgical resection (69.2% of patients with BRPC; 8.3% of patients with LAPC). Overall 6-month progression-free survival (PFS) was 62%, and median PFS was 10.4 months. Median overall survival (OS) was 11.8 months. In patients with LAPC, median OS was 9.3 months; in patients with BRPC, median OS was 24.1 months. In the group of patients who underwent R0 resection (all of which were R0 resections), median survival had not yet been reached at the time of analysis. Conclusions This regimen was well tolerated in patients with BRPC or LAPC, and almost one-third of patients underwent R0 resection. Although OS for the entire cohort was comparable to that in historical controls, PFS and OS in patients with BRPC and/or who underwent R0 resection was markedly improved. PMID:24606850

Genital Herpes

MedlinePlus

... serology is performed for their patients . 11 Several ELISA-based serologic tests are FDA approved and available ... The most commonly used test, HerpeSelect HSV-2 Elisa might be falsely positive at low index values ( ...

An FDA oncology analysis of immune activating products and first-in-human dose selection.

PubMed

Saber, Haleh; Gudi, Ramadevi; Manning, Michael; Wearne, Emily; Leighton, John K

2016-11-01

As sub-therapeutic doses are not medically justifiable in patients with cancer, we retrospectively analyzed data on immune activating products, to assess approaches used in first-in-human (FIH) dose selection, the utility of animal toxicology studies in dose selection, and the length of time to complete FIH trials. The information collected included pharmacology and toxicology data, FIH dose and rationale, and dose-finding trial design. We used the principles of the Hill equation to estimate the FIH doses for antibodies and compared them to the doses administered to patients with acceptable toxicities. For approximately half the antibodies (44%) examined, the FIH doses were at least a hundred-fold lower than the doses safely administered to patients, indicating optimization of FIH dose selection and/or optimization of dose-finding trial design is needed to minimize patient exposure to sub-therapeutic doses. However, selection of the FIH dose for antibodies based on animal toxicology studies using 1/6th the HNSTD or 1/10th the NOAEL resulted in human doses that were unsafe for several antibodies examined. We also concluded that antibodies with Fc-modifications for increased effector function may be less tolerated, resulting in toxicities at lower doses than those without such modifications. There was insufficient information to evaluate CD3 bispecific products. Published by Elsevier Inc.

Gene Expression Analysis Of Circulating Hormone Refractory Prostate Cancer Micrometastases

DTIC Science & Technology

2011-02-01

of prostate cancer. We hypothesized that the copy number changes could be prognostic and aid in future chemotherapy regimen selection. After...Task 1 will be analyzed over the next year to elicit statistically meaningful prognostic DNA based biomarkers. Two of the patients (#8 and #13) had...HRPC), and to determine whether CECs can be used to predict survival in these patients. PATIENTS AND METHODS Several prognostic models that

Adequacy of Online Patient Information Resources on Gout and Potentially Curative Urate-Lowering Treatment.

PubMed

Jimenez-Liñan, L M; Edwards, L; Abhishek, A; Doherty, Michael

2017-05-01

To assess the content and readability of online patient information resources against the current understanding of gout. An online survey was undertaken using Google UK, USA, Australia, and Canada. Information was assessed for content and accuracy on 19 key points regarding core content for gout patient information resources. Readability was assessed using the Flesch-Kincaid Reading Ease score. Fifteen randomly selected websites were reviewed by a blinded second observer. A total of 85 websites were selected. More than 50% of the websites provided no information or had inaccuracies regarding the pathogenesis of gout. Most websites contained information on dietary and lifestyle modifications for treating gout and did not emphasize urate-lowering therapy (ULT) and its potential for cure. Over 75% of the websites had no/inaccurate information on the role of ULT or prophylaxis for preventing gout attacks on starting ULT. The majority of websites were difficult to read, with information in 68% of the websites rated at least fairly difficult. Only a few web-based patient information resources provide accurate and easy-to-read information on gout. This study will help physicians direct patients to currently reliable resources, but there is a need to improve many web-based patient information resources, which at present act as barriers to care. © 2016, American College of Rheumatology.

Verbal learning and memory outcome in selective amygdalohippocampectomy versus temporal lobe resection in patients with hippocampal sclerosis.

PubMed

Foged, Mette Thrane; Vinter, Kirsten; Stauning, Louise; Kjær, Troels W; Ozenne, Brice; Beniczky, Sándor; Paulson, Olaf B; Madsen, Flemming Find; Pinborg, Lars H

2018-02-01

With the advent of new very selective techniques like thermal laser ablation to treat drug-resistant focal epilepsy, the controversy of resection size in relation to seizure outcome versus cognitive deficits has gained new relevance. The purpose of this study was to test the influence of the selective amygdalohippocampectomy (SAH) versus nonselective temporal lobe resection (TLR) on seizure outcome and cognition in patients with mesial temporal lobe epilepsy (MTLE) and histopathological verified hippocampal sclerosis (HS). We identified 108 adults (>16years) with HS, operated between 1995 and 2009 in Denmark. Exclusion criteria are the following: Intelligence below normal range, right hemisphere dominance, other native languages than Danish, dual pathology, and missing follow-up data. Thus, 56 patients were analyzed. The patients were allocated to SAH (n=22) or TLR (n=34) based on intraoperative electrocorticography. Verbal learning and verbal memory were tested pre- and postsurgery. Seizure outcome did not differ between patients operated using the SAH versus the TLR at 1year (p=0.951) nor at 7years (p=0.177). Verbal learning was more affected in patients resected in the left hemisphere than in the right (p=0.002). In patients with left-sided TLR, a worsening in verbal memory performance was found (p=0.011). Altogether, 73% were seizure-free for 1year and 64% for 7years after surgery. In patients with drug-resistant focal MTLE, HS and no magnetic resonance imaging (MRI) signs of dual pathology, selective amygdalohippocampectomy results in sustained seizure freedom and better memory function compared with patients operated with nonselective temporal lobe resection. Copyright © 2017 Elsevier Inc. All rights reserved.

Survival and selected outcomes of older adults with locally advanced head/neck cancer treated with chemoradiation therapy.

PubMed

Maggiore, Ronald J; Curran, Emily K; Witt, Mary Ellyn; Haraf, Daniel J; Vokes, Everett E; Cohen, Ezra E W

2013-10-01

Chemoradiation therapy (CRT) remains a potentially curative treatment in patients with locally advanced head/neck cancer (LA-HNC). However, survival and other outcomes in older patients with head/neck cancer receiving chemoradiotherapy are not well established. This study was performed to elucidate selected outcomes in this patient population. Retrospective study of LA-HNC patients ≥ 70 years of age who had received 5-fluorouracil-hydoxyurea-based CRT with a minimum of 3 years of follow up after therapy initiation was performed. Pre-treatment patient- and cancer-related characteristics were recorded. Survival data in addition to gastrostomy tube utilization, swallowing function, and hematologic toxicity were captured. Eighty-nine patients treated between 1997 and 2009 were eligible for analysis (median age, 76 years; range, 70-94; male, 61%; ECOG PS, 0-1 43%; stage IVA/B, 71%). 86 were evaluable for survival analysis. 5-year overall and event-free survival were both at 32% with a median follow-up time of 39.2 months. The majority (86.5%) were able to complete all planned treatment cycles. A significant proportion of patients, however, required gastrostomy tube during CRT (62%) and developed aspiration during swallowing evaluation post-treatment (44%). Several patients required hospice (9%) or skilled nursing facility (13%) referrals during treatment. Select older adults with LA-HNC can still experience long-term benefits despite 5-year survival rates lower than those historically reported in younger patients undergoing identical CRT regimens although potentially at higher risk for acute toxicities. Assessment and selection of those who can tolerate more intense combined-modality strategies and their long-term outcomes merit further larger, prospective studies. Copyright © 2013 Elsevier Inc. All rights reserved.

Reduce costs and improve patient satisfaction with home pre-operative bowel preparations.

PubMed

Hearn, K; Dailey, M; Harris, M T; Bodian, C

2000-01-01

The results of a home-based preoperative bowel preparation, with and without the support of home care services, are compared with hospital-based preoperative bowel preparation. Length of stay, morbidity, and mortality rates; issues of patient satisfaction; and demographics are reported. The method and tools used in planning, implementing, and evaluating the home preoperative bowel preparation program are also shared. Other issues discussed are the healthcare market forces that promote an increased value of care. Economic and patient satisfaction considerations by employers, payers, and patients; the increasing influence of patient choice on healthcare provider selection and care setting preferences; the nursing workforce issues related to the impending shortage; and issues of regulatory and accrediting agencies are also discussed.

SU-E-J-119: Head-And-Neck Digital Phantoms for Geometric and Dosimetric Uncertainty Evaluation of CT-CBCT Deformable Image Registration

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

Shen, Z; Koyfman, S; Xia, P

2015-06-15

Purpose: To evaluate geometric and dosimetric uncertainties of CT-CBCT deformable image registration (DIR) algorithms using digital phantoms generated from real patients. Methods: We selected ten H&N cancer patients with adaptive IMRT. For each patient, a planning CT (CT1), a replanning CT (CT2), and a pretreatment CBCT (CBCT1) were used as the basis for digital phantom creation. Manually adjusted meshes were created for selected ROIs (e.g. PTVs, brainstem, spinal cord, mandible, and parotids) on CT1 and CT2. The mesh vertices were input into a thin-plate spline algorithm to generate a reference displacement vector field (DVF). The reference DVF was applied tomore » CBCT1 to create a simulated mid-treatment CBCT (CBCT2). The CT-CBCT digital phantom consisted of CT1 and CBCT2, which were linked by the reference DVF. Three DIR algorithms (Demons, B-Spline, and intensity-based) were applied to these ten digital phantoms. The images, ROIs, and volumetric doses were mapped from CT1 to CBCT2 using the DVFs computed by these three DIRs and compared to those mapped using the reference DVF. Results: The average Dice coefficients for selected ROIs were from 0.83 to 0.94 for Demons, from 0.82 to 0.95 for B-Spline, and from 0.67 to 0.89 for intensity-based DIR. The average Hausdorff distances for selected ROIs were from 2.4 to 6.2 mm for Demons, from 1.8 to 5.9 mm for B-Spline, and from 2.8 to 11.2 mm for intensity-based DIR. The average absolute dose errors for selected ROIs were from 0.7 to 2.1 Gy for Demons, from 0.7 to 2.9 Gy for B- Spline, and from 1.3 to 4.5 Gy for intensity-based DIR. Conclusion: Using clinically realistic CT-CBCT digital phantoms, Demons and B-Spline were shown to have similar geometric and dosimetric uncertainties while intensity-based DIR had the worst uncertainties. CT-CBCT DIR has the potential to provide accurate CBCT-based dose verification for H&N adaptive radiotherapy. Z Shen: None; K Bzdusek: an employee of Philips Healthcare; S Koyfman: None; P Xia: received research grants from Philips Healthcare and Siemens Healthcare.« less

Multiclass feature selection for improved pediatric brain tumor segmentation

NASA Astrophysics Data System (ADS)

Ahmed, Shaheen; Iftekharuddin, Khan M.

2012-03-01

In our previous work, we showed that fractal-based texture features are effective in detection, segmentation and classification of posterior-fossa (PF) pediatric brain tumor in multimodality MRI. We exploited an information theoretic approach such as Kullback-Leibler Divergence (KLD) for feature selection and ranking different texture features. We further incorporated the feature selection technique with segmentation method such as Expectation Maximization (EM) for segmentation of tumor T and non tumor (NT) tissues. In this work, we extend the two class KLD technique to multiclass for effectively selecting the best features for brain tumor (T), cyst (C) and non tumor (NT). We further obtain segmentation robustness for each tissue types by computing Bay's posterior probabilities and corresponding number of pixels for each tissue segments in MRI patient images. We evaluate improved tumor segmentation robustness using different similarity metric for 5 patients in T1, T2 and FLAIR modalities.

Office-based anesthesia for the urologist.

PubMed

Galway, Ursula; Borkowski, Raymond

2013-11-01

This article describes office-based surgery and office-based anesthesia (OBA), including the safe setup of OBA and safety concerns regarding OBA. Also discussed are the preoperative selection and workup of a patient undergoing OBA, anesthetic options, the prevention and treatment of postoperative nausea, vomiting, and pain, and planning for safe discharge. Copyright © 2013 Elsevier Inc. All rights reserved.

Implementation of Fuzzy Decision to Control Patient Room Facilities using Eye Blink

NASA Astrophysics Data System (ADS)

Zaeni, Ilham A. E.; Wibawa, Aji P.; Aripriharta; Sendari, Siti

2018-04-01

This study proposed the implementation of Fuzzy decision to control patient’s room facilities. In this study, four icons were sequentially displayed on the computer screen. The icons representing four option that can be selected by the patient is including switch the light on/off, switch the fan on/off, moving the bed’s backrest downward, and moving the bed’s backrest upward. The eye blink was extracted from subject’s electroencephalograph (EEG) signals which acquired from the FP1 region. The attention was also extracted from subject’s EEG signals to ensure that subject concentrate to the task. The eye blink and attention level were used for Fuzzy decision inputs, while the output is a decision that states the selection is valid or not. The selected option is the command that appears on the screen when the selection is valid. In this study, subjects were asked to choose each command several times and the accuracy was computed based on the number of correct selection.

Additive-manufactured patient-specific titanium templates for thoracic pedicle screw placement: novel design with reduced contact area.

PubMed

Takemoto, Mitsuru; Fujibayashi, Shunsuke; Ota, Eigo; Otsuki, Bungo; Kimura, Hiroaki; Sakamoto, Takeshi; Kawai, Toshiyuki; Futami, Tohru; Sasaki, Kiyoyuki; Matsushita, Tomiharu; Nakamura, Takashi; Neo, Masashi; Matsuda, Shuich

2016-06-01

Image-based navigational patient-specific templates (PSTs) for pedicle screw (PS) placement have been described. With recent advances in three-dimensional computer-aided designs and additive manufacturing technology, various PST designs have been reported, although the template designs were not optimized. We have developed a novel PST design that reduces the contact area without sacrificing stability. It avoids susceptibility to intervening soft tissue, template geometric inaccuracy, and difficulty during template fitting. Fourteen candidate locations on the posterior aspect of the vertebra were evaluated. Among them, locations that had high reproducibility on computed tomography (CT) images and facilitated accurate PS placement were selected for the final PST design. An additive manufacturing machine (EOSINT M270) fabricated the PSTs using commercially pure titanium powder. For the clinical study, 36 scoliosis patients and 4 patients with ossification of the posterior longitudinal ligament (OPLL) were treated with thoracic PSs using our newly developed PSTs. We intraoperatively and postoperatively evaluated the accuracy of the PS hole created by the PST. Based on the segmentation reproducibility and stability analyses, we selected seven small, round contact points for our PST: bilateral superior and inferior points on the transverse process base, bilateral inferior points on the laminar, and a superior point on the spinous process. Clinically, the success rates of PS placement using this PST design were 98.6 % (414/420) for scoliosis patients and 100 % (46/46) for OPLL patients. This study provides a useful design concept for the development and introduction of patient-specific navigational templates for placing PSs.

A wavelet-based technique to predict treatment outcome for Major Depressive Disorder

PubMed Central

Xia, Likun; Mohd Yasin, Mohd Azhar; Azhar Ali, Syed Saad

2017-01-01

Treatment management for Major Depressive Disorder (MDD) has been challenging. However, electroencephalogram (EEG)-based predictions of antidepressant’s treatment outcome may help during antidepressant’s selection and ultimately improve the quality of life for MDD patients. In this study, a machine learning (ML) method involving pretreatment EEG data was proposed to perform such predictions for Selective Serotonin Reuptake Inhibitor (SSRIs). For this purpose, the acquisition of experimental data involved 34 MDD patients and 30 healthy controls. Consequently, a feature matrix was constructed involving time-frequency decomposition of EEG data based on wavelet transform (WT) analysis, termed as EEG data matrix. However, the resultant EEG data matrix had high dimensionality. Therefore, dimension reduction was performed based on a rank-based feature selection method according to a criterion, i.e., receiver operating characteristic (ROC). As a result, the most significant features were identified and further be utilized during the training and testing of a classification model, i.e., the logistic regression (LR) classifier. Finally, the LR model was validated with 100 iterations of 10-fold cross-validation (10-CV). The classification results were compared with short-time Fourier transform (STFT) analysis, and empirical mode decompositions (EMD). The wavelet features extracted from frontal and temporal EEG data were found statistically significant. In comparison with other time-frequency approaches such as the STFT and EMD, the WT analysis has shown highest classification accuracy, i.e., accuracy = 87.5%, sensitivity = 95%, and specificity = 80%. In conclusion, significant wavelet coefficients extracted from frontal and temporal pre-treatment EEG data involving delta and theta frequency bands may predict antidepressant’s treatment outcome for the MDD patients. PMID:28152063

Development of theory-based knowledge translation interventions to facilitate the implementation of evidence-based guidelines on the early management of adults with traumatic spinal cord injury.

PubMed

Bérubé, Mélanie; Albert, Martin; Chauny, Jean-Marc; Contandriopoulos, Damien; DuSablon, Anne; Lacroix, Sébastien; Gagné, Annick; Laflamme, Élise; Boutin, Nathalie; Delisle, Stéphane; Pauzé, Anne-Marie; MacThiong, Jean-Marc

2015-12-01

Optimal, early management following a spinal cord injury (SCI) can limit individuals' disabilities and costs related to their care. Several knowledge syntheses were recently published to guide health care professionals with regard to early interventions in SCI patients. However, no knowledge translation (KT) intervention, selected according to a behaviour change theory, has been proposed to facilitate the use of SCI guidelines in an acute care setting. To develop theory-informed KT interventions to promote the application of evidence-based recommendations on the acute care management of SCI patients. The first four phases of the knowledge-to-action model were used to establish the study design. Knowledge selection was based on the Grading of Recommendations Assessment, Development and Evaluation system. Knowledge adaptation to the local context was sourced from the ADAPTE process. The theoretical domains framework oriented the selection and development of the interventions based on an assessment of barriers and enablers to knowledge application. Twenty-nine recommendations were chosen and operationalized in measurable clinical indicators. Barriers related to knowledge, skills, perceived capacities, beliefs about consequences, social influences, and the environmental context and resources theoretical domains were identified. The mapping of behaviour change techniques associated with those barriers led to the development of an online educational curriculum, interdisciplinary clinical pathways as well as policies and procedures. This research project allowed us developing KT interventions according to a thorough behavioural change methodology. Exposure to the generated interventions will support health care professionals in providing the best care to SCI patients. © 2015 John Wiley & Sons, Ltd.

The association of hospital prevention processes and patient risk factors with the risk of Clostridium difficile infection: a population-based cohort study.

PubMed

Daneman, N; Guttmann, A; Wang, X; Ma, X; Gibson, D; Stukel, T A

2015-07-01

Clostridium difficile is the most common cause of healthcare-acquired infection; the real-world impacts of some proposed C. difficile prevention processes are unknown. We conducted a population-based retrospective cohort study of all patients admitted to acute care hospitals between April 2011 and March 2012 in Ontario, Canada. Hospital prevention practices were determined by survey of infection control programmes; responses were linked to patient-level risk factors and C. difficile outcomes in Ontario administrative databases. Multivariable generalised estimating equation (GEE) regression models were used to assess the impact of selected understudied hospital prevention processes on the patient-level risk of C. difficile infection, accounting for patient risk factors, baseline C. difficile rates and structural hospital characteristics. C. difficile infections complicated 2341 of 653 896 admissions (3.6 per 1000 admissions). Implementation of the selected C. difficile prevention practices was variable across the 159 hospitals with isolation of all patients at onset of diarrhoea reported by 43 (27%), auditing of antibiotic stewardship compliance by 26 (16%), auditing of cleaning practices by 115 (72%), on-site diagnostic testing by 74 (47%), vancomycin as first-line treatment by 24 (15%) and reporting rates to senior leadership by 52 (33%). None of these processes were associated with a significantly reduced risk of C. difficile after adjustment for baseline C. difficile rates, structural hospital characteristics and patient-level factors. Patient-level factors were strongly associated with C. difficile risk, including age, comorbidities, non-elective and medical admissions. In the largest study to date, selected hospital prevention strategies were not associated with a statistically significant reduction in patients' risk of C. difficile infection. These prevention strategies have either limited effectiveness or were ineffectively implemented during the study period. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Comparison of printed glycan array, suspension array and ELISA in the detection of human anti-glycan antibodies.

PubMed

Pochechueva, Tatiana; Jacob, Francis; Goldstein, Darlene R; Huflejt, Margaret E; Chinarev, Alexander; Caduff, Rosemarie; Fink, Daniel; Hacker, Neville; Bovin, Nicolai V; Heinzelmann-Schwarz, Viola

2011-12-01

Anti-glycan antibodies represent a vast and yet insufficiently investigated subpopulation of naturally occurring and adaptive antibodies in humans. Recently, a variety of glycan-based microarrays emerged, allowing high-throughput profiling of a large repertoire of antibodies. As there are no direct approaches for comparison and evaluation of multi-glycan assays we compared three glycan-based immunoassays, namely printed glycan array (PGA), fluorescent microsphere-based suspension array (SA) and ELISA for their efficacy and selectivity in profiling anti-glycan antibodies in a cohort of 48 patients with and without ovarian cancer. The ABO blood group glycan antigens were selected as well recognized ligands for sensitivity and specificity assessments. As another ligand we selected P(1), a member of the P blood group system recently identified by PGA as a potential ovarian cancer biomarker. All three glyco-immunoassays reflected the known ABO blood groups with high performance. In contrast, anti-P(1) antibody binding profiles displayed much lower concordance. Whilst anti-P(1) antibody levels between benign controls and ovarian cancer patients were significantly discriminated using PGA (p=0.004), we got only similar results using SA (p=0.03) but not for ELISA. Our findings demonstrate that whilst assays were largely positively correlated, each presents unique characteristic features and should be validated by an independent patient cohort rather than another array technique. The variety between methods presumably reflects the differences in glycan presentation and the antigen/antibody ratio, assay conditions and detection technique. This indicates that the glycan-antibody interaction of interest has to guide the assay selection. © The Author(s) 2011. This article is published with open access at Springerlink.com

Who Should Be Considered for Islet Transplantation Alone?

PubMed

Othonos, Nantia; Choudhary, Pratik

2017-04-01

Episodic hypoglycemia is an almost inevitable consequence of exogenous insulin treatment of type 1 diabetes, and in up to 30% of patients, this can lead to impaired awareness of hypoglycemia. This predisposes to recurrent severe hypoglycemia and has a huge impact on quality of life. Although many patients can get resolution of severe hypoglycemia through novel education and technology, some patients continue to have ongoing life-threatening hypoglycemia. Islet transplantation offers an alternative therapeutic option for these patients, in whom these conventional approaches have been unsuccessful. This review discusses the selection process of identifying suitable candidates based on recent clinical data. Results from studies of islet transplantation suggest the optimal recipient characteristics for successful islet transplantation include age >35 years, insulin requirements <1.0/kg, and weight >85 kg. Islet transplantation can completely resolve hypoglycemia and near-normalize glucose levels, achieving insulin independence for a limited period of time in up to 40% of patients. The selection of appropriate candidates, optimizing donor selection, the use of an optimized protocol for islet cell extraction, and immunosuppression therapy have been proved to be the key criteria for a favorable outcome in islet transplantation.

Rational decision making in a wide scenario of different minimally invasive lumbar interbody fusion approaches and devices.

PubMed

Pimenta, Luiz; Tohmeh, Antoine; Jones, David; Amaral, Rodrigo; Marchi, Luis; Oliveira, Leonardo; Pittman, Bruce C; Bae, Hyun

2018-03-01

With the proliferation of a variety of modern MIS spine surgery procedures, it is mandatory that the surgeon dominate all aspects involved in surgical indication. The information related to the decision making in patient selection for specific procedures is mandatory for surgical success. The objective of this study is to present decision-making criteria in minimally invasive surgery (MIS) selection for a variety of patients and pathologies. In this article, practicing surgeons who specialize in various MIS approaches for spinal fusion were engaged to provide expert opinion and literature review on decision making criteria for several MIS procedures. Pros, cons, relative limitations, and case examples are provided for patient selection in treatment with MIS posterolateral fusion (MIS-PLF), mini anterior lumbar interbody fusion (mini-ALIF), lateral interbody fusion (LLIF), MIS posterior lumbar interbody fusion (MIS-PLIF) and MIS transforaminal lumbar interbody fusion (MIS-TLIF). There is a variety of aspects to consider when deciding which modern MIS surgical approach is most appropriate to use based on patient and pathologic characteristics. The surgeon must adapt them to the characteristic of each type of patients, helping them to choose the most effective and efficient therapeutic option for each case.

Matching the bipolar patient and the mood stabilizer.

PubMed

Gelenberg, Alan J; Pies, Ronald

2003-01-01

Bipolar disorder poses many treatment challenges, including "matching" a particular patient with the optimal treatment regimen. Although there are a number of extant guidelines to assist the clinician in selecting treatment, these recommendations are largely based on general variables and fail to take into account the subtleties and complications that confront a clinician in practice. An analysis of predictors of medication response in bipolar disorder provides a basis for matching patients with optimal medication regimens. Response to treatment may depend on the polarity of an episode or on clinical features such as mixed or psychotic symptomatology and rate of cycling. Comorbid psychiatric disorders such as substance abuse, anxiety disorders, or attention-deficit/hyperactivity disorder should also be considered in designing a treatment regimen. Similarly, medical conditions, especially metabolic abnormalities or kidney insufficiency, must be taken into account. Selection of medication may also involve an analysis of demographic factors, including family and personal history of response to a particular agent. When selecting the most appropriate mood stabilizer for a patient--particularly when polypharmacy is required--the clinician should keep potential side effects and drug interactions in mind. Randomized, controlled studies in bipolar populations are needed to further characterize optimal matching of patient and medication.

Price transparency for MRIs increased use of less costly providers and triggered provider competition.

PubMed

Wu, Sze-jung; Sylwestrzak, Gosia; Shah, Christiane; DeVries, Andrea

2014-08-01

To encourage patients to select high-value providers, an insurer-initiated price transparency program that focused on elective advanced imaging procedures was implemented. Patients having at least one outpatient magnetic resonance imaging (MRI) scan in 2010 or 2012 were divided according to their membership in commercial health plans participating in the program (the intervention group) or in nonparticipating commercial health plans (the reference group) in similar US geographic regions. Patients in the intervention group were informed of price differences among available MRI facilities and given the option of selecting different providers. For those patients, the program resulted in a $220 cost reduction (18.7 percent) per test and a decrease in use of hospital-based facilities from 53 percent in 2010 to 45 percent in 2012. Price variation between hospital and nonhospital facilities for the intervention group was reduced by 30 percent after implementation. Nonparticipating members residing in intervention areas also observed price reductions, which indicates increased price competition among providers. The program significantly reduced imaging costs. This suggests that patients select lower-price facilities when informed about available alternatives. Project HOPE—The People-to-People Health Foundation, Inc.

Disparities in medication therapy in patients with heart failure across the State of Hawai'i.

PubMed

Goo, Roy Alan; Ma, Carolyn; Juarez, Deborah Taira

2015-01-01

The purpose of this study is to evaluate if heart failure patients in Hawai'i are receiving recommended standard therapy of a select beta-blocker in combination with an ACE inhibitor (ACEI) or angiotensin receptor blocker (ARB), and to determine if a gap in quality of care exists between the different regions within the state. A retrospective claims-based analysis of all adult patients (age > 18 years of age) with CHF who were enrolled in a large health plan in Hawai'i was performed (n = 24,149). Data collected included the presence of pharmaceutical claims for ACEI, ARBs and select β-blockers, region of residence, gender, and age. Multivariable logistic regression was used to examine whether there were regional differences in Hawai'i related to medication usage, after adjustment for age and gender. Results showed that only 28.4 % of patients were placed on the recommended therapy of an ACEI or ARB and a select β-blocker with significant differences being found between different regions. Further research is needed to better understand factors affecting regional differences in prescribing patterns.

Segmentation in local hospital markets.

PubMed

Dranove, D; White, W D; Wu, L

1993-01-01

This study examines evidence of market segmentation on the basis of patients' insurance status, demographic characteristics, and medical condition in selected local markets in California in the years 1983 and 1989. Substantial differences exist in the probability patients may be admitted to particular hospitals based on insurance coverage, particularly Medicaid, and race. Segmentation based on insurance and race is related to hospital characteristics, but not the characteristics of the hospital's community. Medicaid patients are more likely to go to hospitals with lower costs and fewer service offerings. Privately insured patients go to hospitals offering more services, although cost concerns are increasing. Hispanic patients also go to low-cost hospitals, ceteris paribus. Results indicate little evidence of segmentation based on medical condition in either 1983 or 1989, suggesting that "centers of excellence" have yet to play an important role in patient choice of hospital. The authors found that distance matters, and that patients prefer nearby hospitals, moreso for some medical conditions than others, in ways consistent with economic theories of consumer choice.

Narrowed indications improve outcomes for hip resurfacing arthroplasty.

PubMed

Johnson, Aaron J; Zywiel, Michael G; Hooper, Hassan; Mont, Michael A

2011-01-01

Hip resurfacing arthroplasty has had excellent clinical outcomes from multiple centers. However, controversy exists regarding the most appropriate patient selection criteria. Many proponents of hip resurfacing believe that narrowing the patient indications with strict inclusion and exclusion criteria may lead to improved outcomes and decreased complication rates. The purpose of this study was to review the results of resurfacing performed by an experienced surgeon to determine if implant survival and complication rates were different between subgroups of patients with different demographic factors. We evaluated 311 patients who had a hip resurfacing arthroplasty performed after the initial learning curve and who had a minimum follow-up of 5 years (mean, 93 months). These patients were compared to a group of 93 patients (96 hips) who underwent resurfacings, with newer selection criteria based on the findings of the first cohort. Overall, there were 10 failures in the first patient cohort (97% survivorship), compared to no failures in the second cohort. Higher revision rates were associated with patients who had osteonecrosis or rheumatoid arthritis. Patients who had femoral component sizes larger than 50 millimeters had lower revision rates. There were no revisions in patients who were under 50 years of age, had head sizes greater than 50 millimeters, and who had a primary diagnosis of osteoarthritis. After evaluating our initial experience after the learning curve, the ideal patient selection criteria was determined to be young males who have femoral head sizes greater than 50 millimeters. The early results are encouraging in that, although resurfacing may not be appropriate for all patients, it can provide predictable, excellent survivorship in these patients.

Teaching Evidence-based Medicine Using Literature for Problem Solving.

ERIC Educational Resources Information Center

Mottonen, Merja; Tapanainen, Paivi; Nuutinen, Matti; Rantala, Heikki; Vainionpaa, Leena; Uhari, Matti

2001-01-01

Evidence-based medicine--the process of using research findings systematically as the basis for clinical decisions--can be taught using problem-solving teaching methods. Evaluates whether it was possible to motivate students to use the original literature by giving them selected patient problems to solve. (Author/ASK)

Identification of Genes Involved in Breast Cancer Metastasis by Integrating Protein-Protein Interaction Information with Expression Data.

PubMed

Tian, Xin; Xin, Mingyuan; Luo, Jian; Liu, Mingyao; Jiang, Zhenran

2017-02-01

The selection of relevant genes for breast cancer metastasis is critical for the treatment and prognosis of cancer patients. Although much effort has been devoted to the gene selection procedures by use of different statistical analysis methods or computational techniques, the interpretation of the variables in the resulting survival models has been limited so far. This article proposes a new Random Forest (RF)-based algorithm to identify important variables highly related with breast cancer metastasis, which is based on the important scores of two variable selection algorithms, including the mean decrease Gini (MDG) criteria of Random Forest and the GeneRank algorithm with protein-protein interaction (PPI) information. The new gene selection algorithm can be called PPIRF. The improved prediction accuracy fully illustrated the reliability and high interpretability of gene list selected by the PPIRF approach.

Factors that Can Help Select the Timing for Decompressive Hemicraniectomy for Malignant MCA Stroke.

PubMed

Kamran, Saadat; Salam, Abdul; Akhtar, Naveed; Alboudi, Ayman; Kamran, Kainat; Singh, Rajvir; Amir, Numan; Inshasi, Jihad; Qidwai, Uwais; Malik, Rayaz A; Shuaib, Ashfaq

2018-03-06

In patients with malignant middle cerebral artery (MMCA) stroke, a vital clinically relevant question is determination of the speed with which infarction evolves to select the time for decompressive hemicraniectomy [DHC]. A retrospective, multicenter cross-sectional study of patients referred for DHC, based on the criteria of randomized controlled trials, was undertaken to identify factors for selecting the timing of DHC in MMCA stroke, stratified by time [< 48, 48-72, > 72 h]. Infarction volume and infarct growth rate [IGR] were measured on all CT scans. One hundred eighty-two patients [135 underwent DHC and 47 survived without DHC] were included in the analysis. After multivariate adjustment, factors showing the strongest independent association with DHC were patients < 55 years of age, septum pellucidum deviation, temporal lobe involvement, MCA with additional infarcts, and IGR on second CT. Of the five factors identified, different combinations of determining factors were observed in each subgroup. Both first and second IGRs were highest in the < 48, 48-< 72, and > 72 h [p < 0.001]. Patients who survived without surgery had the slowest IGRs. There was no association between time to DHC and infarct volume, although infarct volume was lower in patients who survived without DHC compared to the DHC subgroups. We identify the major risk factors associated with DHC in time-stratified subgroups of patients with MMCA. Evaluation of IGRs between the first and second scan and when possible second and third scan can help in selecting the timing of hemicraniectomy.

Improving physician-patient communication in cancer care: outcome of a workshop for oncologists.

PubMed

Baile, W F; Lenzi, R; Kudelka, A P; Maguire, P; Novack, D; Goldstein, M; Myers, E G; Bast, R C

1997-01-01

Physicians caring for cancer patients receive little formal training in difficult communications such as breaking bad news, discussing life support, and addressing patients' emotional concerns. The authors conducted a three-day workshop in communication skills for nine oncology attendings and three fellows. Topics for the workshop were selected by participants by a pre-workshop questionnaire. Small groups of four to five participants interviewed simulated patients who role-played scripts based on the selected topics. Sessions on self-awareness and one on planning for continuing the work of the group after the workshop were included. Responses to pretest and posttest questionnaires showed that the workshop increased the participants' confidence in a number of communication areas and also in managing physician burnout. Process issues such as patient death and expectations for cure were also discussed. Interactive workshops offer a promising way of teaching communication skills and aspects of the physician-patient relationship to oncologists. Conclusions regarding outcome, however, are preliminary and tentative, and long-term results are uncertain.

Should ribavirin be used to treat hepatitis C in dialysis patients?

PubMed

Carrion, Andres F; Fabrizi, Fabrizio; Martin, Paul

2011-01-01

Hepatitis C virus infection adversely affects outcomes in patients with chronic kidney disease undergoing maintenance dialysis. Pegylated interferon and ribavirin, the standard-of-care treatment in patients with intact renal function, is associated with severe side effects, toxicity, and high dropout rates in this population. Ribavirin has an important role in maintaining antiviral response following completion of therapy and increases sustained viral response (SVR) rates. However, the use of ribavirin in dialysis patients has been limited by the high frequency of severe hemolytic anemia and is currently reserved for study protocols and highly selected candidates treated at experienced centers. Encouraging data from small trials have shown a significant increase in SVR rates with the use of different dosing regimens of ribavirin in addition to interferon-based therapy and aggressive erythroid-stimulating agent support in dialysis patients. Use of ribavirin in selected dialysis patients, particularly renal transplant candidates, by experienced clinicians is appropriate. © 2011 Wiley Periodicals, Inc.

A prototype system to support evidence-based practice.

PubMed

Demner-Fushman, Dina; Seckman, Charlotte; Fisher, Cheryl; Hauser, Susan E; Clayton, Jennifer; Thoma, George R

2008-11-06

Translating evidence into clinical practice is a complex process that depends on the availability of evidence, the environment into which the research evidence is translated, and the system that facilitates the translation. This paper presents InfoBot, a system designed for automatic delivery of patient-specific information from evidence-based resources. A prototype system has been implemented to support development of individualized patient care plans. The prototype explores possibilities to automatically extract patients problems from the interdisciplinary team notes and query evidence-based resources using the extracted terms. Using 4,335 de-identified interdisciplinary team notes for 525 patients, the system automatically extracted biomedical terminology from 4,219 notes and linked resources to 260 patient records. Sixty of those records (15 each for Pediatrics, Oncology & Hematology, Medical & Surgical, and Behavioral Health units) have been selected for an ongoing evaluation of the quality of automatically proactively delivered evidence and its usefulness in development of care plans.

Evidence of susceptibility to lamivudine-based HAART and genetic stability of hepatitis B virus (HBV) in HIV co-infected patients: A South African longitudinal HBV whole genome study.

PubMed

Amponsah-Dacosta, Edina; Rakgole, J Nare; Gededzha, Maemu P; Lukhwareni, Azwidowi; Blackard, Jason T; Selabe, Selokela G; Mphahlele, M Jeffrey

2016-09-01

Reports on the concomitant impact of HIV co-infection and long term highly active anti-retroviral therapy (HAART) on the genetic stability and molecular evolution of HBV are limited in sub-Saharan Africa. This retrospective study investigated the molecular evolution of chronic HBV in HIV co-infected patients on lamivudine (3TC)-based HAART over a 5year period. Four HIV co-infected patients, consecutively recruited and followed-up, were screened for hepatitis B serological markers, and their viral loads determined. The HBV genome was amplified from longitudinal samples and characterized by Bayesian inference, mutational analysis, and identification of immune selection pressure. All patients exhibited persistent chronic HBV infection at baseline, as well as over the course of follow-up despite exposure to 3TC-based HAART. The polymerase gene in all isolates was relatively variable prior to HAART initiation at baseline and during the course of follow-up, although primary drug resistance mutations were not detected. All but one patient were infected with HBV subgenotype A1. The divergence rates between baseline and the last follow-up sequences ranged from 0 to 2.0×10(-3) substitutions per site per year (s/s/y). Positive selection pressure was evident within the surface and core genes. Despite persistent HBV infection in the HIV co-infected patients exposed to long term 3TC-based HAART, the molecular evolution of HBV over a 5year period was unremarkable. In addition, HBV exhibited minimal genetic variability overtime. Copyright © 2016 Elsevier B.V. All rights reserved.

Vision after trans-sylvian or temporobasal selective amygdalohippocampectomy: a prospective randomised trial.

PubMed

Delev, Daniel; Wabbels, Bettina; Schramm, Johannes; Nelles, Michael; Elger, Christian E; von Lehe, Marec; Clusmann, Hans; Grote, Alexander

2016-09-01

Selective amygdalohippocampectomy (SAH) is an accepted surgical procedure for treatment of pharmacoresistant mesial temporal lobe epilepsy, but it may lead to postoperative visual field deficits (VFDs). Here we present a prospective randomised trial comparing the postoperative VFDs after either a trans-sylvian or temporobasal approach for SAH. Forty-eight patients were randomly assigned to trans-sylvian (n = 24) or temporobasal (n = 24) SAH. Postoperative VFD were quantitatively evaluated using automated static and kinetic perimetry. In 24 cases, diffusion tensor imaging-based deterministic fibre-tracking of the optic radiation was performed. The primary endpoint was absence of postoperative VFD. The secondary endpoint was seizure outcome and driving ability. Three patients (13 %) from the trans-sylvian group showed no VFD, compared to 11 patients (46 %) from the temporobasal group without VFD (p = 0.01, RR = 3.7; CI = 1.2-11.5). Fifteen patients from each group (63 %) became completely seizure-free (ILAE1). Among those seizure-free cases, five trans-sylvian (33 %) and ten temporobasal (66 %) patients could apply for a driving licence (NNT = 3) when VFDs were considered. Although the trans-sylvian group experienced more frequent VFDs, the mean functional visual impairment showed a tendency to be less pronounced compared with the temporobasal group. DTI-based tracking of the optic radiation revealed that a lower distance of optic radiation to the temporal base correlated with increased rate of VFD in the temporobasal group. Temporobasal SAH shows significantly fewer VFDs and equal seizure-free rate compared with the trans-sylvian SAH. However, in patients in whom the optic radiation is close to the temporal base, the trans-sylvian approach may be a preferred alternative.

Using sentiment analysis to review patient satisfaction data located on the internet.

PubMed

Hopper, Anthony M; Uriyo, Maria

2015-01-01

The purpose of this paper is to test the usefulness of sentiment analysis and time-to-next-complaint methods in quantifying text-based information located on the internet. As important, the authors demonstrate how managers can use time-to-next-complaint techniques to organize sentiment analysis derived data into useful information, which can be shared with doctors and other staff. The authors used sentiment analysis to review patient feedback for a select group of gynecologists in Virginia. The authors utilized time-to-next-complaint methods along with other techniques to organize this data into meaningful information. The authors demonstrated that sentiment analysis and time-to-next-complaint techniques might be useful tools for healthcare managers who are interested in transforming web-based text into meaningful, quantifiable information. This study has several limitations. For one thing, neither the data set nor the techniques the authors used to analyze it will account for biases that resulted from selection issues related to gender, income, and culture, as well as from other socio-demographic concerns. Additionally, the authors lacked key data concerning patient volumes for the targeted physicians. Finally, it may be difficult to convince doctors to consider web-based comments as truthful, thereby preventing healthcare managers from using data located on the internet. The report illustrates some of the ways in which healthcare administrators can utilize sentiment analysis, along with time-to-next-complaint techniques, to mine web-based, patient comments for meaningful information. The paper is one of the first to illustrate ways in which administrators at clinics and physicians' offices can utilize sentiment analysis and time-to-next-complaint methods to analyze web-based patient comments.

Evaluating the influence of motor control on selective attention through a stochastic model: the paradigm of motor control dysfunction in cerebellar patient.

PubMed

Veneri, Giacomo; Federico, Antonio; Rufa, Alessandra

2014-01-01

Attention allows us to selectively process the vast amount of information with which we are confronted, prioritizing some aspects of information and ignoring others by focusing on a certain location or aspect of the visual scene. Selective attention is guided by two cognitive mechanisms: saliency of the image (bottom up) and endogenous mechanisms (top down). These two mechanisms interact to direct attention and plan eye movements; then, the movement profile is sent to the motor system, which must constantly update the command needed to produce the desired eye movement. A new approach is described here to study how the eye motor control could influence this selection mechanism in clinical behavior: two groups of patients (SCA2 and late onset cerebellar ataxia LOCA) with well-known problems of motor control were studied; patients performed a cognitively demanding task; the results were compared to a stochastic model based on Monte Carlo simulations and a group of healthy subjects. The analytical procedure evaluated some energy functions for understanding the process. The implemented model suggested that patients performed an optimal visual search, reducing intrinsic noise sources. Our findings theorize a strict correlation between the "optimal motor system" and the "optimal stimulus encoders."

Using multiple classifiers for predicting the risk of endovascular aortic aneurysm repair re-intervention through hybrid feature selection.

PubMed

Attallah, Omneya; Karthikesalingam, Alan; Holt, Peter Je; Thompson, Matthew M; Sayers, Rob; Bown, Matthew J; Choke, Eddie C; Ma, Xianghong

2017-11-01

Feature selection is essential in medical area; however, its process becomes complicated with the presence of censoring which is the unique character of survival analysis. Most survival feature selection methods are based on Cox's proportional hazard model, though machine learning classifiers are preferred. They are less employed in survival analysis due to censoring which prevents them from directly being used to survival data. Among the few work that employed machine learning classifiers, partial logistic artificial neural network with auto-relevance determination is a well-known method that deals with censoring and perform feature selection for survival data. However, it depends on data replication to handle censoring which leads to unbalanced and biased prediction results especially in highly censored data. Other methods cannot deal with high censoring. Therefore, in this article, a new hybrid feature selection method is proposed which presents a solution to high level censoring. It combines support vector machine, neural network, and K-nearest neighbor classifiers using simple majority voting and a new weighted majority voting method based on survival metric to construct a multiple classifier system. The new hybrid feature selection process uses multiple classifier system as a wrapper method and merges it with iterated feature ranking filter method to further reduce features. Two endovascular aortic repair datasets containing 91% censored patients collected from two centers were used to construct a multicenter study to evaluate the performance of the proposed approach. The results showed the proposed technique outperformed individual classifiers and variable selection methods based on Cox's model such as Akaike and Bayesian information criterions and least absolute shrinkage and selector operator in p values of the log-rank test, sensitivity, and concordance index. This indicates that the proposed classifier is more powerful in correctly predicting the risk of re-intervention enabling doctor in selecting patients' future follow-up plan.

Multiresolution texture models for brain tumor segmentation in MRI.

PubMed

Iftekharuddin, Khan M; Ahmed, Shaheen; Hossen, Jakir

2011-01-01

In this study we discuss different types of texture features such as Fractal Dimension (FD) and Multifractional Brownian Motion (mBm) for estimating random structures and varying appearance of brain tissues and tumors in magnetic resonance images (MRI). We use different selection techniques including KullBack - Leibler Divergence (KLD) for ranking different texture and intensity features. We then exploit graph cut, self organizing maps (SOM) and expectation maximization (EM) techniques to fuse selected features for brain tumors segmentation in multimodality T1, T2, and FLAIR MRI. We use different similarity metrics to evaluate quality and robustness of these selected features for tumor segmentation in MRI for real pediatric patients. We also demonstrate a non-patient-specific automated tumor prediction scheme by using improved AdaBoost classification based on these image features.

Tissue-Selective Salvage of the White Matter by Successful Endovascular Stroke Therapy.

PubMed

Kleine, Justus F; Kaesmacher, Mirjam; Wiestler, Benedikt; Kaesmacher, Johannes

2017-10-01

White matter (WM) is less vulnerable to ischemia than gray matter. In ischemic stroke caused by acute large-vessel occlusion, successful recanalization might therefore sometimes selectively salvage the WM, leading to infarct patterns confined to gray matter. This study examines occurrence, determinants, and clinical significance of such effects. Three hundred twenty-two patients with acute middle cerebral artery occlusion subjected to mechanical thrombectomy were included. Infarct patterns were categorized into WM - (sparing the WM) and WM + (involving WM). National Institutes of Health Stroke Scale-based measures of neurological outcome, including National Institutes of Health Stroke Scale improvement or National Institutes of Health Stroke Scale worsening, good functional midterm outcome (day 90-modified Rankin Scale score of ≤2), the occurrence of malignant swelling, and in-hospital mortality were predefined outcome measures. WM - infarcts occurred in 118 of 322 patients and were associated with successful recanalization and better collateral grades ( P <0.05). Shorter symptom-onset to recanalization times were also associated with WM - infarcts in univariate analysis, but not when adjusted for collateral grades. WM - infarcts were independently associated with good neurological outcome (adjusted odds ratio, 3.003; 95% confidence interval, 1.186-7.607; P =0.020) and good functional midterm outcome (adjusted odds ratio, 8.618; 95% confidence interval, 2.409-30.828; P =0.001) after correcting for potential confounders, including final infarct volume. Only 2.6% of WM - patients, but 20.5% of WM + patients exhibited neurological worsening, and none versus 12.8% developed malignant swelling ( P <0.001), contributing to lower mortality in this group (2.5% versus 10.3%; P =0.014). WM infarction commonly commences later than gray matter infarction after acute middle cerebral artery occlusion. Successful recanalization can therefore salvage completely the WM at risk in many patients even several hours after symptom onset. Preservation of the WM is associated with better neurological recovery, prevention of malignant swelling, and reduced mortality. This has important implications for neuroprotective strategies, and perfusion imaging-based patient selection, and provides a rationale for treating selected patients in extended time windows. © 2017 American Heart Association, Inc.

Reporting 'Denominator' data is essential for benchmarking and quality standards in ovarian cancer.

PubMed

Phillips, Andrew; Balega, Janos; Nevin, James; Singh, Kavita; Elattar, Ahmed; Kehoe, Sean; Sundar, Sudha

2017-07-01

Combined surgery and platinum-based chemotherapy is the internationally agreed standard therapy for advanced ovarian cancer (AOC). However international cancer registry datasets demonstrate a significant proportion of patients do not receive both or either therapies. Our objective was to evaluate the effect of total patient cohort data ('Denominator') on median overall survival (OS) and determine how frequently this was reported in literature. We retrospectively reviewed OS outcomes for 593 patients diagnosed with AOC for 77 months at a regional cancer centre. Patients were stratified into five progressively overlapping categories based on treatment received - Primary debulking surgery (PDS), PDS or Interval debulking (IDS), all surgery and those considered for IDS, patients receiving any treatment and total patient cohort. A systematic search of literature was performed. Median OS progressively decreased from 54.5 months in patients receiving PDS, 38.7 months in the PDS+IDS group, 35.4 months in the PDS/IDS+patients considered for IDS, 33.3 months in patients receiving any treatment and 30.2 months in the total patient cohort. OS in the surgically treated group was statistically significantly different from the OS in the total patient cohort (Denominator)(p=0.000353). Denominator descriptors were identified in 11% of studies. Denominator data is critical to understanding selection and OS in AOC. Published outcomes of selected cohorts should routinely incorporate outcomes for all women managed within the reporting Centre. This is essential for benchmarking and quality assurance in gynaecological cancer and should be an integral part of any publication on outcomes from AOC. Copyright © 2017 Elsevier Inc. All rights reserved.

Characteristics of patients with lower extremity symptoms treated with slump stretching: a case series.

PubMed

George, Steven Z

2002-08-01

Prospective case series. The purpose of this case series was to describe the criteria used to determine if patients were to receive slump stretch treatment within a treatment-based classification system and to describe selected symptom characteristics associated with these patients. Previous reports from the literature suggest that the slump test position may be a useful treatment and evaluation technique. However, little information has been presented regarding how to identify patients who are appropriate to treat with slump stretching and the symptom characteristics associated with these patients. Prior to recruitment, criteria were established to identify patients who would be considered appropriate to treat with slump stretching. Consecutive patients referred with low back diagnosis or low-back-related diagnoses were then evaluated using a treatment-based classification system. Selected symptom characteristics were collected from patients treated with slump stretching. Out of 88 consecutive patients with low back diagnoses or low-back-related diagnoses, 6 met the study's inclusion criteria and were treated with slump stretching. All pain diagrams were classified as "organic" or "possibly organic," and the most common symptom descriptor was "deep ache." At the discharge session of physical therapy, 5 of 6 patients had symptoms that were more proximally located and all patients reported a decrease in symptom intensity. Favorable changes in symptom intensity and location were observed for this case series, but definitive conclusions cannot be drawn from this study design. Additional research needs to be completed to determine if the slump test position is an effective evaluation and treatment technique.

Noninvasive Treatments for Acute, Subacute, and Chronic Low Back Pain: A Clinical Practice Guideline From the American College of Physicians.

PubMed

Qaseem, Amir; Wilt, Timothy J; McLean, Robert M; Forciea, Mary Ann

2017-04-04

The American College of Physicians (ACP) developed this guideline to present the evidence and provide clinical recommendations on noninvasive treatment of low back pain. Using the ACP grading system, the committee based these recommendations on a systematic review of randomized, controlled trials and systematic reviews published through April 2015 on noninvasive pharmacologic and nonpharmacologic treatments for low back pain. Updated searches were performed through November 2016. Clinical outcomes evaluated included reduction or elimination of low back pain, improvement in back-specific and overall function, improvement in health-related quality of life, reduction in work disability and return to work, global improvement, number of back pain episodes or time between episodes, patient satisfaction, and adverse effects. The target audience for this guideline includes all clinicians, and the target patient population includes adults with acute, subacute, or chronic low back pain. Given that most patients with acute or subacute low back pain improve over time regardless of treatment, clinicians and patients should select nonpharmacologic treatment with superficial heat (moderate-quality evidence), massage, acupuncture, or spinal manipulation (low-quality evidence). If pharmacologic treatment is desired, clinicians and patients should select nonsteroidal anti-inflammatory drugs or skeletal muscle relaxants (moderate-quality evidence). (Grade: strong recommendation). For patients with chronic low back pain, clinicians and patients should initially select nonpharmacologic treatment with exercise, multidisciplinary rehabilitation, acupuncture, mindfulness-based stress reduction (moderate-quality evidence), tai chi, yoga, motor control exercise, progressive relaxation, electromyography biofeedback, low-level laser therapy, operant therapy, cognitive behavioral therapy, or spinal manipulation (low-quality evidence). (Grade: strong recommendation). In patients with chronic low back pain who have had an inadequate response to nonpharmacologic therapy, clinicians and patients should consider pharmacologic treatment with nonsteroidal anti-inflammatory drugs as first-line therapy, or tramadol or duloxetine as second-line therapy. Clinicians should only consider opioids as an option in patients who have failed the aforementioned treatments and only if the potential benefits outweigh the risks for individual patients and after a discussion of known risks and realistic benefits with patients. (Grade: weak recommendation, moderate-quality evidence).

Methods for the guideline-based development of quality indicators--a systematic review

PubMed Central

2012-01-01

Background Quality indicators (QIs) are used in many healthcare settings to measure, compare, and improve quality of care. For the efficient development of high-quality QIs, rigorous, approved, and evidence-based development methods are needed. Clinical practice guidelines are a suitable source to derive QIs from, but no gold standard for guideline-based QI development exists. This review aims to identify, describe, and compare methodological approaches to guideline-based QI development. Methods We systematically searched medical literature databases (Medline, EMBASE, and CINAHL) and grey literature. Two researchers selected publications reporting methodological approaches to guideline-based QI development. In order to describe and compare methodological approaches used in these publications, we extracted detailed information on common steps of guideline-based QI development (topic selection, guideline selection, extraction of recommendations, QI selection, practice test, and implementation) to predesigned extraction tables. Results From 8,697 hits in the database search and several grey literature documents, we selected 48 relevant references. The studies were of heterogeneous type and quality. We found no randomized controlled trial or other studies comparing the ability of different methodological approaches to guideline-based development to generate high-quality QIs. The relevant publications featured a wide variety of methodological approaches to guideline-based QI development, especially regarding guideline selection and extraction of recommendations. Only a few studies reported patient involvement. Conclusions Further research is needed to determine which elements of the methodological approaches identified, described, and compared in this review are best suited to constitute a gold standard for guideline-based QI development. For this research, we provide a comprehensive groundwork. PMID:22436067

Magnetic resonance imaging (MRI)-based indication for neoadjuvant treatment of rectal carcinoma and the surrogate endpoint CRM status.

PubMed

Strassburg, Joachim; Junginger, Theo; Trinh, Trong; Püttcher, Olaf; Oberholzer, Katja; Heald, Richard J; Hermanek, Paul

2008-11-01

Is it possible to reduce the frequency of neoadjuvant therapy for rectal carcinoma and nevertheless achieve a rate of more than 90% circumferential resection margin (CRM)-negative resection specimens by a novel concept of magnetic resonance imaging (MRI)-based therapy planning? One hundred eighty-one patients from Berlin and Mainz, Germany, with primary rectal carcinoma, without distant metastasis, underwent radical surgery with curative intention. Surgical procedures applied were anterior resection with total mesorectal excision (TME) or partial mesorectal excision (PME; PME for tumours of the upper rectum) or abdominoperineal excision with TME. With MRI selection of the highest-risk cases, neoadjuvant therapy was given to only 62 of 181 (34.3%). The rate of CRM-negative resection specimens on histology was 170 of 181 (93.9%) for all patients, and in Berlin, only 1 of 93 (1%) specimens was CRM-positive. Patients selected for primary surgery had CRM-negative specimens on histology in 114 of 119 (95.8%). Those selected for neoadjuvant therapy had a lower rate of clear margin: 56 of 62 (90%). By applying a MRI-based indication, the frequency of neoadjuvant treatment with its acute and late adverse effects can be reduced to 30-35% without reduction of pathologically CRM-negative resection specimens and, thus, without the danger of worsening the oncological long-term results. This concept should be confirmed in prospective multicentre observation studies with quality assurance of MRI, surgery and pathology.

Randomized clinical trial of Appendicitis Inflammatory Response score-based management of patients with suspected appendicitis.

PubMed

Andersson, M; Kolodziej, B; Andersson, R E

2017-10-01

The role of imaging in the diagnosis of appendicitis is controversial. This prospective interventional study and nested randomized trial analysed the impact of implementing a risk stratification algorithm based on the Appendicitis Inflammatory Response (AIR) score, and compared routine imaging with selective imaging after clinical reassessment. Patients presenting with suspicion of appendicitis between September 2009 and January 2012 from age 10 years were included at 21 emergency surgical centres and from age 5 years at three university paediatric centres. Registration of clinical characteristics, treatments and outcomes started during the baseline period. The AIR score-based algorithm was implemented during the intervention period. Intermediate-risk patients were randomized to routine imaging or selective imaging after clinical reassessment. The baseline period included 1152 patients, and the intervention period 2639, of whom 1068 intermediate-risk patients were randomized. In low-risk patients, use of the AIR score-based algorithm resulted in less imaging (19·2 versus 34·5 per cent; P < 0·001), fewer admissions (29·5 versus 42·8 per cent; P < 0·001), and fewer negative explorations (1·6 versus 3·2 per cent; P = 0·030) and operations for non-perforated appendicitis (6·8 versus 9·7 per cent; P = 0·034). Intermediate-risk patients randomized to the imaging and observation groups had the same proportion of negative appendicectomies (6·4 versus 6·7 per cent respectively; P = 0·884), number of admissions, number of perforations and length of hospital stay, but routine imaging was associated with an increased proportion of patients treated for appendicitis (53·4 versus 46·3 per cent; P = 0·020). AIR score-based risk classification can safely reduce the use of diagnostic imaging and hospital admissions in patients with suspicion of appendicitis. Registration number: NCT00971438 ( http://www.clinicaltrials.gov). © 2017 BJS Society Ltd Published by John Wiley & Sons Ltd.

An ontology-based approach to patient follow-up assessment for continuous and personalized chronic disease management.

PubMed

Zhang, Yi-Fan; Gou, Ling; Zhou, Tian-Shu; Lin, De-Nan; Zheng, Jing; Li, Ye; Li, Jing-Song

2017-08-01

Chronic diseases are complex and persistent clinical conditions that require close collaboration among patients and health care providers in the implementation of long-term and integrated care programs. However, current solutions focus partially on intensive interventions at hospitals rather than on continuous and personalized chronic disease management. This study aims to fill this gap by providing computerized clinical decision support during follow-up assessments of chronically ill patients at home. We proposed an ontology-based framework to integrate patient data, medical domain knowledge, and patient assessment criteria for chronic disease patient follow-up assessments. A clinical decision support system was developed to implement this framework for automatic selection and adaptation of standard assessment protocols to suit patient personal conditions. We evaluated our method in the case study of type 2 diabetic patient follow-up assessments. The proposed framework was instantiated using real data from 115,477 follow-up assessment records of 36,162 type 2 diabetic patients. Standard evaluation criteria were automatically selected and adapted to the particularities of each patient. Assessment results were generated as a general typing of patient overall condition and detailed scoring for each criterion, providing important indicators to the case manager about possible inappropriate judgments, in addition to raising patient awareness of their disease control outcomes. Using historical data as the gold standard, our system achieved a rate of accuracy of 99.93% and completeness of 95.00%. This study contributes to improving the accessibility, efficiency and quality of current patient follow-up services. It also provides a generic approach to knowledge sharing and reuse for patient-centered chronic disease management. Copyright © 2017 Elsevier Inc. All rights reserved.

Insights into next developments in advanced gastric cancer.

PubMed

Obermannová, Radka; Lordick, Florian

2016-07-01

The purpose of the review is to delineate novel approaches for biology-based treatment in advanced gastric cancer. We reviewed the latest translational and clinical research articles and congress presentations. A new molecular classification of gastric cancer based on histology, genetic and proteomic alterations has evolved. It provides a roadmap for development of new drugs and combinations and for patient stratification. Anti-HER2 treatment, which is an effective strategy in metastatic gastric cancer, is now also being studied in the perioperative setting. However, resistance mechanisms in advanced disease are poorly understood and optimal patient selection remains challenging. Targeting angiogenesis is an emerging concept in the management of advanced gastric cancer, and ramucirumab has prolonged survival in the second line either as a monotherapy or in combination with paclitaxel. Biomarkers for selecting patients who benefit from ramucirumab are still lacking. Immune checkpoint blockade and inhibition of cancer stemness targets are other emerging directions for the medical treatment of gastric cancer. Large-scale international studies are ongoing. Promising biology-based treatment strategies are evolving. But tumor heterogeneity which is an inherent feature of gastric cancer challenges the development of molecularly targeted and personalized treatment strategies.

CT dose minimization using personalized protocol optimization and aggressive bowtie

NASA Astrophysics Data System (ADS)

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

2016-03-01

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

The Usefulness of Diffusion Tensor Imaging and Tractography in Surgery of Brainstem Cavernous Malformations.

PubMed

Januszewski, Jacob; Albert, Lauren; Black, Karen; Dehdashti, Amir R

2016-09-01

Diffusion tensor imaging (DTI) estimates the course and connectivity patterns of white matter tracts. The objective of this study is to evaluate whether findings in the brain stem modify the preoperative surgical trajectory planning or postoperative outcome in patients with brain stem cavernous malformations. Ten patients with symptomatic brainstem cavernous malformation underwent surgical resection. Five patients received preoperative DTI evaluation and the remaining 5 did not. Reconstructed DTI tracts consisted of corticospinal, medial lemnisci, and cerebellar peduncles. The surgical planning and postoperative outcome were evaluated. In 5 patients with no preoperative DTI evaluation, surgical planning was based on anatomic landmark and the 2-point technique. The other 5 patients underwent preoperative DTI, and findings were factored into the selection of the surgical approach. In 3 of the 5 cases with DTI evaluation, the 2-point technique suggested a similar trajectory. In the other 2, the DTI findings suggested a different approach to avoid damage to the white matter tract. Two patients in the group with no DTI had immediate postoperative new or worsened deficit, which improved at long-term follow-up. No patient in the DTI group had a new neurologic deficit. Compared with the standard magnetic resonance imaging, DTI provided improved visualization of cavernous malformation involvement in eloquent fiber tracts of the brainstem. This additional information might help in selecting a more appropriate surgical trajectory in selected lesions. Larger patient cohorts are needed to assess the effect of this modality in patients' outcome. Published by Elsevier Inc.

Eligibility of real-life patients with COPD for inclusion in trials of inhaled long-acting bronchodilator therapy.

PubMed

Halpin, David M G; Kerkhof, Marjan; Soriano, Joan B; Mikkelsen, Helga; Price, David B

2016-09-23

Management guidelines of chronic obstructive pulmonary disease (COPD) are mainly based on results of randomised controlled trials (RCTs), but some authors have suggested limited representativeness of patients included in these trials. No previous studies have applied the full range of selection criteria to a broad COPD patient population in a real-life setting. We identified all RCTs of inhaled long-acting bronchodilator therapy, during 1999-2013, at ClinicalTrials.gov and translated trial selection criteria into definitions compatible with electronic medical records. Eligibility was calculated for each RCT by applying these criteria to a uniquely representative, well-characterised population of patients with COPD from the Optimum Patient Care Research Database (OPCRD). Median eligibility of 36 893 patients with COPD for participation in 31 RCTs was 23 % (interquartile range 12-38). Two studies of olodaterol showed the highest eligibility of 55 and 58 %. Conversely, the lowest eligibility was observed in two studies that required a history of exacerbations in the past year (3.5 and 3.9 %). For the patient subgroup with modified Medical Research Council score ≥2, the overall median eligibility was 27 %. By applying an extensive range of RCT selection criteria to a large, representative COPD patient population, this study highlights that the interpretation of results from RCTs must take into account that RCT participants are variably, but generally more representative of patients in the community than previously believed.

Risk stratification and management of acute pulmonary embolism.

PubMed

Becattini, Cecilia; Agnelli, Giancarlo

2016-12-02

The clinical management of patients with acute pulmonary embolism is rapidly changing over the years. The widening spectrum of clinical management strategies for these patients requires effective tools for risk stratification. Patients at low risk for death could be candidates for home treatment or early discharge. Clinical models with high negative predictive value have been validated that could be used to select patients at low risk for death. In a major study and in several meta-analyses, thrombolysis in hemodynamically stable patients was associated with unacceptably high risk for major bleeding complications or intracranial hemorrhage. Thus, the presence of shock or sustained hypotension continues to be the criterion for the selection of candidates for thrombolytic treatment. Interventional procedures for early revascularization should be reserved to selected patients until further evidence is available. No clinical advantage is expected with the insertion of a vena cava filter in the acute-phase management of patients with acute pulmonary embolism. Direct oral anticoagulants used in fixed doses without laboratory monitoring showed similar efficacy (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.70-1.12) and safety (OR, 0.89; 95% CI, 0.77-1.03) in comparison with conventional anticoagulation in patients with acute pulmonary embolism. Based on these results and on their practicality, direct oral anticoagulants are the agents of choice for the treatment of the majority of patients with acute pulmonary embolism. © 2016 by The American Society of Hematology. All rights reserved.

Case Mix Difference Can Affect Evaluation of Outcome of Treatment for Colorectal Cancer.

PubMed

Ljungman, David; Kodeda, Karl; Derwinger, Kristoffer

2015-07-01

To explore the potential effects of patient selection, for example by organization, on survival as outcome parameter in colorectal cancer treatment. The main cohort was identified in a Hospital-based registry and outcome data of all 2,717 patients operated on for colorectal cancer between 2000-2011 were evaluated. A simulation of different center settings was performed using several potential selection criteria, including emergency cases, referral surgery and palliative resection, and used for comparison of outcome data. Overall survival and cancer-specific survival can be significantly affected in both short-term (30-/90-day) mortality and long-term survival by factors of organizational level. Survival data as an outcome parameter can be affected by the composition of the patient cohort and thus reflect possible selection bias for example due to organization, referral patterns and practice customs. This potential bias should be acknowledged when making inter-hospital comparisons of outcome. Copyright© 2015 International Institute of Anticancer Research (Dr. John G. Delinassios), All rights reserved.

Selection of Fusion Levels Using the Fulcrum Bending Radiograph for the Management of Adolescent Idiopathic Scoliosis Patients with Alternate Level Pedicle Screw Strategy: Clinical Decision-making and Outcomes.

PubMed

Samartzis, Dino; Leung, Yee; Shigematsu, Hideki; Natarajan, Deepa; Stokes, Oliver; Mak, Kin-Cheung; Yao, Guanfeng; Luk, Keith D K; Cheung, Kenneth M C

2015-01-01

Selecting fusion levels based on the Luk et al criteria for operative management of thoracic adolescent idiopathic scoliosis (AIS) with hook and hybrid systems yields acceptable curve correction and balance parameters; however, it is unknown whether utilizing a purely pedicle screw strategy is effective. Utilizing the fulcrum bending radiographic (FBR) to assess curve flexibility to select fusion levels, the following study assessed the efficacy of pedicle screw fixation with alternate level screw strategy (ALSS) for thoracic AIS. A retrospective study with prospective radiographic data collection/analyses (preoperative, postoperative 1-week and minimum 2-year follow-up) of 28 operative thoracic AIS patients undergoing ALSS was performed. Standing coronal/sagittal and FBR Cobb angles, FBR flexibility, fulcrum bending correction index (FBCI), trunkal shift, radiographic shoulder height (RSH), and list were assessed on x-rays. Fusion level selection was based on the Luk et al criteria and compared to conventional techniques. In the primary curve, the mean preoperative and postoperative 1 week and last follow-up standing coronal Cobb angles were 59.9, 17.2 and 20.0 degrees, respectively. Eighteen patients (64.3%) had distal levels saved (mean: 1.6 levels) in comparison to conventional techniques. Mean immediate and last follow-up FBCIs were 122.6% and 115.0%, respectively. Sagittal alignment did not statistically differ between any assessment intervals (p>0.05). A decrease in trunkal shift was noted from preoperative to last follow-up (p = 0.003). No statistically significant difference from preoperative to last follow-up was noted in RSH and list (p>0.05). No "add-on" of other vertebra or decompensation was noted and all patients achieved fusion. This is the first report to note that using the FBR for decision-making in selecting fusion levels in thoracic AIS patients undergoing management with pedicle screw constructs (e.g. ALSS) is a cost-effective strategy that can achieve clinically-relevant deformity correction that is maintained and without compromising fusion levels.

Three-dimensional virtual bone bank system for selecting massive bone allograft in orthopaedic oncology.

PubMed

Wu, Zhigang; Fu, Jun; Wang, Zhen; Li, Xiangdong; Li, Jing; Pei, Yanjun; Pei, Guoxian; Li, Dan; Guo, Zheng; Fan, Hongbin

2015-06-01

Although structural bone allografts have been used for years to treat large defects caused by tumour or trauma, selecting the most appropriate allograft is still challenging. The objectives of this study were to: (1) describe the establishment of a visual bone bank system and workflow of allograft selection, and (2) show mid-term follow-up results of patients after allograft implantation. Allografts were scanned and stored in Digital Imaging and Communications in Medicine (DICOM) files. Then, image segmentation was conducted and 3D model reconstructed to establish a visual bone bank system. Based on the volume registration method, allografts were selected after a careful matching process. From November 2010 to June 2013, with the help of the Computer-assisted Orthopaedic Surgery (CAOS) navigation system, the allografts were implanted in 14 patients to fill defects after tumour resection. By combining the virtual bone bank and CAOS, selection time was reduced and matching accuracy was increased. After 27.5 months of follow-up, the mean Musculoskeletal Tumor Society (MSTS) 93 functional score was 25.7 ± 1.1 points. Except for two patients with pulmonary metastases, 12 patents were alive without evidence of disease at the time this report was written. The virtual bone bank system was helpful for allograft selection, tumour excision and bone reconstruction, thereby improving the safety and effectiveness of limb-salvage surgery.

[Clinical characteristics and surgical management in patients with third and fourth branchial anomalies].

PubMed

Li, Y X; He, X G; Wang, Y; Yang, X

2016-08-05

Objective: To analysize the clinical characteristics as well as the effect and methods of the surgical treatment in patiets with the third and fourth branchial anomalies. Method: The clinical data of 25 patients diagnosed as third and fourth branchial cleft fistula by pathological method were analyzed retrospectively.Two of 25 patients had undergone fistulectomy simply.Based on the embryologicc and anatomic features of branchial anomalies,23 of 25 patients had received different types of selective neck dissection.All of lesions were confirmed as branchial cleft fistula by pathology.All patients were received the examinations of Esophagus myelography,MRI and CT preoperatively. Result: The features of the third and the fourth bianchial fistula were as following:most patients suffered from recurrent neck abscess and had undergone incision and drainage. Esophagus myelography and CT were important auxiliary examination for branchial anomalies.No recurrent and complications were found in all patients by using treatment of selective neck dissection (23/25 cases) and fistulectomy simply(2/25 cases) within 12 to 36 months following-up,postoperatively. Conclusion: Branchial anomalies is characterized by recurrent acute abscess,acute thyroiditis or fistula secretion inferior to neck.Complete removal of branchial lesions and inflammatory granuloma using selective neck dissection is a safty and effective treatment for recurrent branchial anomalies. Copyright© by the Editorial Department of Journal of Clinical Otorhinolaryngology Head and Neck Surgery.

[Selective alteration of the declarative memory systems in patients treated with a high number of electroconvulsive therapy sessions].

PubMed

Rami-González, L; Boget-Llucià, T; Bernardo, M; Marcos, T; Cañizares-Alejos, S; Penadés, R; Portella, M J; Castelví, M; Raspall, T; Salamero, M

The reversible electrochemical effects of electroconvulsive therapy (ECT) on specific areas of the brain enable the neuroanatomical bases of some cognitive functions to be studied. In research carried out on memory systems, a selective alteration of the declarative ones has been observed after treatment with ECT. Little work has been done to explore the differential alteration of the memory subsystems in patients with a high number of ECT sessions. AIM. To study the declarative and non declarative memory system in psychiatric patients submitted to maintenance ECT treatment, with a high number of previous ECT sessions. 20 patients submitted to treatment with ECT (10 diagnosed as having depression and 10 with schizophrenia) and 20 controls, who were paired by age, sex and psychopathological diagnosis. For the evaluation of the declarative memory system, the Wechsler Memory Scale (WMS) logical memory test was used. The Hanoi Tower procedural test was employed to evaluate the non declarative system. Patients treated with ECT performed worse in the WMS logical memory test, but this was only significant in patients diagnosed as suffering from depression. No significant differences were observed in the Hanoi Tower test. A selective alteration of the declarative systems was observed in patients who had been treated with a high number of ECT sessions, while the non declarative memory systems remain unaffected.

SU-G-BRC-13: Model Based Classification for Optimal Position Selection for Left-Sided Breast Radiotherapy: Free Breathing, DIBH, Or Prone

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

Lin, H; Liu, T; Xu, X

Purpose: There are clinical decision challenges to select optimal treatment positions for left-sided breast cancer patients—supine free breathing (FB), supine Deep Inspiration Breath Hold (DIBH) and prone free breathing (prone). Physicians often make the decision based on experiences and trials, which might not always result optimal OAR doses. We herein propose a mathematical model to predict the lowest OAR doses among these three positions, providing a quantitative tool for corresponding clinical decision. Methods: Patients were scanned in FB, DIBH, and prone positions under an IRB approved protocol. Tangential beam plans were generated for each position, and OAR doses were calculated.more » The position with least OAR doses is defined as the optimal position. The following features were extracted from each scan to build the model: heart, ipsilateral lung, breast volume, in-field heart, ipsilateral lung volume, distance between heart and target, laterality of heart, and dose to heart and ipsilateral lung. Principal Components Analysis (PCA) was applied to remove the co-linearity of the input data and also to lower the data dimensionality. Feature selection, another method to reduce dimensionality, was applied as a comparison. Support Vector Machine (SVM) was then used for classification. Thirtyseven patient data were acquired; up to now, five patient plans were available. K-fold cross validation was used to validate the accuracy of the classifier model with small training size. Results: The classification results and K-fold cross validation demonstrated the model is capable of predicting the optimal position for patients. The accuracy of K-fold cross validations has reached 80%. Compared to PCA, feature selection allows causal features of dose to be determined. This provides more clinical insights. Conclusion: The proposed classification system appeared to be feasible. We are generating plans for the rest of the 37 patient images, and more statistically significant results are to be presented.« less

[Patients are not prepared to choose: another example of a failing market?].

PubMed

Levi, Marcel; Bos, Wouter

2015-01-01

The Netherlands has a demand-driven health care system based on market mechanisms. However, the system is a hybrid between two potential situations: one in which healthcare insurance companies have a leading role, with consumers and patients choosing for the company that most suits them, and one in which patients have a leading role and select their favourite caregiver, whereby the insurance company has to follow. Current research concludes that the vast majority of patients are not able or even willing to choose, but instead place their trust in referring physicians and local hospitals. Additionally, many patients feel that they are not capable of making informed choices. If patients cannot or do not want to choose their healthcare providers, then one of the mainstays of a market-based health care system should perhaps be seriously re-evaluated.

Cluster Analysis to Identify Possible Subgroups in Tinnitus Patients.

PubMed

van den Berge, Minke J C; Free, Rolien H; Arnold, Rosemarie; de Kleine, Emile; Hofman, Rutger; van Dijk, J Marc C; van Dijk, Pim

2017-01-01

In tinnitus treatment, there is a tendency to shift from a "one size fits all" to a more individual, patient-tailored approach. Insight in the heterogeneity of the tinnitus spectrum might improve the management of tinnitus patients in terms of choice of treatment and identification of patients with severe mental distress. The goal of this study was to identify subgroups in a large group of tinnitus patients. Data were collected from patients with severe tinnitus complaints visiting our tertiary referral tinnitus care group at the University Medical Center Groningen. Patient-reported and physician-reported variables were collected during their visit to our clinic. Cluster analyses were used to characterize subgroups. For the selection of the right variables to enter in the cluster analysis, two approaches were used: (1) variable reduction with principle component analysis and (2) variable selection based on expert opinion. Various variables of 1,783 tinnitus patients were included in the analyses. Cluster analysis (1) included 976 patients and resulted in a four-cluster solution. The effect of external influences was the most discriminative between the groups, or clusters, of patients. The "silhouette measure" of the cluster outcome was low (0.2), indicating a "no substantial" cluster structure. Cluster analysis (2) included 761 patients and resulted in a three-cluster solution, comparable to the first analysis. Again, a "no substantial" cluster structure was found (0.2). Two cluster analyses on a large database of tinnitus patients revealed that clusters of patients are mostly formed by a different response of external influences on their disease. However, both cluster outcomes based on this dataset showed a poor stability, suggesting that our tinnitus population comprises a continuum rather than a number of clearly defined subgroups.

An Excel-Based System to Manage Radiation Safety for the Family of Patients Undergoing 131I Therapy.

PubMed

Steward, Palmer G

2017-06-01

The purpose of this study was to develop spreadsheet workbooks that assist in the radiation safety counseling of 131 I therapy patients and their families, providing individualized guidelines that avoid imposing overly conservative restrictions on family members and others. Methods: The mathematic model included biphasic patient radionuclide retention. The extrathyroidal component was a cylindric volume with a diameter corresponding to the patient's size and included patient self-absorption, whereas the thyroidal component was a point source whose transmission was reduced by self-absorption. A separate model in which the thyroid, extrathyroid, and bladder compartments fed serially from one to the next was developed to depict the radionuclide levels within the patient and to estimate the activity entering the environment at each urination. Results: The system was organized into a set of 4 workbooks: the first to be used with ablation patients prepared using thyrogen, the second with ablation patients prepared by deprivation, the third with hyperthyroid patients, and the fourth with the unusual hyperthyroid patient who finds the restrictions to be oppressive and returns 5-10 d after administration for a measurement and reassessment. The workbooks evaluated the radiation field strength external to the patient and indicated restrictions based on selected dose limits. To assist physicians in suggesting contamination precautions, the workbooks also evaluated the radioactivity present within the patient and the estimated discharge into the environment as a function of time. Conclusion: The workbooks that were developed assist the radiation safety counselor in individualizing radiation protection procedures for the family of patients undergoing 131 I therapy. The workbook system avoids overly conservative assumptions while permitting selection of appropriate dose limits for each individual. © 2017 by the Society of Nuclear Medicine and Molecular Imaging.

Locoregional control of tongue base adenoid cystic carcinoma with primary resection and radial forearm free flap reconstruction.

PubMed

Yarlagadda, Bharat B; Meier, Josh C; Lin, Derrick T; Emerick, Kevin S; Deschler, Daniel G

2017-01-01

Adenoid cystic carcinoma of the minor salivary glands can be challenging and marked by high rates of local recurrence despite appropriate surgical resection. Management of this pathology in the base of the tongue is particularly difficult given the poor functional outcomes traditionally associated with an aggressive surgical approach. This article presents a case series of patients who underwent up-front surgical resection followed by free tissue transfer reconstruction. A retrospective analysis was performed of patients with adenoid cystic carcinoma of the base of the tongue who underwent composite resection and reconstruction with a radial forearm free flap. Three patients met inclusion criteria and underwent analysis. All patients achieved locoregional control after at least 4 years of surveillance. In addition, all patients were decannulated and were swallowing without the need for gastrostomy tube feeding. This series demonstrates that for select patients with adenoid cystic carcinoma of the base of the tongue, excellent locoregional control can be achieved with acceptable functional outcomes and prolonged survival when appropriate reconstructive measures are employed.

Patient reported outcome measures (PROMs) for goalsetting and outcome measurement in primary care physiotherapy, an explorative field study.

PubMed

van Dulmen, Simone A; van der Wees, Philip J; Bart Staal, J; Braspenning, J C C; Nijhuis-van der Sanden, Maria W G

2017-03-01

Routine use of patient reported outcome measures (PROMs) may provide an effective way of monitoring patient valued outcomes. In this study we explored (1) the current use of PROMs; (2) to what extent the goals correspond with the selected PROMs; (3) the health outcomes based on PROMs. Observational clinical cohort study. Dutch primary care physiotherapy practices (n=43). Patients (n=299) with neck pain or low back pain. The number of PROMs used per patient were calculated. The International Classification of Functioning, Disability and Health was used to map the patients' goals and the percentages of PROMS selected that match the domains of the goals were calculated. Health outcomes were assessed using two approaches for estimating the minimal clinically important difference (MCID). Repeated measurements with the Visual Analogue Scale, the Patient Specific Complaints questionnaire, the Quebec Back Pain Disability Scale, or the Neck Disability Index were completed by more than 60% of the patients. The PROMs used matched in 46% of the cases with goals for pain improvement, and in 43% with goals set at activity/participation level. The mean differences between baseline and follow up scores for all PROMs were statistically significant. Improvements of patients based on MCID varied from 57% to 90%. PROMs were used in the majority of the patients, showed improved health outcomes and fitted moderately with goals. The results of this study can be used for future research assessing the routine use of outcome measurements with PROMs. Copyright © 2016 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

Cohort Selection and Management Application Leveraging Standards-based Semantic Interoperability and a Groovy DSL

PubMed Central

Bucur, Anca; van Leeuwen, Jasper; Chen, Njin-Zu; Claerhout, Brecht; de Schepper, Kristof; Perez-Rey, David; Paraiso-Medina, Sergio; Alonso-Calvo, Raul; Mehta, Keyur; Krykwinski, Cyril

2016-01-01

This paper describes a new Cohort Selection application implemented to support streamlining the definition phase of multi-centric clinical research in oncology. Our approach aims at both ease of use and precision in defining the selection filters expressing the characteristics of the desired population. The application leverages our standards-based Semantic Interoperability Solution and a Groovy DSL to provide high expressiveness in the definition of filters and flexibility in their composition into complex selection graphs including splits and merges. Widely-adopted ontologies such as SNOMED-CT are used to represent the semantics of the data and to express concepts in the application filters, facilitating data sharing and collaboration on joint research questions in large communities of clinical users. The application supports patient data exploration and efficient collaboration in multi-site, heterogeneous and distributed data environments. PMID:27570644

Outpatient desensitization in selected patients with platinum hypersensitivity reactions.

PubMed

O'Malley, David M; Vetter, Monica Hagan; Cohn, David E; Khan, Ambar; Hays, John L

2017-06-01

Platinum-based chemotherapies are a standard treatment for both initial and recurrent gynecologic cancers. Given this widespread use, it is important to be aware of the features of platinum hypersensitivity reactions and the subsequent treatment of these reactions. There is also increasing interest in the development of desensitization protocols to allow patients with a history of platinum hypersensitivity to receive further platinum based therapy. In this review, we describe the management of platinum hypersensitivity reactions and the desensitization protocols utilized at our institution. We also describe the clinical categorizations utilized to triage patients to appropriate desensitization protocols. Copyright © 2017 Elsevier Inc. All rights reserved.

Tool use and mechanical problem solving in apraxia.

PubMed

Goldenberg, G; Hagmann, S

1998-07-01

Moorlaas (1928) proposed that apraxic patients can identify objects and can remember the purpose they have been made for but do not know the way in which they must be used to achieve that purpose. Knowledge about the use of objects and tools can have two sources: It can be based on retrieval of instructions of use from semantic memory or on a direct inference of function from structure. The ability to infer function from structure enables subjects to use unfamiliar tools and to detect alternative uses of familiar tools. It is the basis of mechanical problem solving. The purpose of the present study was to analyze retrieval of instruction of use, mechanical problem solving, and actual tool use in patients with apraxia due to circumscribed lesions of the left hemisphere. For assessing mechanical problem solving we developed a test of selection and application of novel tools. Access to instruction of use was tested by pantomime of tool use. Actual tool use was examined for the same familiar tools. Forty two patients with left brain damage (LBD) and aphasia, 22 patients with right brain damage (RBD) and 22 controls were examined. Only LBD patients differed from controls on all tests. RBD patients had difficulties with the use but not with the selection of novel tools. In LBD patients there was a significant correlation between pantomime of tool use and novel tool selection but there were single cases who scored in the defective range on one of these tests and normally on the other. Analysis of LBD patients' lesions suggested that frontal lobe damage does not disturb novel tool selection. Only LBD patients who failed on pantomime of object use and on novel tool selection committed errors in actual use of familiar tools. The finding that mechanical problem solving is invariably defective in apraxic patients who commit errors with familiar tools is in good accord with clinical observations, as the gravity of their errors goes beyond what one would expect as a mere sequel of loss of access to instruction of use.

Treatment and Prognosis of Isolated Local Relapse after Stereotactic Body Radiotherapy for Clinical Stage I Non-Small-Cell Lung Cancer: Importance of Salvage Surgery.

PubMed

Hamaji, Masatsugu; Chen, Fengshi; Matsuo, Yukinori; Ueki, Nami; Hiraoka, Masahiro; Date, Hiroshi

2015-11-01

Many efforts have been made to detect local relapse (LR) in the follow-up after stereotactic body radiotherapy (SBRT) for non-small-cell lung cancer (NSCLC) although limited data are available on its treatment and prognosis. We aimed to characterize treatment options and clarify long-term outcomes of isolated LR after SBRT for patients with clinical stage I NSCLC. We reviewed our institutional database in search of patients with isolated LR after SBRT for clinical stage I NSCLC at our institution between 1999 and 2013. Patient characteristics were compared with Mann-Whitney U test, χ2 test, or Fisher's exact test as appropriate. Survival outcomes were estimated with Kaplan-Meier method. Potential prognostic factors were investigated using Cox proportional hazard model. Of 308 patients undergoing SBRT for clinical stage I NSCLC, 49 patients were identified to have isolated LR. Twelve patients underwent salvage surgery, none underwent radiotherapy, and eight patients received chemotherapy, whereas 29 patients received best supportive care. No patient characteristic except operability was significantly related with patient selection for LR treatments. Five-year overall survival (OS) rate of the whole cohort was 47.9% from SBRT and 25.7% from LR. Salvage surgery was associated with improved OS after LR (p = 0.014), and 5-year OS for patients undergoing salvage surgery was 79.5% from LR. It was confirmed that our patient selection for salvage surgery for isolated LR was associated with favorable survival outcomes. Operability based on multidisciplinary conferences, rather than measurable patient characteristics, is essential for appropriate patient selection for salvage surgery.

Mortality in perforated peptic ulcer patients after selective management of stratified poor risk cases.

PubMed

Rahman, M Mizanur; Islam, M Saiful; Flora, Sabrina; Akhter, S Fariduddin; Hossain, Shahid; Karim, Fazlul

2007-12-01

Perforated peptic ulcer disease continues to inflict high morbidity and mortality. Although patients can be stratified according to their surgical risk, optimal management has yet to be described. In this study we demonstrate a treatment option that improves the mortality among critically ill, poor risk patients with perforated peptic ulcer disease. In our study, two series were retrospectively reviewed: group A patients (n = 522) were treated in a single surgical unit at the Dhaka Medical College Hospital, Dhaka, Bangladesh during the 1980s. Among them, 124 patients were stratified as poor risk based on age, delayed presentation, peritoneal contamination, and coexisting medical problems. These criteria were the basis for selecting a group of poor risk patients (n = 84) for minimal surgical intervention (percutaneous peritoneal drainage) out of a larger group of patients, group B (n = 785) treated at Khulna Medical College Hospital during the 1990s. In group A, 479 patients underwent conventional operative management with an operative mortality of 8.97%. Among the 43 deaths, 24 patients were >60 years of age (55.8%), 12 patients had delayed presentation (27.9%), and 7 patients were in shock or had multiple coexisting medical problems (16.2%). In group B, 626 underwent conventional operative management, with 26 deaths at a mortality rate of 4.15%. Altogether, 84 patients were stratified as poor risk and were managed with minimal surgical intervention (percutaneous peritoneal drainage) followed by conservative treatment. Three of these patients died with an operative mortality of 3.5%. Minimal surgical intervention (percutaneous peritoneal drainage) can significantly lower the mortality rate among a selected group of critically ill, poor risk patients with perforated peptic ulcer disease.

Emergency Kausch-Whipple procedure: indications and experiences.

PubMed

Standop, Jens; Glowka, Tim; Schmitz, Volker; Schaefer, Nico; Hirner, Andreas; Kalff, Jörg C

2010-03-01

Pancreaticoduodenectomy is a demanding procedure even in selected patients but becomes formidable when performed in cases of emergency. This study analyzed our experience with urgent pancreatoduodenectomies; special emphases were put on the evaluation of diagnostic means and the validation of existing indications for performance of this procedure. Three hundred one patients who underwent pancreatoduodenectomy between 1989 and 2008 were identified from a pancreatic resection database and reviewed for emergency indications. Six patients (2%) underwent emergency pancreatoduodenectomy. Indications included endoscopy-related perforation, postoperative complications, and uncontrollable intraduodenal tumor bleeding. Length of stay and occurrence of nonsurgical complications were increased in emergency compared with elective pancreatoduodenectomies. Although increased, no significant differences were found regarding mortality and surgery-related complications. Indications for emergency pancreatoduodenectomies were based on clinical decisions rather than on radiologic diagnostics. Urgent pancreatic head resections may be considered as an option in selected patients if handling of local complications by interventional measures or limited surgery seems unsafe.

Sacubitril/Valsartan: From Clinical Trials to Real-world Experience.

PubMed

Joly, Joanna M; Desai, Akshay S

2018-04-23

Compared to enalapril, use of angiotensin-receptor blocker and neprilysin inhibitor sacubitril/valsartan to treat patients with heart failure and reduced ejection fraction (HFrEF) is associated with substantial reductions in both cardiovascular mortality and heart failure progression. The purpose of this review is to discuss the real-world experience of sacubitril/valsartan. In the years following the publication of the landmark PARADIGM-HF trial in 2014 and its subsequent FDA approval, a growing evidence base supports the safety and efficacy of sacubitril/valsartan in a broad spectrum of patients with HFrEF. Updated clinical practice guidelines have embraced the use of sacubitril/valsartan in preference to ACE inhibitors or ARBs in selected patients. In this review, we highlight the clinical trials that led to these key updates to clinical guidelines, offer practical strategies for patient selection and utilization in clinical practice, and identify important areas of uncertainty that require future research.

Carotid Artery Stenting – Strategies to Improve Procedural Performance and Reduce the Learning Curve

PubMed Central

Van Herzeele, Isabelle

2013-01-01

Carotid artery stenting (CAS) remains an appealing intervention to reduce the stroke risk because of its minimal invasive nature. Nevertheless, landmark randomised controlled trials have not been able to resolve the controversies surrounding this complex procedure as the peri-operative stroke risk in a non-selected patient population still seems to be higher after CAS in comparison to carotid endarterectomy. What is more, these trials have highlighted that patient outcome after CAS is influenced by patient- and operator-dependant factors. The CAS procedure exhibits a definitive learning curve resulting in higher complication rates if the procedure is performed by inexperienced interventionists or in low-volume centres. This article will outline strategies to improve the performance of physicians carrying out the CAS procedure by means of proficiency-based training, credentialing, virtual reality rehearsal and optimal patient selection. PMID:29588751

Fracture risk assessment: improved evaluation of vertebral integrity among metastatic cancer patients to aid in surgical decision-making

NASA Astrophysics Data System (ADS)

Augustine, Kurt E.; Camp, Jon J.; Holmes, David R.; Huddleston, Paul M.; Lu, Lichun; Yaszemski, Michael J.; Robb, Richard A.

2012-03-01

Failure of the spine's structural integrity from metastatic disease can lead to both pain and neurologic deficit. Fractures that require treatment occur in over 30% of bony metastases. Our objective is to use computed tomography (CT) in conjunction with analytic techniques that have been previously developed to predict fracture risk in cancer patients with metastatic disease to the spine. Current clinical practice for cancer patients with spine metastasis often requires an empirical decision regarding spinal reconstructive surgery. Early image-based software systems used for CT analysis are time consuming and poorly suited for clinical application. The Biomedical Image Resource (BIR) at Mayo Clinic, Rochester has developed an image analysis computer program that calculates from CT scans, the residual load-bearing capacity in a vertebra with metastatic cancer. The Spine Cancer Assessment (SCA) program is built on a platform designed for clinical practice, with a workflow format that allows for rapid selection of patient CT exams, followed by guided image analysis tasks, resulting in a fracture risk report. The analysis features allow the surgeon to quickly isolate a single vertebra and obtain an immediate pre-surgical multiple parallel section composite beam fracture risk analysis based on algorithms developed at Mayo Clinic. The analysis software is undergoing clinical validation studies. We expect this approach will facilitate patient management and utilization of reliable guidelines for selecting among various treatment option based on fracture risk.

Optimizing physician access to surgical intensive care unit laboratory information through mobile computing.

PubMed

Strain, J J; Felciano, R M; Seiver, A; Acuff, R; Fagan, L

1996-01-01

Approximately 30 minutes of computer access time are required by surgical residents at Stanford University Medical Center (SUMC) to examine the lab values of all patients on a surgical intensive care unit (ICU) service, a task that must be performed several times a day. To reduce the time accessing this information and simultaneously increase the readability and currency of the data, we have created a mobile, pen-based user interface and software system that delivers lab results to surgeons in the ICU. The ScroungeMaster system, loaded on a portable tablet computer, retrieves lab results for a subset of patients from the central laboratory computer and stores them in a local database cache. The cache can be updated on command; this update takes approximately 2.7 minutes for all ICU patients being followed by the surgeon, and can be performed as a background task while the user continues to access selected lab results. The user interface presents lab results according to physiologic system. Which labs are displayed first is governed by a layout selection algorithm based on previous accesses to the patient's lab information, physician preferences, and the nature of the patient's medical condition. Initial evaluation of the system has shown that physicians prefer the ScroungeMaster interface to that of existing systems at SUMC and are satisfied with the system's performance. We discuss the evolution of ScroungeMaster and make observations on changes to physician work flow with the presence of mobile, pen-based computing in the ICU.

[Treatment for locally advanced prostate cancer: value of surgery].

PubMed

Azuma, Haruhito; Katsuoka, Yoji

2006-06-01

Surgical therapy is not only a therapeutic method but also an important procedure to provide useful information in determining a postoperative treatment strategy. Compared with postoperative cancer staging based on specimens obtained during surgery, more than 30% of cancers were inaccurately staged preoperatively, even when a current advanced diagnostic imaging technique was used. Compared with postoperative histological 30-40% of cancer staging were inaccurately staged based on a preoperative biopsy. These misstaging cases pose a significantly important problem. Approximately 15% and 30% of clinical stage C prostate cancers have been rated as pT2 and pN(+), respectively. Patients with pT3 prostate cancer who underwent radical prostatectomy had 5-year and 10-year overall survival rates of 82% and 67%, respectively, which were comparable to those in patients with pT2 prostate cancer (82% and 67%, respectively). However, patients with prostate cancer rated as pT4 and pN(+) had very poor outcomes with 5-year overall survival rates of 42.4% and 32.6%, respectively. Therefore, even in patients with stage C prostate cancer, surgical therapy should be recommended if no infiltration of adjacent tissue has been noted and the operation is applicable; and an optimal postoperative therapeutic strategy should be selected based on the accurate pathological staging and histological grading using postoperative pathological specimens. Such approaches will prevent unnecessary hormone therapy in patients with pT2 prostate cancer and prevent missing optimal timing for radical cure, as well as allowing appropriate therapy to be selected for patients with pT4 and pN(+) prostate cancer, for whom prognosis may be poor.

Mathematical Modelling for Patient Selection in Proton Therapy.

PubMed

Mee, T; Kirkby, N F; Kirkby, K J

2018-05-01

Proton beam therapy (PBT) is still relatively new in cancer treatment and the clinical evidence base is relatively sparse. Mathematical modelling offers assistance when selecting patients for PBT and predicting the demand for service. Discrete event simulation, normal tissue complication probability, quality-adjusted life-years and Markov Chain models are all mathematical and statistical modelling techniques currently used but none is dominant. As new evidence and outcome data become available from PBT, comprehensive models will emerge that are less dependent on the specific technologies of radiotherapy planning and delivery. Copyright © 2018 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Precision Medicine in Cancer Treatment

Cancer.gov

Precision medicine helps doctors select cancer treatments that are most likely to help patients based on a genetic understanding of their disease. Learn about the promise of precision medicine and the role it plays in cancer treatment.

Alteration of histological gastritis after cure of Helicobacter pylori infection.

PubMed

Hojo, M; Miwa, H; Ohkusa, T; Ohkura, R; Kurosawa, A; Sato, N

2002-11-01

It is still disputed whether gastric atrophy or intestinal metaplasia improves after the cure of Helicobacter pylori infection. To clarify the histological changes after the cure of H. pylori infection through a literature survey. Fifty-one selected reports from 1066 relevant articles were reviewed. The extracted data were pooled according to histological parameters of gastritis based on the (updated) Sydney system. Activity improved more rapidly than inflammation. Eleven of 25 reports described significant improvement of atrophy. Atrophy was not improved in one of four studies with a large sample size (> 100 samples) and in two of five studies with a long follow-up period (> 12 months), suggesting that disagreement between the studies was not totally due to sample size or follow-up period. Methodological flaws, such as patient selection, and statistical analysis based on the assumption that atrophy improves continuously and generally in all patients might be responsible for the inconsistent results. Four of 28 studies described significant improvement of intestinal metaplasia [corrected]. Activity and inflammation were improved after the cure of H. pylori infection. Atrophy did not improve generally among all patients, but improved in certain patients. Improvement of intestinal metaplasia was difficult to analyse due to methodological problems including statistical power.

Towards an optimal treatment algorithm for metastatic pancreatic ductal adenocarcinoma (PDA)

PubMed Central

Uccello, M.; Moschetta, M.; Mak, G.; Alam, T.; Henriquez, C. Murias; Arkenau, H.-T.

2018-01-01

Chemotherapy remains the mainstay of treatment for advanced pancreatic ductal adenocarcinoma (pda). Two randomized trials have demonstrated superiority of the combination regimens folfirinox (5-fluorouracil, leucovorin, oxaliplatin, and irinotecan) and gemcitabine plus nab-paclitaxel over gemcitabine monotherapy as a first-line treatment in adequately fit subjects. Selected pda patients progressing to first-line therapy can receive secondline treatment with moderate clinical benefit. Nevertheless, the optimal algorithm and the role of combination therapy in second-line are still unclear. Published second-line pda clinical trials enrolled patients progressing to gemcitabine-based therapies in use before the approval of nab-paclitaxel and folfirinox. The evolving scenario in second-line may affect the choice of the first-line treatment. For example, nanoliposomal irinotecan plus 5-fluouracil and leucovorin is a novel second-line option which will be suitable only for patients progressing to gemcitabine-based therapy. Therefore, clinical judgement and appropriate patient selection remain key elements in treatment decision. In this review, we aim to illustrate currently available options and define a possible algorithm to guide treatment choice. Future clinical trials taking into account sequential treatment as a new paradigm in pda will help define a standard algorithm. PMID:29507500

Alternative Treatment in Prostate Pain Syndrome Based on Iranian Traditional Medicine

PubMed Central

Latifi, Seied Amirhossein; Kamalinejad, Mohammad; Minaiee, Bagher; Bahrami, Mohsen; Gooran, Shahram; Nikbakht Nasrabadi, Alireza

2014-01-01

Introduction: Unknown etiology and pathophysiology of prostate pain syndrome (PPS) has led to a lack of proper and competent treatment in modern medicine. According to the guidelines of European Association of Urology (EAU), use of complementary treatments is recommended for PPS. In this preliminary study, analyzing the signs and symptoms of PPS from the viewpoint of Iranian traditional medicine (ITM) was helpful in selecting the appropriate alternative treatment. Case Presentation: Two male patients diagnosed with PPS were evaluated and treated according to the ITM. Each patient took 15 mL oxymel 45 minutes after lunch and dinner. For each patient, four clinical visits were made with one week intervals and the validated Farsi version of international prostate symptom score (IPSS) and numeric pain rating score (NPRS) were completed for them. Conclusions: Considering the fact that other major pathological causes are ruled out, many of the symptoms and signs observed in these patients were similar to those associated with flatulency-related diseases in ITM. Selecting treatment with oxymel was based on this view and led to improvements in the digestive and urinary symptoms according to Farsi version of the IPSS and NPRS. PMID:25237573

Cost Analysis of Selected Patient Categories within a Dermatology Department Using an ABC Approach

PubMed Central

Papadaki, Šárka; Popesko, Boris

2016-01-01

Background: Present trends in hospital management are facilitating the utilization of more accurate costing methods, which potentially results in superior cost-related information and improved managerial decision-making. However, the Activity-Based Costing method (ABC), which was designed for cost allocation purposes in the 1980s, is not widely used by healthcare organizations. This study analyzes costs related to selected categories of patients, those suffering from psoriasis, varicose ulcers, eczema and other conditions, within a dermatology department at a Czech regional hospital. Methods: The study was conducted in a hospital department where both inpatient and outpatient care are offered. Firstly, the diseases treated at the department were identified. Further costs were determined for each activity using ABC. The study utilized data from managerial and financial accounting, as well as data obtained through interviews with departmental staff. Using a defined cost-allocation procedure makes it possible to determine the cost of an individual patient with a given disease more accurately than via traditional costing procedures. Results: The cost analysis focused on the differences between the costs related to individual patients within the selected diagnoses, variations between inpatient and outpatient treatments and the costs of activities performed by the dermatology department. Furthermore, comparing the costs identified through this approach and the revenue stemming from the health insurance system is an option. Conclusions: Activity-Based Costing is more accurate and relevant than the traditional costing method. The outputs of ABC provide an abundance of additional information for managers. The benefits of this research lie in its practically-tested outputs, resulting from calculating the costs of hospitalization, which could prove invaluable to persons involved in hospital management and decision-making. The study also defines the managerial implications of the performed cost analysis for the hospital management. Based on the analysis results, it is possible to standardize activities and performance appraisal (Benchmarking), and provide all necessary information for hospital budgeting practices, especially Activity-Based Budgeting (ABB). PMID:26755477

Cost Analysis of Selected Patient Categories Within A Dermatology Department Using an ABC Approach.

PubMed

Papadaki, Šárka; Popesko, Boris

2015-11-17

Present trends in hospital management are facilitating the utilization of more accurate costing methods, which potentially results in superior cost-related information and improved managerial decision-making. However, the Activity-Based Costing method (ABC), which was designed for cost allocation purposes in the 1980s, is not widely used by healthcare organizations. This study analyzes costs related to selected categories of patients, those suffering from psoriasis, varicose ulcers, eczema and other conditions, within a dermatology department at a Czech regional hospital. The study was conducted in a hospital department where both inpatient and outpatient care are offered. Firstly, the diseases treated at the department were identified. Further costs were determined for each activity using ABC. The study utilized data from managerial and financial accounting, as well as data obtained through interviews with departmental staff. Using a defined cost-allocation procedure makes it possible to determine the cost of an individual patient with a given disease more accurately than via traditional costing procedures. The cost analysis focused on the differences between the costs related to individual patients within the selected diagnoses, variations between inpatient and outpatient treatments and the costs of activities performed by the dermatology department. Furthermore, comparing the costs identified through this approach and the revenue stemming from the health insurance system is an option. Activity-Based Costing is more accurate and relevant than the traditional costing method. The outputs of ABC provide an abundance of additional information for managers. The benefits of this research lie in its practically-tested outputs, resulting from calculating the costs of hospitalization, which could prove invaluable to persons involved in hospital management and decision-making. The study also defines the managerial implications of the performed cost analysis for the hospital management. Based on the analysis results, it is possible to standardize activities and performance appraisal (Benchmarking), and provide all necessary information for hospital budgeting practices, especially Activity-Based Budgeting (ABB).

Relationship between obsessive-compulsive personality disorder and obsessive-compulsive disorder.

PubMed

Diaferia, G; Bianchi, I; Bianchi, M L; Cavedini, P; Erzegovesi, S; Bellodi, L

1997-01-01

This study investigated the presence of obsessive-compulsive personality disorder (OCPD) in a group of 277 patients (88 with obsessive-compulsive disorder [OCD], 58 with major depressive disorder [MDD], and 131 with panic disorder [Panic]) to test the specificity of the relationship between OCPD and OCD. OCPD is statistically significantly more frequent in patients with OCD than in those with Panic and MDD. The distribution of single criteria of OCPD in the three groups does not differ significantly. Discriminant analysis selects a list of items that provide a correct classification rate of 66% based on OCPD criteria selected by canonical function. OCD patients with and without OCPD do not differ in sex, age of onset, duration of illness, positive family history for Tics disorder/Tourette syndrome (TS), or morbidity risk for OCD.

Cost-effectiveness of lower extremity compression ultrasound in emergency department patients with a high risk of hemodynamically stable pulmonary embolism.

PubMed

Ward, Michael J; Sodickson, Aaron; Diercks, Deborah B; Raja, Ali S

2011-01-01

Computed tomography angiograms (CTAs) for patients with suspected pulmonary embolism (PE) are being ordered with increasing frequency from the emergency department (ED). Strategies are needed to safely decrease the utilization of CTs to control rising health care costs and minimize the associated risks of anaphylaxis, contrast-induced nephropathy, and radiation-induced carcinogenesis. The use of compression ultrasonography (US) to identify deep vein thromboses (DVTs) in hemodynamically stable patients with signs and symptoms suggestive of PE is highly specific for the diagnosis of PE and may represent a cost-effective alternative to CT imaging.   The objective was to analyze the cost-effectiveness of a selective CT strategy incorporating the use of compression US to diagnose and treat DVT in patients with a high pretest probability of PE. The authors constructed a decision analytic model to evaluate the scenario of an otherwise healthy 59-year-old female in whom PE was being considered as a diagnosis. Two strategies were used. The selective CT strategy began with a screening compression US. Negative studies were followed up with a CTA, while patients with positive studies identifying a DVT were treated as though they had a PE and were anticoagulated. The universal CT strategy used CTA as the initial test, and anticoagulation was based on the CT result. Costs were estimated from the 2009 Medicare data for hospital reimbursement, and professional fees were obtained from the 2009 National Physician Fee Schedule. Clinical probabilities were obtained from existing published data, and sensitivity analyses were performed across plausible ranges for all clinical variables. In the base case, the selective CT strategy cost $1,457.70 less than the universal CT strategy and resulted in a gain of 0.0213 quality-adjusted life-years (QALYs). Sensitivity analyses confirm that the selective CT strategy is dominant above both a pretest probability for PE of 8.3% and a compression US specificity of 87.4%. A selective CT strategy using compression US is cost-effective for patients provided they have a high pretest probability of PE. This may reduce the need for, and decrease the adverse events associated with, CTAs. © 2010 by the Society for Academic Emergency Medicine.

A Focus Group Exploration of Automated Case-Finders to Identify High-Risk Heart Failure Patients Within an Urban Safety Net Hospital.

PubMed

Patterson, Mark E; Miranda, Derick; Schuman, Greg; Eaton, Christopher; Smith, Andrew; Silver, Brad

2016-01-01

Leveraging "big data" as a means of informing cost-effective care holds potential in triaging high-risk heart failure (HF) patients for interventions within hospitals seeking to reduce 30-day readmissions. Explore provider's beliefs and perceptions about using an electronic health record (EHR)-based tool that uses unstructured clinical notes to risk-stratify high-risk heart failure patients. Six providers from an inpatient HF clinic within an urban safety net hospital were recruited to participate in a semistructured focus group. A facilitator led a discussion on the feasibility and value of using an EHR tool driven by unstructured clinical notes to help identify high-risk patients. Data collected from transcripts were analyzed using a thematic analysis that facilitated drawing conclusions clustered around categories and themes. From six categories emerged two themes: (1) challenges of finding valid and accurate results, and (2) strategies used to overcome these challenges. Although employing a tool that uses electronic medical record (EMR) unstructured text as the benchmark by which to identify high-risk patients is efficient, choosing appropriate benchmark groups could be challenging given the multiple causes of readmission. Strategies to mitigate these challenges include establishing clear selection criteria to guide benchmark group composition, and quality outcome goals for the hospital. Prior to implementing into practice an innovative EMR-based case-finder driven by unstructured clinical notes, providers are advised to do the following: (1) define patient quality outcome goals, (2) establish criteria by which to guide benchmark selection, and (3) verify the tool's validity and reliability. Achieving consensus on these issues would be necessary for this innovative EHR-based tool to effectively improve clinical decision-making and in turn, decrease readmissions for high-risk patients.

Developing a Tool for Increasing the Awareness about Gendered and Intersectional Processes in the Clinical Assessment of Patients--A Study of Pain Rehabilitation.

PubMed

Hammarström, Anne; Wiklund, Maria; Stålnacke, Britt-Marie; Lehti, Arja; Haukenes, Inger; Fjellman-Wiklund, Anncristine

2016-01-01

There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation. In the overarching project named "Equal care in rehabilitation" we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes. The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age. The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias. Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level.

Developing a Tool for Increasing the Awareness about Gendered and Intersectional Processes in the Clinical Assessment of Patients – A Study of Pain Rehabilitation

PubMed Central

Hammarström, Anne; Wiklund, Maria; Stålnacke, Britt-Marie; Lehti, Arja; Haukenes, Inger; Fjellman-Wiklund, Anncristine

2016-01-01

Objective There is a need for tools addressing gender inequality in the everyday clinical work in health care. The aim of our paper was to develop a tool for increasing the awareness of gendered and intersectional processes in clinical assessment of patients, based on a study of pain rehabilitation. Methods In the overarching project named “Equal care in rehabilitation” we used multiple methods (both quantitative and qualitative) in five sub studies. With a novel approach we used Grounded Theory in order to synthesize the results from our sub studies, in order to develop the gender equality tool. The gender equality tool described and developed in this article is thus based on results from sub studies about the processes of assessment and selection of patients in pain rehabilitation. Inspired by some questions in earlier tools, we posed open ended questions and inductively searched for findings and concepts relating to gendered and social selection processes in pain rehabilitation, in each of our sub studies. Through this process, the actual gender equality tool was developed as 15 questions about the process of assessing and selecting patients to pain rehabilitation. As a more comprehensive way of understanding the tool, we performed a final step of the GT analyses. Here we synthesized the results of the tool into a comprehensive model with two dimensions in relation to several possible discrimination axes. Results The process of assessing and selecting patients was visualized as a funnel, a top down process governed by gendered attitudes, rules and structures. We found that the clinicians judged inner and outer characteristics and status of patients in a gendered and intersectional way in the process of clinical decision-making which thus can be regarded as (potentially) biased with regard to gender, socio-economic status, ethnicity and age. Implications The clinical implications of our tool are that the tool can be included in the systematic routine of clinical assessment of patients for both awareness raising and as a base for avoiding gender bias in clinical decision-making. The tool could also be used in team education for health professionals as an instrument for critical reflection on gender bias. Conclusions Thus, tools for clinical assessment can be developed from empirical studies in various clinical settings. However, such a micro-level approach must be understood from a broader societal perspective including gender relations on both the macro- and the meso-level. PMID:27055029

Risk factors for treatment default among re-treatment tuberculosis patients in India, 2006.

PubMed

Jha, Ugra Mohan; Satyanarayana, Srinath; Dewan, Puneet K; Chadha, Sarabjit; Wares, Fraser; Sahu, Suvanand; Gupta, Devesh; Chauhan, L S

2010-01-25

Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment. To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients. For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters. 1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%-75% interquartile range 44-117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2-1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1-1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0-1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1-1.6). Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pre-treatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening.

Acute Anticholinesterase Pesticide Poisoning Caused a Long-Term Mortality Increase: A Nationwide Population-Based Cohort Study.

PubMed

Huang, Hung-Sheng; Hsu, Chien-Chin; Weng, Shih-Feng; Lin, Hung-Jung; Wang, Jhi-Joung; Su, Shih-Bin; Huang, Chien-Cheng; Guo, How-Ran

2015-07-01

Acute anticholinesterase pesticide (organophosphate and carbamate) poisoning (ACPP) often produces severe complications, and sometimes death. We investigated the long-term mortality of patients with ACPP because it is not sufficiently understood. In this retrospective nationwide population-based cohort study, 818 patients with ACPP and 16,360 healthy comparisons from 1999 to 2010 were selected from Taiwan's National Health Insurance Research Database. They were followed until 2011. Ninety-four (11.5%) ACPP patients and 793 (4.9%) comparisons died (P < 0.01) during follow-up. The incidence rate ratios (IRRs) of death were 2.5 times higher in ACPP patients than in comparisons (P < 0.01). The risk of death was particularly high in the first month after ACPP (IRR: 92.7; 95% confidence interval [CI]: 45.0-191.0) and still high for ~6 months (IRR: 3.8; 95% CI: 1.9-7.4). After adjusting for age, gender, selected comorbidities, geographic area, and monthly income, the hazard ratio of death for ACPP patients was still 2.4 times higher than for comparisons. Older age (≥35 years), male gender, diabetes mellitus, coronary artery disease, hypertension, stroke, mental disorder, and lower monthly income also predicted death. ACPP significantly increased long-term mortality. In addition to early follow-up after acute treatment, comorbidity control and socioeconomic assistance are needed for patients with ACPP.

Treatment preferences of patients with binge eating disorder.

PubMed

Brody, Michelle L; Masheb, Robin M; Grilo, Carlos M

2005-05-01

The current study examined the treatment preferences of obese patients with binge eating disorder (BED). Participants were 103 consecutive patients with BED who responded to advertisements for treatment studies looking for persons who wanted to "stop binge eating and lose weight." In addition to completing comprehensive assessment batteries, participants were provided descriptions of cognitive-behavioral therapy (CBT) and behavioral weight loss therapy (BWL) after which they were asked to choose and rate their preferred treatment. Sixty-three percent of participants stated they preferred CBT. Treatment preferences were not associated with (1) histories of obesity, dieting, binge eating, or weight cycling, (2) current obesity or eating disorder features, or (3) psychological features such as depression or self-esteem levels. In contrast, participants' stated treatment preferences were aligned with their perception of their primary problem (eating disorder vs. obesity) and their primary goals for treatment (stop binge eating vs. lose weight). The patients who preferred CBT based their treatment selection more on their problem perception than on their primary treatment goal, whereas the patients who preferred BWL selected treatment based more on their primary treatment goal (weight loss) than on their problem perception. Obese patients with BED express treatment preferences that are not associated with variability in their clinical characteristics but are aligned with their perception of their primary problem and with their primary goals for treatment. Copyright 2005 by Wiley Periodicals, Inc

A novel computer based expert decision making model for prostate cancer disease management.

PubMed

Richman, Martin B; Forman, Ernest H; Bayazit, Yildirim; Einstein, Douglas B; Resnick, Martin I; Stovsky, Mark D

2005-12-01

We propose a strategic, computer based, prostate cancer decision making model based on the analytic hierarchy process. We developed a model that improves physician-patient joint decision making and enhances the treatment selection process by making this critical decision rational and evidence based. Two groups (patient and physician-expert) completed a clinical study comparing an initial disease management choice with the highest ranked option generated by the computer model. Participants made pairwise comparisons to derive priorities for the objectives and subobjectives related to the disease management decision. The weighted comparisons were then applied to treatment options to yield prioritized rank lists that reflect the likelihood that a given alternative will achieve the participant treatment goal. Aggregate data were evaluated by inconsistency ratio analysis and sensitivity analysis, which assessed the influence of individual objectives and subobjectives on the final rank list of treatment options. Inconsistency ratios less than 0.05 were reliably generated, indicating that judgments made within the model were mathematically rational. The aggregate prioritized list of treatment options was tabulated for the patient and physician groups with similar outcomes for the 2 groups. Analysis of the major defining objectives in the treatment selection decision demonstrated the same rank order for the patient and physician groups with cure, survival and quality of life being more important than controlling cancer, preventing major complications of treatment, preventing blood transfusion complications and limiting treatment cost. Analysis of subobjectives, including quality of life and sexual dysfunction, produced similar priority rankings for the patient and physician groups. Concordance between initial treatment choice and the highest weighted model option differed between the groups with the patient group having 59% concordance and the physician group having only 42% concordance. This study successfully validated the usefulness of a computer based prostate cancer management decision making model to produce individualized, rational, clinically appropriate disease management decisions without physician bias.

Content comparison of haemophilia specific patient-rated outcome measures with the international classification of functioning, disability and health (ICF, ICF-CY)

PubMed Central

2010-01-01

Background Patient-Reported Outcomes (PROs) are considered important outcomes because they reflect the patient's experience in clinical trials. PROs have been included in the field of haemophilia only recently. Purpose Comparing the contents of PROs measures used in haemophilia, based on the ICF/ICF-CY as frame of reference. Methods Haemophilia-specific PROs for adults and children were selected on the grounds of international accessibility. The content of the selected instruments were examined by linking the concepts within the items of these instruments to the ICF/ICF-CY. Results Within the 5 selected instruments 365 concepts were identified, of which 283 concepts were linked to the ICF/ICF CY and mapped into 70 different categories. The most frequently used categories were "b152: Emotional functions" and "e1101: Drugs". Conclusions The present paper provides an overview on current PROs in haemophilia and facilitates the selection of appropriate instruments for specific purposes in clinical and research settings. This work was made possible by the grant of the European Murinet Project (Multidisciplinary Research Network on Health and Disability in Europe). PMID:21108796

Selection of the initial design for the two-stage continual reassessment method.

PubMed

Jia, Xiaoyu; Ivanova, Anastasia; Lee, Shing M

2017-01-01

In the two-stage continual reassessment method (CRM), model-based dose escalation is preceded by a pre-specified escalating sequence starting from the lowest dose level. This is appealing to clinicians because it allows a sufficient number of patients to be assigned to each of the lower dose levels before escalating to higher dose levels. While a theoretical framework to build the two-stage CRM has been proposed, the selection of the initial dose-escalating sequence, generally referred to as the initial design, remains arbitrary, either by specifying cohorts of three patients or by trial and error through extensive simulations. Motivated by a currently ongoing oncology dose-finding study for which clinicians explicitly stated their desire to assign at least one patient to each of the lower dose levels, we proposed a systematic approach for selecting the initial design for the two-stage CRM. The initial design obtained using the proposed algorithm yields better operating characteristics compared to using a cohort of three initial design with a calibrated CRM. The proposed algorithm simplifies the selection of initial design for the two-stage CRM. Moreover, initial designs to be used as reference for planning a two-stage CRM are provided.

WebBio, a web-based management and analysis system for patient data of biological products in hospital.

PubMed

Lu, Ying-Hao; Kuo, Chen-Chun; Huang, Yaw-Bin

2011-08-01

We selected HTML, PHP and JavaScript as the programming languages to build "WebBio", a web-based system for patient data of biological products and used MySQL as database. WebBio is based on the PHP-MySQL suite and is run by Apache server on Linux machine. WebBio provides the functions of data management, searching function and data analysis for 20 kinds of biological products (plasma expanders, human immunoglobulin and hematological products). There are two particular features in WebBio: (1) pharmacists can rapidly find out whose patients used contaminated products for medication safety, and (2) the statistics charts for a specific product can be automatically generated to reduce pharmacist's work loading. WebBio has successfully turned traditional paper work into web-based data management.

Sources of drinking water in a pediatric population.

PubMed

Jadav, Urvi G; Acharya, Bhavini S; Velasquez, Gisela M; Vance, Bradley J; Tate, Robert H; Quock, Ryan L

2014-01-01

The purpose of this study was to determine the primary sources of water used for consumption and cooking by the patients of a university-based pediatric dental practice. A simple, prewritten questionnaire-consisting of seven questions and available in English and Spanish-was conducted verbally with the caregivers of 123 pediatric patients during a designated timeframe. Analysis of responses included descriptive statistics and a chi-square test for a single proportion. Nonfiltered tap water accounted for the primary drinking water source in only 10 percent of the respondents. Firty-two percent of the respondents selected bottled water as the primary source of drinking water, and 24 percent selected vended water stations as a primary drinking water source. Nonfiltered tap water was much more likely to be utilized in cooking (58 percent). The majority of the patients in this study's pediatric dental practice do not consume fluoridated tap water. With the vast majority of the patients primarily consuming bottled or vended water, these patients are likely missing out on the caries-protective effects of water fluoridation.

Cost-effective hydrocele ablation.

PubMed

Fracchia, J A; Armenakas, N A; Kohan, A D

1998-03-01

The surgical repair of hydroceles can be relatively expensive in some cases in terms of costs and initial limitation of activity. We ascertain whether aspiration and sclerotherapy of hydroceles is a safe, efficient, cost-effective treatment modality in select patients. In 47 patients 51 hydroceles were treated in the office with aspiration and instillation of a sclerosing solution based on a sodium tetradecyl sulfate preparation. One treatment was done in 14 cases and 2 in the remainder. Medicare data for 1995 were used for charge analysis. The overall success rate was 61% (34 of 51 cases) with success defined as no perceptible ipsilateral scrotal fluid reaccumulation on palpation by a physician and complete patient satisfaction. The failure rate was 39% (17 cases) with failure defined as perceptible ipsilateral scrotal fluid reaccumulation on palpation by a physician and/or patient dissatisfaction. The charge differential of surgery versus aspiration and sclerotherapy was greater than 9:1. The aspiration and sclerotherapy technique that we used appears to be an efficacious, safe, cost-effective treatment modality in select patients with idiopathic hydroceles.

Comparative Clinical Pharmacokinetics of Midodrine and Its Active Metabolite Desglymidodrine in Cirrhotic Patients with Tense Ascites Versus Healthy Volunteers.

PubMed

Ali, Ahmed; Farid, Samar; Amin, Mona; Kassem, Mohamed; Al-Garem, Nouman; Al-Ghobashy, Medhat

2016-02-01

Midodrine is an α-agonist prodrug of desglymidodrine used for the management of hypotension, and can also be used for hepatorenal syndrome and cirrhotic patients with tense ascites. The objective of the present work was to study the clinical pharmacokinetic parameters of midodrine and its active metabolite desglymidodrine in cirrhotic patients with tense ascites, which may help in dose selection and improve treatment outcome. This was a prospective, open-label, single-dose, parallel-group study. At first, a pilot study was performed on one healthy volunteer by taking serial blood samples at scheduled time intervals to validate the method of analysis and sampling times. The full study was then conducted by selecting 12 cirrhotic patients with tense ascites in one group and taking nine blood samples. We also selected five healthy volunteers as the control group and took 11 blood samples. Statistically significant differences were observed between the healthy volunteer group and the patients group in the area under the concentration versus time curve (AUC0-t) and maximum plasma concentration (Cmax) values of midodrine and desglymidodrine. Based on the results of the pharmacokinetic analysis, the patient group was further subdivided into those receiving the interacting drug ranitidine (five patients) and those not receiving the interacting drug (seven patients). Pharmacokinetic parameters of midodrine can differ significantly in cirrhotic patients with tense ascites from those in healthy individuals. Drug monitoring, dose adjustments, and drug-drug interactions should all be considered during therapy in this vulnerable patient group.

[Study of algorithms to identify schizophrenia in the SNIIRAM database conducted by the REDSIAM network].

PubMed

Quantin, C; Collin, C; Frérot, M; Besson, J; Cottenet, J; Corneloup, M; Soudry-Faure, A; Mariet, A-S; Roussot, A

2017-10-01

The aim of the REDSIAM network is to foster communication between users of French medico-administrative databases and to validate and promote analysis methods suitable for the data. Within this network, the working group "Mental and behavioral disorders" took an interest in algorithms to identify adult schizophrenia in the SNIIRAM database and inventoried identification criteria for patients with schizophrenia in these databases. The methodology was based on interviews with nine experts in schizophrenia concerning the procedures they use to identify patients with schizophrenia disorders in databases. The interviews were based on a questionnaire and conducted by telephone. The synthesis of the interviews showed that the SNIIRAM contains various tables which allow coders to identify patients suffering from schizophrenia: chronic disease status, drugs and hospitalizations. Taken separately, these criteria were not sufficient to recognize patients with schizophrenia, an algorithm should be based on all of them. Apparently, only one-third of people living with schizophrenia benefit from the longstanding disease status. Not all patients are hospitalized, and coding for diagnoses at the hospitalization, notably for short stays in medicine, surgery or obstetrics departments, is not exhaustive. As for treatment with antipsychotics, it is not specific enough as such treatments are also prescribed to patients with bipolar disorders, or even other disorders. It seems appropriate to combine these complementary criteria, while keeping in mind out-patient care (every year 80,000 patients are seen exclusively in an outpatient setting), even if these data are difficult to link with other information. Finally, the experts made three propositions for selection algorithms of patients with schizophrenia. Patients with schizophrenia can be relatively accurately identified using SNIIRAM data. Different combinations of the selected criteria must be used depending on the objectives and they must be related to an appropriate length of time. Copyright © 2017 Elsevier Masson SAS. All rights reserved.

Selected HIV-1 Env Trimeric Formulations Act as Potent Immunogens in a Rabbit Vaccination Model

PubMed Central

Heyndrickx, Leo; Stewart-Jones, Guillaume; Jansson, Marianne; Schuitemaker, Hanneke; Bowles, Emma; Buonaguro, Luigi; Grevstad, Berit; Vinner, Lasse; Vereecken, Katleen; Parker, Joe; Ramaswamy, Meghna; Biswas, Priscilla; Vanham, Guido; Scarlatti, Gabriella; Fomsgaard, Anders

2013-01-01

Background Ten to 30% of HIV-1 infected subjects develop broadly neutralizing antibodies (bNAbs) during chronic infection. We hypothesized that immunizing rabbits with viral envelope glycoproteins (Envs) from these patients may induce bNAbs, when formulated as a trimeric protein and in the presence of an adjuvant. Methods Based on in vitro neutralizing activity in serum, patients with bNAbs were selected for cloning of their HIV-1 Env. Seven stable soluble trimeric gp140 proteins were generated from sequences derived from four adults and two children infected with either clade A or B HIV-1. From one of the clade A Envs both the monomeric and trimeric Env were produced for comparison. Rabbits were immunized with soluble gp120 or trimeric gp140 proteins in combination with the adjuvant dimethyl dioctadecyl ammonium/trehalose dibehenate (CAF01). Env binding in rabbit immune serum was determined using ELISAs based on gp120-IIIB protein. Neutralizing activity of IgG purified from rabbit immune sera was measured with the pseudovirus-TZMbl assay and a PBMC-based neutralization assay for selected experiments. Results It was initially established that gp140 trimers induce better antibody responses over gp120 monomers and that the adjuvant CAF01 was necessary for such strong responses. Gp140 trimers, based on HIV-1 variants from patients with bNAbs, were able to elicit both gp120IIIB specific IgG and NAbs to Tier 1 viruses of different subtypes. Potency of NAbs closely correlated with titers, and an gp120-binding IgG titer above a threshold of 100,000 was predictive of neutralization capability. Finally, peptide inhibition experiments showed that a large fraction of the neutralizing IgG was directed against the gp120 V3 region. Conclusions Our results indicate that the strategy of reverse immunology based on selected Env sequences is promising when immunogens are delivered as stabilized trimers in CAF01 adjuvant and that the rabbit is a valuable model for HIV vaccine studies. PMID:24023951

Standard operating procedures for vascular surgery in erectile dysfunction: revascularization and venous procedures.

PubMed

Sohn, Michael; Hatzinger, Martin; Goldstein, Irwin; Krishnamurti, Sudhakar

2013-01-01

The impact of penile blood supply on erectile function was recognized some 500 years ago. At the turn of the 20th century first results of penile venous ligation were published and in 1973 the first surgical attempts to restore penile arterial inflow were undertaken. Numerous techniques were published in the meantime, but inclusion criteria, patient selection, and success evaluation differed extremely between study groups. To develop evidence-based standard operating procedures (SOPs) for vascular surgery in erectile dysfunction, based on recent state of the art consensus reports and recently published articles in peer-reviewed journals. Based on the recent publication of the consensus process during the 2009 International Consultation on Sexual Medicine in Paris, recommendations are derived for diagnosis and surgical treatment of vascular erectile dysfunction. In addition several recent publications in this field not mentioned in the consensus statements are included in the discussion. The Oxford system of evidence-based review was systematically applied. Due to the generally low level of evidence in this field expert opinions were accepted, if published after a well-defined consensus process in peer-reviewed journals. Referring to penile revascularization it may be concluded, that in the face of missing randomized trials, only recommendations grade D may be given: this kind of surgery may be offered to men less than 55 years, who are nonsmokers, nondiabetic, and demonstrate isolated arterial stenoses in the absence of generalized vascular disease. The evidence level for recommendations concerning penile venous ligations may be even lower. Too many unsolved controversies exist and universal diagnostic criteria for patient selection as well as operative technique selection have not been unequivocally established. This kind of surgery is still considered investigational but may be offered in special situations on an individualized basis in an investigational or research setting after obtaining written consent, using both pre- and postoperatively validated measuring instruments of success evaluation. SOPs for penile revascularization procedures can be developed, concerning a highly selected patient group with isolated arterial stenoses. Based on the available data it is not yet possible to define SOPs for surgical treatment of corporal veno-occlusive dysfunction. © 2012 International Society for Sexual Medicine.

Appropriateness guidelines and predictive rules to select patients for upper endoscopy: a nationwide multicenter study.

PubMed

Buri, Luigi; Hassan, Cesare; Bersani, Gianluca; Anti, Marcello; Bianco, Maria Antonietta; Cipolletta, Livio; Di Giulio, Emilio; Di Matteo, Giovanni; Familiari, Luigi; Ficano, Leonardo; Loriga, Pietro; Morini, Sergio; Pietropaolo, Vincenzo; Zambelli, Alessandro; Grossi, Enzo; Intraligi, Marco; Buscema, Massimo

2010-06-01

Selecting patients appropriately for upper endoscopy (EGD) is crucial for efficient use of endoscopy. The objective of this study was to compare different clinical strategies and statistical methods to select patients for EGD, namely appropriateness guidelines, age and/or alarm features, and multivariate and artificial neural network (ANN) models. A nationwide, multicenter, prospective study was undertaken in which consecutive patients referred for EGD during a 1-month period were enrolled. Before EGD, the endoscopist assessed referral appropriateness according to the American Society for Gastrointestinal Endoscopy (ASGE) guidelines, also collecting clinical and demographic variables. Outcomes of the study were detection of relevant findings and new diagnosis of malignancy at EGD. The accuracy of the following clinical strategies and predictive rules was compared: (i) ASGE appropriateness guidelines (indicated vs. not indicated), (ii) simplified rule (>or=45 years or alarm features vs. <45 years without alarm features), (iii) logistic regression model, and (iv) ANN models. A total of 8,252 patients were enrolled in 57 centers. Overall, 3,803 (46%) relevant findings and 132 (1.6%) new malignancies were detected. Sensitivity, specificity, and area under the receiver-operating characteristic curve (AUC) of the simplified rule were similar to that of the ASGE guidelines for both relevant findings (82%/26%/0.55 vs. 88%/27%/0.52) and cancer (97%/22%/0.58 vs. 98%/20%/0.58). Both logistic regression and ANN models seemed to be substantially more accurate in predicting new cases of malignancy, with an AUC of 0.82 and 0.87, respectively. A simple predictive rule based on age and alarm features is similarly effective to the more complex ASGE guidelines in selecting patients for EGD. Regression and ANN models may be useful in identifying a relatively small subgroup of patients at higher risk of cancer.

Effect of an emergency department-based electronic system for musculoskeletal consultation on facilitating care for common injuries.

PubMed

Mears, Simon C; Pantle, Hardin A; Bessman, Edward S; Lifchez, Scott D

2015-05-01

Access to musculoskeletal consultation in the emergency department (ED) is a nationwide problem. In addition, consultation from a subspecialist may be delayed or may not be available, which can slow down the ED flow and reduce patient satisfaction. The purpose of this study was to review the 1-year results of a change in the authors' institutional practice to reduce subspecialty consultation for select musculoskeletal problems while still ensuring adequate patient follow-up in orthopedic or plastic surgery clinics for patients not seen by these services in the ED. The authors hypothesized that select injuries could be safely managed in the ED by using an electronic system to ensure appropriate follow-up care. Using Kaizen methodology, a multidisciplinary group (including ED staff, orthopedics, plastic surgery, pediatrics, nursing, radiology, therapy, and administration) met to improve care for select musculoskeletal injuries. A system was agreed on in which ED providers managed select musculoskeletal injuries without subspecialist consultation. Follow-up was organized using an electronic system, which facilitated communication between the ED staff and the secretarial staff of the subspecialist departments. Over a 1-year period, 150 patients were treated using this system. Charts and radiographs were reviewed for missed injuries. Radiographic review revealed 2 missed injuries. One patient had additional back pain and a lumbar spine fracture was found during the subspecialist follow-up visit; it was treated nonoperatively. Another patient appeared to have scapholunate widening on the injury radiograph that was not appreciated in the ED. Of the 150 patients, 51 were seen in follow-up by a subspecialist at the authors' institution. An electronic system to organize follow-up with a subspecialist allowed the ED providers to deliver safe and effective care for simple musculoskeletal injuries. Copyright 2015, SLACK Incorporated.

Patient-reported outcome measures for patients with meniscal tears: a systematic review of measurement properties and evaluation with the COSMIN checklist

PubMed Central

Middleton, Robert; Beard, David J; Price, Andrew J; Hopewell, Sally

2017-01-01

Objective Meniscal tears occur frequently in the population and the most common surgical treatment, arthroscopic partial meniscectomy, is performed in approximately two million cases worldwide each year. The purpose of this systematic review is to summarise and critically appraise the evidence for the use of patient-reported outcome measures (PROMs) in patients with meniscal tears. Design A systematic review was undertaken. Data on reported measurement properties were extracted and the quality of the studies appraised according to Consensus-based Standards for the Selection of Health Measurement Instruments. Data sources A search of MEDLINE, Embase, AMED and PsycINFO, unlimited by language or publication date (last search 20 February 2017). Eligibility criteria for selecting studies Development and validation studies reporting the measurement properties of PROMs in patients with meniscal tears were included. Results 11 studies and 10 PROMs were included. The overall quality of studies was poor. For measurement of symptoms and functional status, there is only very limited evidence supporting the selection of either the Lysholm Knee Scale, International Knee Documentation Committee Subjective Knee Form or the Dutch version of the Knee injury and Osteoarthritis Outcome Score. For measuring health-related quality of life, only limited evidence supports the selection of the Western Ontario Meniscal Evaluation Tool (WOMET). Of all the PROMs evaluated, WOMET has the strongest evidence for content validity. Conclusion For patients with meniscal tears, there is poor quality and incomplete evidence regarding the validity of the currently available PROMs. Further research is required to ensure these PROMs truly reflect the symptoms, function and quality of life of patients with meniscal tears. PROSPERO registration number CRD42017056847. PMID:29030413

Use of Machine Learning Classifiers and Sensor Data to Detect Neurological Deficit in Stroke Patients.

PubMed

Park, Eunjeong; Chang, Hyuk-Jae; Nam, Hyo Suk

2017-04-18

The pronator drift test (PDT), a neurological examination, is widely used in clinics to measure motor weakness of stroke patients. The aim of this study was to develop a PDT tool with machine learning classifiers to detect stroke symptoms based on quantification of proximal arm weakness using inertial sensors and signal processing. We extracted features of drift and pronation from accelerometer signals of wearable devices on the inner wrists of 16 stroke patients and 10 healthy controls. Signal processing and feature selection approach were applied to discriminate PDT features used to classify stroke patients. A series of machine learning techniques, namely support vector machine (SVM), radial basis function network (RBFN), and random forest (RF), were implemented to discriminate stroke patients from controls with leave-one-out cross-validation. Signal processing by the PDT tool extracted a total of 12 PDT features from sensors. Feature selection abstracted the major attributes from the 12 PDT features to elucidate the dominant characteristics of proximal weakness of stroke patients using machine learning classification. Our proposed PDT classifiers had an area under the receiver operating characteristic curve (AUC) of .806 (SVM), .769 (RBFN), and .900 (RF) without feature selection, and feature selection improves the AUCs to .913 (SVM), .956 (RBFN), and .975 (RF), representing an average performance enhancement of 15.3%. Sensors and machine learning methods can reliably detect stroke signs and quantify proximal arm weakness. Our proposed solution will facilitate pervasive monitoring of stroke patients. ©Eunjeong Park, Hyuk-Jae Chang, Hyo Suk Nam. Originally published in the Journal of Medical Internet Research (http://www.jmir.org), 18.04.2017.

[Use of adsorption methods for plasma component apheresis].

PubMed

Bang, B; Heegaard, N H

1991-11-25

Plasma-apheresis is a nonspecific and wasteful intervention requiring the use of potentially infectious and expensive replacement fluids. Selective removal of the unwanted plasma component circumvents most of the problems. For selective binding and removal of plasma components adsorption methods based on the principles of affinity chromatography have been useful. The ideal adsorption column still does not exist, but the number of clinical applications is increasing. The results vary, but the treatment has been used with success in hypercholesterolemia, and in patients with hemophilia with antifactor antibodies and patients with antibodies directed towards HLA-antigens awaiting renal transplantation. In conclusion selective plasma component-apheresis is an improvement in some diseases as compared to conventional plasma-apheresis. The technique is still being improved but large clinical trials examining the effects of plasma-component-apheresis have not yet been published.

Support Vector Feature Selection for Early Detection of Anastomosis Leakage From Bag-of-Words in Electronic Health Records.

PubMed

Soguero-Ruiz, Cristina; Hindberg, Kristian; Rojo-Alvarez, Jose Luis; Skrovseth, Stein Olav; Godtliebsen, Fred; Mortensen, Kim; Revhaug, Arthur; Lindsetmo, Rolv-Ole; Augestad, Knut Magne; Jenssen, Robert

2016-09-01

The free text in electronic health records (EHRs) conveys a huge amount of clinical information about health state and patient history. Despite a rapidly growing literature on the use of machine learning techniques for extracting this information, little effort has been invested toward feature selection and the features' corresponding medical interpretation. In this study, we focus on the task of early detection of anastomosis leakage (AL), a severe complication after elective surgery for colorectal cancer (CRC) surgery, using free text extracted from EHRs. We use a bag-of-words model to investigate the potential for feature selection strategies. The purpose is earlier detection of AL and prediction of AL with data generated in the EHR before the actual complication occur. Due to the high dimensionality of the data, we derive feature selection strategies using the robust support vector machine linear maximum margin classifier, by investigating: 1) a simple statistical criterion (leave-one-out-based test); 2) an intensive-computation statistical criterion (Bootstrap resampling); and 3) an advanced statistical criterion (kernel entropy). Results reveal a discriminatory power for early detection of complications after CRC (sensitivity 100%; specificity 72%). These results can be used to develop prediction models, based on EHR data, that can support surgeons and patients in the preoperative decision making phase.

Disentangling the adult attention-deficit hyperactivity disorder endophenotype: parametric measurement of attention.

PubMed

Finke, Kathrin; Schwarzkopf, Wolfgang; Müller, Ulrich; Frodl, Thomas; Müller, Hermann J; Schneider, Werner X; Engel, Rolf R; Riedel, Michael; Möller, Hans-Jürgen; Hennig-Fast, Kristina

2011-11-01

Attention deficit hyperactivity disorder (ADHD) persists frequently into adulthood. The decomposition of endophenotypes by means of experimental neuro-cognitive assessment has the potential to improve diagnostic assessment, evaluation of treatment response, and disentanglement of genetic and environmental influences. We assessed four parameters of attentional capacity and selectivity derived from simple psychophysical tasks (verbal report of briefly presented letter displays) and based on a "theory of visual attention." These parameters are mathematically independent, quantitative measures, and previous studies have shown that they are highly sensitive for subtle attention deficits. Potential reductions of attentional capacity, that is, of perceptual processing speed and working memory storage capacity, were assessed with a whole report paradigm. Furthermore, possible pathologies of attentional selectivity, that is, selection of task-relevant information and bias in the spatial distribution of attention, were measured with a partial report paradigm. A group of 30 unmedicated adult ADHD patients and a group of 30 demographically matched healthy controls were tested. ADHD patients showed significant reductions of working memory storage capacity of a moderate to large effect size. Perceptual processing speed, task-based, and spatial selection were unaffected. The results imply a working memory deficit as an important source of behavioral impairments. The theory of visual attention parameter working memory storage capacity might constitute a quantifiable and testable endophenotype of ADHD.

Validation of an administrative claims-based diagnostic code for pneumonia in a US-based commercially insured COPD population

PubMed Central

Kern, David M; Davis, Jill; Williams, Setareh A; Tunceli, Ozgur; Wu, Bingcao; Hollis, Sally; Strange, Charlie; Trudo, Frank

2015-01-01

Objective To estimate the accuracy of claims-based pneumonia diagnoses in COPD patients using clinical information in medical records as the reference standard. Methods Selecting from a repository containing members’ data from 14 regional United States health plans, this validation study identified pneumonia diagnoses within a group of patients initiating treatment for COPD between March 1, 2009 and March 31, 2012. Patients with ≥1 claim for pneumonia (International Classification of Diseases Version 9-CM code 480.xx–486.xx) were identified during the 12 months following treatment initiation. A subset of 800 patients was randomly selected to abstract medical record data (paper based and electronic) for a target sample of 400 patients, to estimate validity within 5% margin of error. Positive predictive value (PPV) was calculated for the claims diagnosis of pneumonia relative to the reference standard, defined as a documented diagnosis in the medical record. Results A total of 388 records were reviewed; 311 included a documented pneumonia diagnosis, indicating 80.2% (95% confidence interval [CI]: 75.8% to 84.0%) of claims-identified pneumonia diagnoses were validated by the medical charts. Claims-based diagnoses in inpatient or emergency departments (n=185) had greater PPV versus outpatient settings (n=203), 87.6% (95% CI: 81.9%–92.0%) versus 73.4% (95% CI: 66.8%–79.3%), respectively. Claims-diagnoses verified with paper-based charts had similar PPV as the overall study sample, 80.2% (95% CI: 71.1%–87.5%), and higher PPV than those linked to electronic medical records, 73.3% (95% CI: 65.5%–80.2%). Combined paper-based and electronic records had a higher PPV, 87.6% (95% CI: 80.9%–92.6%). Conclusion Administrative claims data indicating a diagnosis of pneumonia in COPD patients are supported by medical records. The accuracy of a medical record diagnosis of pneumonia remains unknown. With increased use of claims data in medical research, COPD researchers can study pneumonia with confidence that claims data are a valid tool when studying the safety of COPD therapies that could potentially lead to increased pneumonia susceptibility or severity. PMID:26229461

Validation of an administrative claims-based diagnostic code for pneumonia in a US-based commercially insured COPD population.

PubMed

Kern, David M; Davis, Jill; Williams, Setareh A; Tunceli, Ozgur; Wu, Bingcao; Hollis, Sally; Strange, Charlie; Trudo, Frank

2015-01-01

To estimate the accuracy of claims-based pneumonia diagnoses in COPD patients using clinical information in medical records as the reference standard. Selecting from a repository containing members' data from 14 regional United States health plans, this validation study identified pneumonia diagnoses within a group of patients initiating treatment for COPD between March 1, 2009 and March 31, 2012. Patients with ≥1 claim for pneumonia (International Classification of Diseases Version 9-CM code 480.xx-486.xx) were identified during the 12 months following treatment initiation. A subset of 800 patients was randomly selected to abstract medical record data (paper based and electronic) for a target sample of 400 patients, to estimate validity within 5% margin of error. Positive predictive value (PPV) was calculated for the claims diagnosis of pneumonia relative to the reference standard, defined as a documented diagnosis in the medical record. A total of 388 records were reviewed; 311 included a documented pneumonia diagnosis, indicating 80.2% (95% confidence interval [CI]: 75.8% to 84.0%) of claims-identified pneumonia diagnoses were validated by the medical charts. Claims-based diagnoses in inpatient or emergency departments (n=185) had greater PPV versus outpatient settings (n=203), 87.6% (95% CI: 81.9%-92.0%) versus 73.4% (95% CI: 66.8%-79.3%), respectively. Claims-diagnoses verified with paper-based charts had similar PPV as the overall study sample, 80.2% (95% CI: 71.1%-87.5%), and higher PPV than those linked to electronic medical records, 73.3% (95% CI: 65.5%-80.2%). Combined paper-based and electronic records had a higher PPV, 87.6% (95% CI: 80.9%-92.6%). Administrative claims data indicating a diagnosis of pneumonia in COPD patients are supported by medical records. The accuracy of a medical record diagnosis of pneumonia remains unknown. With increased use of claims data in medical research, COPD researchers can study pneumonia with confidence that claims data are a valid tool when studying the safety of COPD therapies that could potentially lead to increased pneumonia susceptibility or severity.

An advanced selective liquid-metal plating technique for stretchable biosensor applications.

PubMed

Li, Guangyong; Lee, Dong-Weon

2017-10-11

This paper presents a novel stretchable pulse sensor fabricated by a selective liquid-metal plating process (SLMP), which can conveniently attach to the human skin and monitor the patient's heartbeat. The liquid metal-based stretchable pulse sensor consists of polydimethylsiloxane (PDMS) thin films and liquid metal functional circuits with electronic elements that are embedded into the PDMS substrate. In order to verify the utility of the fabrication process, various complex liquid-metal patterns are achieved by using the selective wetting behavior of the reduced liquid metal on the Cu patterns of the PDMS substrate. The smallest liquid-metal pattern is approximately 2 μm in width with a uniform surface. After verification, a transparent flowing LED light with programmed circuits is realized and exhibits stable mechanical and electrical properties under various deformations (bending, twisting and stretching). Finally, based on SLMP, a wireless pulse measurement system is developed which is composed of the liquid metal-based stretchable pulse sensor, a Bluetooth module, an Arduino development board, a laptop computer and a self-programmed visualized software program. The experimental results reveal that the portable non-invasive pulse sensor has the potential to reduce costs, simplify biomedical diagnostic procedures and help patients to improve their life in the future.

A surrogate-based metaheuristic global search method for beam angle selection in radiation treatment planning.

PubMed

Zhang, H H; Gao, S; Chen, W; Shi, L; D'Souza, W D; Meyer, R R

2013-03-21

An important element of radiation treatment planning for cancer therapy is the selection of beam angles (out of all possible coplanar and non-coplanar angles in relation to the patient) in order to maximize the delivery of radiation to the tumor site and minimize radiation damage to nearby organs-at-risk. This category of combinatorial optimization problem is particularly difficult because direct evaluation of the quality of treatment corresponding to any proposed selection of beams requires the solution of a large-scale dose optimization problem involving many thousands of variables that represent doses delivered to volume elements (voxels) in the patient. However, if the quality of angle sets can be accurately estimated without expensive computation, a large number of angle sets can be considered, increasing the likelihood of identifying a very high quality set. Using a computationally efficient surrogate beam set evaluation procedure based on single-beam data extracted from plans employing equallyspaced beams (eplans), we have developed a global search metaheuristic process based on the nested partitions framework for this combinatorial optimization problem. The surrogate scoring mechanism allows us to assess thousands of beam set samples within a clinically acceptable time frame. Tests on difficult clinical cases demonstrate that the beam sets obtained via our method are of superior quality.

A surrogate-based metaheuristic global search method for beam angle selection in radiation treatment planning

PubMed Central

Zhang, H H; Gao, S; Chen, W; Shi, L; D’Souza, W D; Meyer, R R

2013-01-01

An important element of radiation treatment planning for cancer therapy is the selection of beam angles (out of all possible coplanar and non-coplanar angles in relation to the patient) in order to maximize the delivery of radiation to the tumor site and minimize radiation damage to nearby organs-at-risk. This category of combinatorial optimization problem is particularly difficult because direct evaluation of the quality of treatment corresponding to any proposed selection of beams requires the solution of a large-scale dose optimization problem involving many thousands of variables that represent doses delivered to volume elements (voxels) in the patient. However, if the quality of angle sets can be accurately estimated without expensive computation, a large number of angle sets can be considered, increasing the likelihood of identifying a very high quality set. Using a computationally efficient surrogate beam set evaluation procedure based on single-beam data extracted from plans employing equally-spaced beams (eplans), we have developed a global search metaheuristic process based on the Nested Partitions framework for this combinatorial optimization problem. The surrogate scoring mechanism allows us to assess thousands of beam set samples within a clinically acceptable time frame. Tests on difficult clinical cases demonstrate that the beam sets obtained via our method are superior quality. PMID:23459411

Cost effectiveness of adding clostridial collagenase ointment to selective debridement in individuals with stage IV pressure ulcers.

PubMed

Carter, Marissa J; Gilligan, Adrienne M; Waycaster, Curtis R; Schaum, Kathleen; Fife, Caroline E

2017-03-01

The purpose of this study was to determine the cost effectiveness (from a payer's perspective) of adding clostridial collagenase ointment (CCO) to selective debridement compared with selective debridement alone (non-CCO) in the treatment of stage IV pressure ulcers among patients identified from the US Wound Registry. A 3-state Markov model was developed to determine costs and outcomes between the CCO and non-CCO groups over a 2-year time horizon. Outcome data were derived from a retrospective clinical study and included the proportion of pressure ulcers that were closed (epithelialized) over 2 years and the time to wound closure. Transition probabilities for the Markov states were estimated from the clinical study. In the Markov model, the clinical outcome is presented as ulcer-free weeks, which represents the time the wound is in the epithelialized state. Costs for each 4-week cycle were based on frequencies of clinic visits, debridement, and CCO application rates from the clinical study. The final model outputs were cumulative costs (in US dollars), clinical outcome (ulcer-free weeks), and incremental cost-effectiveness ratio (ICER) at 2 years. Compared with the non-CCO group, the CCO group incurred lower costs ($11,151 vs $17,596) and greater benefits (33.9 vs 16.8 ulcer-free weeks), resulting in an economically dominant ICER of -$375 per ulcer. Thus, for each additional ulcer-free week that can be gained, there is a concurrent cost savings of $375 if CCO treatment is selected. Over a 2-year period, an additional 17.2 ulcer-free weeks can be gained with concurrent cost savings of $6,445 for each patient. In this Markov model based on real-world data from the US Wound Registry, the addition of CCO to selective debridement in the treatment of pressure ulcers was economically dominant over selective debridement alone, resulting in greater benefit to the patient at lower cost.

Dosimetric advantages of a clinical daily adaptive plan selection strategy compared with a non-adaptive strategy in cervical cancer radiation therapy.

PubMed

van de Schoot, Agustinus J A J; de Boer, Peter; Visser, Jorrit; Stalpers, Lukas J A; Rasch, Coen R N; Bel, Arjan

2017-05-01

Radiation therapy (RT) using a daily plan selection adaptive strategy can be applied to account for interfraction organ motion while limiting organ at risk dose. The aim of this study was to quantify the dosimetric consequences of daily plan selection compared with non-adaptive RT in cervical cancer. Ten consecutive patients who received pelvic irradiation, planning CTs (full and empty bladder), weekly post-fraction CTs and pre-fraction CBCTs were included. Non-adaptive plans were generated based on the PTV defined using the full bladder planning CT. For the adaptive strategy, multiple PTVs were created based on both planning CTs by ITVs of the primary CTVs (i.e., GTV, cervix, corpus-uterus and upper part of the vagina) and corresponding library plans were generated. Daily CBCTs were rigidly aligned to the full bladder planning CT for plan selection. For daily plan recalculation, selected CTs based on initial similarity were deformably registered to CBCTs. Differences in daily target coverage (D 98%  > 95%) and in V 0.5Gy , V 1.5Gy , V 2Gy , D 50% and D 2% for rectum, bladder and bowel were assessed. Non-adaptive RT showed inadequate primary CTV coverage in 17% of the daily fractions. Plan selection compensated for anatomical changes and improved primary CTV coverage significantly (p < 0.01) to 98%. Compared with non-adaptive RT, plan selection decreased the fraction dose to rectum and bowel indicated by significant (p < 0.01) improvements for daily V 0.5Gy , V 1.5Gy , V 2Gy , D 50% and D 2% . However, daily plan selection significantly increased the bladder V 1.5Gy , V 2Gy , D 50% and D 2% . In cervical cancer RT, a non-adaptive strategy led to inadequate target coverage for individual patients. Daily plan selection corrected for day-to-day anatomical variations and resulted in adequate target coverage in all fractions. The dose to bowel and rectum was decreased significantly when applying adaptive RT.

Disease management programmes for patients with coronary heart disease--an empirical study of German programmes.

PubMed

Gapp, Oliver; Schweikert, Bernd; Meisinger, Christa; Holle, Rolf

2008-12-01

To evaluate healthcare and outcomes of disease management programmes (DMPs) for patients with coronary heart disease (CHD) in primary care, and to assess selection of enrollment for these programmes. A cross-sectional survey of 2330 statutorily insured patients with a history of acute myocardial infarction (AMI) was performed in 2006 by the population-based KORA Myocardial Infarction Register from the region of Augsburg, Germany. Patients enrolled in DMP-CHDs receive evidence-based care, with patients not enrolled receiving standard care. To control for selection bias, a propensity score approach was used. Main factors influencing DMP participation were age (OR 0.98, 95% CI 0.96-0.99), diabetes (OR 1.56, CI 1.25-1.95) and time since last heart attack (OR 0.98, CI 0.95-0.99). Significantly more patients enrolled in DMP-CHDs stated that they received medical counselling for smoking (OR 3.77, CI 1.07-13.34), nutrition (OR 2.15, 1.69-2.74) and for physical activity (OR 2.58, 1.99-3.35). Furthermore, prescription of statins (OR 1.58, CI 1.24-2.00), antiplatelets (OR 1.96, CI 1.43-2.69) and beta-blockers (not significant) were higher in the DMP group. With respect to outcomes, we did not see relevant differences in quality of life and body mass index, and only a minor reduction in smoking. Enrollment into DMPs for CHD exhibits systematic selection effects. Participants tend to experience--at least on a short to medium term and for AMI patients--better quality of healthcare services. However, since DMP-CHDs were initiated only 2 years ago, we were unable to identify significant improvements in health outcomes. Only the reduction in smoking provides a first indication of better quality outcomes following DMP-CHD. Thus, policy-makers must provide appropriate incentives to sickness funds and physicians in order to ensure initiation and continuation of high quality DMPs.

Obesity and response to anti-tumor necrosis factor-α agents in patients with select immune-mediated inflammatory diseases: A systematic review and meta-analysis.

PubMed

Singh, Siddharth; Facciorusso, Antonio; Singh, Abha G; Casteele, Niels Vande; Zarrinpar, Amir; Prokop, Larry J; Grunvald, Eduardo L; Curtis, Jeffrey R; Sandborn, William J

2018-01-01

We sought to evaluate the association between obesity and response to anti-tumor necrosis factor-α (TNF) agents, through a systematic review and meta-analysis. Through a systematic search through January 24, 2017, we identified randomized controlled trials (RCTs) or observational studies in adults with select immune-mediated inflammatory diseases-inflammatory bowel diseases (IBD), rheumatoid arthritis (RA), spondyloarthropathies (SpA), psoriasis and psoriatic arthritis (PsA)-treated with anti-TNF agents, and reporting outcomes, stratified by body mass index (BMI) categories or weight. Primary outcome was failure to achieve clinical remission or response or treatment modification. We performed random effects meta-analysis and estimated odds ratios (OR) and 95% confidence interval (CI). Based on 54 cohorts including 19,372 patients (23% obese), patients with obesity had 60% higher odds of failing therapy (OR,1.60; 95% CI,1.39-1.83;I2 = 71%). Dose-response relationship was observed (obese vs. normal BMI: OR,1.87 [1.39-2.52]; overweight vs. normal BMI: OR,1.38 [1.11-1.74],p = 0.11); a 1kg/m2 increase in BMI was associated with 6.5% higher odds of failure (OR,1.065 [1.043-1.087]). These effects were observed across patients with rheumatic diseases, but not observed in patients with IBD. Effect was consistent based on dosing regimen/route, study design, exposure definition, and outcome measures. Less than 10% eligible RCTs reported outcomes stratified by BMI. Obesity is an under-reported predictor of inferior response to anti-TNF agents in patients with select immune-mediated inflammatory diseases. A thorough evaluation of obesity as an effect modifier in clinical trials is warranted, and intentional weight loss may serve as adjunctive treatment in patients with obesity failing anti-TNF therapy.

Selective non-operative management of stab wounds to the posterior abdomen is safe: the Pietermaritzburg experience.

PubMed

Kong, Victor; Oosthuizen, George; Sartorius, Benn; Clarke, Damian

2015-09-01

The selective non-operative management (SNOM) of stab injuries of the anterior abdomen is well established, but its application to the posterior abdomen remains controversial. A retrospective review of 1013 patients was undertaken at a major trauma service in South Africa over a five-year period. Ninety per cent of patients were males, and the mean age was 25 years. The mean time from injury to presentation was 4h and 73% of all injuries were inflicted by knives. A total of 9% (93) of patients required a laparotomy [Group A] and 82% (833) were successfully observed without the need for operative intervention [Group B]. CT imaging was performed on 52 patients (5%) who had haematuria [Group C], 25 (3%) who had neurological deficits [Group D], and 10 (1%) with retained weapon injuries [Group E]. The accuracy of physical examination for identifying the presence of organ injury was 88%. All observed patients who required laparotomy declared themselves within 24h. There were no mortalities as direct result of our current management protocol. Selective management based on active clinical observation and serial physical examination is safe, and when coupled with the judicious use of advanced imaging, is a prudent and reliable approach in a resource constrained environment. Copyright © 2015 Elsevier Ltd. All rights reserved.

An FDA oncology analysis of CD3 bispecific constructs and first-in-human dose selection.

PubMed

Saber, Haleh; Del Valle, Pedro; Ricks, Tiffany K; Leighton, John K

2017-11-01

We retrospectively examined the nonclinical studies conducted with 17 CD3 bispecific constructs in support of first-in-human (FIH) trials in oncology. We also collected information on the design of dose-finding clinical trials. Sponsors have used different MABEL approaches for FIH dose selection. To better assess acceptable approaches, FIH doses were computed from nonclinical studies and compared to the maximum tolerated doses (MTDs) in patients, to the highest human doses (HHDs) when an MTD was not identified, or to the recommended human dose (RHD) for blinatumomab. We concluded that approaches based on receptor occupancy, highest non-severely toxic dose, or no-observed adverse effect level are not acceptable for selecting the FIH dose as they resulted in doses close to or above the MTDs, HHDs, or the RHD. A FIH dose corresponding to 10%-30% pharmacologic activity (PA) was an acceptable approach. A FIH dose corresponding to 50% PA was acceptable for all except one construct, potentially due to its biological or structural properties. The most common toxicities in animals and patients were those related to cytokine release. Doses were better tolerated when intra-animal or intra-patient dose escalation was used. Exposing naïve patients to an MTD achieved with intra-patient dose escalation design may be unsafe. Published by Elsevier Inc.

Refinement of the magnetic resonance diffusion-perfusion mismatch concept for thrombolytic patient selection: insights from the desmoteplase in acute stroke trials.

PubMed

Warach, Steven; Al-Rawi, Yasir; Furlan, Anthony J; Fiebach, Jochen B; Wintermark, Max; Lindstén, Annika; Smyej, Jamal; Bharucha, David B; Pedraza, Salvador; Rowley, Howard A

2012-09-01

The DIAS-2 study was the only large, randomized, intravenous, thrombolytic trial that selected patients based on the presence of ischemic penumbra. However, DIAS-2 did not confirm the positive findings of the smaller DEDAS and DIAS trials, which also used penumbral selection. Therefore, a reevaluation of the penumbra selection strategy is warranted. In post hoc analyses we assessed the relationships of magnetic resonance imaging-measured lesion volumes with clinical measures in DIAS-2, and the relationships of the presence and size of the diffusion-perfusion mismatch with the clinical effect of desmoteplase in DIAS-2 and in pooled data from DIAS, DEDAS, and DIAS-2. In DIAS-2, lesion volumes correlated with National Institutes of Health Stroke Scale (NIHSS) at both baseline and final time points (P<0.0001), and lesion growth was inversely related to good clinical outcome (P=0.004). In the pooled analysis, desmoteplase was associated with 47% clinical response rate (n=143) vs 34% in placebo (n=73; P=0.08). For both the pooled sample and for DIAS-2, increasing the minimum baseline mismatch volume (MMV) for inclusion increased the desmoteplase effect size. The odds ratio for good clinical response between desmoteplase and placebo treatment was 2.83 (95% confidence interval, 1.16-6.94; P=0.023) for MMV >60 mL. Increasing the minimum NIHSS score for inclusion did not affect treatment effect size. Pooled across all desmoteplase trials, desmoteplase appears beneficial in patients with large MMV and ineffective in patients with small MMV. These results support a modified diffusion-perfusion mismatch hypothesis for patient selection in later time-window thrombolytic trials. Clinical Trial Registration- URL: http://www.clinicaltrials.gov. Unique Identifiers: NCT00638781, NCT00638248, NCT00111852.

Comparison of Risk of Carpal Tunnel Syndrome in Patients with Distal Radius Fractures After 7 Treatments

PubMed Central

Zhao, Huan-Li; Wang, Gui-Bin; Jia, Yue-Qing; Zhu, Shi-Cai; Zhang, Feng-Fang; Liu, Hong-Mei

2015-01-01

Background To compare risk of carpal tunnel syndrome (CTS) in distal radius fracture (DRF) patients after 7 treatments using bridging external fixation (BrEF), non-bridging external fixation (non-BrEF), plaster fixation, K-wire fixation, dorsal plating fixation, volar plating fixation, and dorsal and volar plating by performing a network meta-analysis. Material/Methods An exhaustive search of electronic databases identified randomized controlled trails (RCTs) closely related to our study topic. The published articles were screened, based on predefined inclusion and exclusion criteria, to select high-quality studies for the present network meta-analysis. Data extracted from the selected studies were analyzed using STATA version 12.0 software. Results The literature search and selection process identified 12 eligible RCTs that contained a total of 1370 DRF patients (394 patients with BrEF, 377 patients with non-BrEF, 89 patients with K-wire fixation, 192 patients with plaster fixation, 42 patients with dorsal plating fixation, 152 patients with volar plating fixation, and 124 patients with dorsal and volar plating fixation). Our network meta-analysis results demonstrated no significant differences in CTS risk among the 7 treatments (P>0.05). The value of surface under the cumulative ranking curve (SUCRA), however, suggested that dorsal plating fixation is the optimal treatment, with the lowest risk of CTS in DRF patients (dorsal plating fixation: 89.2%; dorsal and volar plating: 57.8%; plaster fixation: 50.9%; non-BrEF: 50.6%; volar plating fixation: 39.6%; BrEF: 38.4%; K-wire fixation: 23.6%). Conclusions Our network meta-analysis provides evidence that dorsal plating fixation significantly decreases the risk of CTS and could be the method of choice in DRF patients. PMID:26391617

Neoadjuvant radiotherapy followed by mastectomy and immediate breast reconstruction : An alternative treatment option for locally advanced breast cancer.

PubMed

Pazos, Montserrat; Corradini, Stefanie; Dian, Darius; von Bodungen, Vera; Ditsch, Nina; Wuerstlein, Rachel; Schönecker, Stephan; Harbeck, Nadia; Scheithauer, Heike; Belka, Claus

2017-04-01

The optimal sequence of mastectomy with immediate breast reconstruction (IBR) and radiotherapy (RT) for the treatment of locally advanced breast cancer (LABC) is still under debate. Increased rates of postoperative complications are described following postmastectomy RT. Neoadjuvant RT aims to improve the aesthetic results and simplify the reconstructive pathway. A total of 22 patients diagnosed with LABC and treated with neoadjuvant RT followed by mastectomy and IBR between 04/2012 and 03/2015 were retrospectively analyzed. RT consisted of external beam RT to the breast and the regional lymphatics, if indicated. Both implant-based and autologous tissue-transfer reconstruction techniques were used. At the time of RT, 10 patients had no prior surgery and 12 patients had previously undergone breast-conserving surgery (BCS) with positive resection margins without the possibility to perform a second BCS. Additional neoadjuvant chemotherapy was administered in 18 patients prior to RT. A complete pathological response was achieved in 55.0% of patients. The 2‑year overall survival rate was 89.3%, the 2‑year disease-free-survival 79.8% and the local-recurrence-free survival was 95.2%. The cosmetic result was excellent or good in 66% of the patients treated with upfront mastectomy and 37% of the patients who had previously undergone BCS. Among patients who received implant-based IBR, 4 patients developed serious wound-healing problems with implant loss. The most satisfactory results were achieved with autologous tissue reconstruction. A sequential neoadjuvant chemo-/radiotherapy to allow IBR following mastectomy in selected cases of LABC seems feasible and can be safely attempted. Careful patient selection, close monitoring, and continuous patient support is mandatory to ensure compliance in this treatment strategy.

Theory-informed design of values clarification methods: a cognitive psychological perspective on patient health-related decision making.

PubMed

Pieterse, Arwen H; de Vries, Marieke; Kunneman, Marleen; Stiggelbout, Anne M; Feldman-Stewart, Deb

2013-01-01

Healthcare decisions, particularly those involving weighing benefits and harms that may significantly affect quality and/or length of life, should reflect patients' preferences. To support patients in making choices, patient decision aids and values clarification methods (VCM) in particular have been developed. VCM intend to help patients to determine the aspects of the choices that are important to their selection of a preferred option. Several types of VCM exist. However, they are often designed without clear reference to theory, which makes it difficult for their development to be systematic and internally coherent. Our goal was to provide theory-informed recommendations for the design of VCM. Process theories of decision making specify components of decision processes, thus, identify particular processes that VCM could aim to facilitate. We conducted a review of the MEDLINE and PsycINFO databases and of references to theories included in retrieved papers, to identify process theories of decision making. We selected a theory if (a) it fulfilled criteria for a process theory; (b) provided a coherent description of the whole process of decision making; and (c) empirical evidence supports at least some of its postulates. Four theories met our criteria: Image Theory, Differentiation and Consolidation theory, Parallel Constraint Satisfaction theory, and Fuzzy-trace Theory. Based on these, we propose that VCM should: help optimize mental representations; encourage considering all potentially appropriate options; delay selection of an initially favoured option; facilitate the retrieval of relevant values from memory; facilitate the comparison of options and their attributes; and offer time to decide. In conclusion, our theory-based design recommendations are explicit and transparent, providing an opportunity to test each in a systematic manner. Copyright © 2012 Elsevier Ltd. All rights reserved.

A PRIM approach to predictive-signature development for patient stratification

PubMed Central

Chen, Gong; Zhong, Hua; Belousov, Anton; Devanarayan, Viswanath

2015-01-01

Patients often respond differently to a treatment because of individual heterogeneity. Failures of clinical trials can be substantially reduced if, prior to an investigational treatment, patients are stratified into responders and nonresponders based on biological or demographic characteristics. These characteristics are captured by a predictive signature. In this paper, we propose a procedure to search for predictive signatures based on the approach of patient rule induction method. Specifically, we discuss selection of a proper objective function for the search, present its algorithm, and describe a resampling scheme that can enhance search performance. Through simulations, we characterize conditions under which the procedure works well. To demonstrate practical uses of the procedure, we apply it to two real-world data sets. We also compare the results with those obtained from a recent regression-based approach, Adaptive Index Models, and discuss their respective advantages. In this study, we focus on oncology applications with survival responses. PMID:25345685

A Prototype System to Support Evidence-based Practice

PubMed Central

Demner-Fushman, Dina; Seckman, Charlotte; Fisher, Cheryl; Hauser, Susan E.; Clayton, Jennifer; Thoma, George R.

2008-01-01

Translating evidence into clinical practice is a complex process that depends on the availability of evidence, the environment into which the research evidence is translated, and the system that facilitates the translation. This paper presents InfoBot, a system designed for automatic delivery of patient-specific information from evidence-based resources. A prototype system has been implemented to support development of individualized patient care plans. The prototype explores possibilities to automatically extract patients’ problems from the interdisciplinary team notes and query evidence-based resources using the extracted terms. Using 4,335 de-identified interdisciplinary team notes for 525 patients, the system automatically extracted biomedical terminology from 4,219 notes and linked resources to 260 patient records. Sixty of those records (15 each for Pediatrics, Oncology & Hematology, Medical & Surgical, and Behavioral Health units) have been selected for an ongoing evaluation of the quality of automatically proactively delivered evidence and its usefulness in development of care plans. PMID:18998835

Hydrocephalus and mucopolysaccharidoses: what do we know and what do we not know?

PubMed

Dalla Corte, Amauri; de Souza, Carolina F M; Anés, Maurício; Giugliani, Roberto

2017-07-01

The precise incidence of hydrocephalus in patients with mucopolysaccharidoses (MPS) is hard to determine, because the condition lacks a formal, consensus-based definition. The diagnosis of hydrocephalus depends on symptom profile, presence of neuroimaging features, and the outcome of diagnostic tests. Although numerous techniques are used to identify MPS patients who are most likely to have hydrocephalus and respond to treatment, no definitive method exists to prove diagnosis. The authors propose an algorithm to aid in the diagnosis and management of hydrocephalus in MPS patients. The theory of venous hypertension associated with the morphological changes in the skull base and craniocervical junction indicate the need for future neuroimaging studies including cerebrospinal fluid (CSF) and venous flow measurements to monitor hydrocephalus progression and select therapeutic interventions in MPS patients. Preoperative planning should also be based on the increased risk of intraoperative and postoperative hemorrhagic complications.

Multiplex profiling of tumor-associated proteolytic activity in serum of colorectal cancer patients.

PubMed

Yepes, Diego; Costina, Victor; Pilz, Lothar R; Hofheinz, Ralf; Neumaier, Michael; Findeisen, Peter

2014-06-01

The monitoring of tumor-associated protease activity in blood specimens has recently been proposed as new diagnostic tool in cancer research. In this paper, we describe the screening of a peptide library for identification of reporter peptides (RPs) that are selectively cleaved in serum specimens from colorectal cancer patients and investigate the benefits of RP multiplexing. A library of 144 RPs was constructed that contained amino acid sequences of abundant plasma proteins. Proteolytic cleavage of RPs was monitored with MS. Five RPs that were selectively cleaved in serum specimens from tumor patients were selected for further validation in serum specimens of colorectal tumor patients (n = 30) and nonmalignant controls (n = 60). RP spiking and subsequent quantification of proteolytic fragments with LC-MS showed good reproducibility with CVs always below 26%. The linear discriminant analysis and PCA revealed that a combination of RPs for diagnostic classification is superior to single markers. Classification accuracy reached 88% (79/90) when all five markers were combined. Functional protease profiling with RPs might improve the laboratory-based diagnosis, monitoring and prognosis of malignant disease, and has to be evaluated thoroughly in future studies. © 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Current drug therapy of patients with BPH-LUTS with the special emphasis on PDE5 inhibitors

PubMed Central

Govorov, Alexander; Kasyan, George; Priymak, Diana; Pushkar, Dmitry

2016-01-01

Introduction Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptom (LUTS) development in men [1]. The intensity of the symptoms may vary from mild to severe, significantly affecting the quality of life. Erectile dysfunction (ED) is one of the most challenging issues in modern urology that significantly influences the quality of life in men worldwide. The objective of this literature review was to analyze the current drug therapies of patients with BPH-LUTS, with the special emphasis on PDE5 inhibitors. Material and methods The authors searched the literature for the period from 2000 until 2015 in MEDLINE and PubMed. Results Twenty-three articles were selected based on their reliability. A detailed analysis of the selected papers was performed. Primary attention was given to articles describing the use of PDE5. Works describing the use of different groups of drugs in patients with BPH-LUTS were also selected. Conclusions The current literature analysis suggests that the introduction of PDE5 inhibitors in clinical practice for the treatment of patients with BPH-LUTS will allow for significant expansion of the therapeutic options for the treatment of this disease. PMID:28127458

Current drug therapy of patients with BPH-LUTS with the special emphasis on PDE5 inhibitors.

PubMed

Kolontarev, Konstantin; Govorov, Alexander; Kasyan, George; Priymak, Diana; Pushkar, Dmitry

2016-01-01

Benign prostatic hyperplasia (BPH) is the most common cause of lower urinary tract symptom (LUTS) development in men [1]. The intensity of the symptoms may vary from mild to severe, significantly affecting the quality of life. Erectile dysfunction (ED) is one of the most challenging issues in modern urology that significantly influences the quality of life in men worldwide. The objective of this literature review was to analyze the current drug therapies of patients with BPH-LUTS, with the special emphasis on PDE5 inhibitors. The authors searched the literature for the period from 2000 until 2015 in MEDLINE and PubMed. Twenty-three articles were selected based on their reliability. A detailed analysis of the selected papers was performed. Primary attention was given to articles describing the use of PDE5. Works describing the use of different groups of drugs in patients with BPH-LUTS were also selected. The current literature analysis suggests that the introduction of PDE5 inhibitors in clinical practice for the treatment of patients with BPH-LUTS will allow for significant expansion of the therapeutic options for the treatment of this disease.

Patient selection for transcatheter aortic valve replacement: A combined clinical and multimodality imaging approach

PubMed Central

Cocchia, Rosangela; D’Andrea, Antonello; Conte, Marianna; Cavallaro, Massimo; Riegler, Lucia; Citro, Rodolfo; Sirignano, Cesare; Imbriaco, Massimo; Cappelli, Maurizio; Gregorio, Giovanni; Calabrò, Raffaele; Bossone, Eduardo

2017-01-01

Transcatheter aortic valve replacement (TAVR) has been validated as a new therapy for patients affected by severe symptomatic aortic stenosis who are not eligible for surgical intervention because of major contraindication or high operative risk. Patient selection for TAVR should be based not only on accurate assessment of aortic stenosis morphology, but also on several clinical and functional data. Multi-Imaging modalities should be preferred for assessing the anatomy and the dimensions of the aortic valve and annulus before TAVR. Ultrasounds represent the first line tool in evaluation of this patients giving detailed anatomic description of aortic valve complex and allowing estimating with enough reliability the hemodynamic entity of valvular stenosis. Angiography should be used to assess coronary involvement and plan a revascularization strategy before the implant. Multislice computed tomography play a central role as it can give anatomical details in order to choice the best fitting prosthesis, evaluate the morphology of the access path and detect other relevant comorbidities. Cardiovascular magnetic resonance and positron emission tomography are emergent modality helpful in aortic stenosis evaluation. The aim of this review is to give an overview on TAVR clinical and technical aspects essential for adequate selection. PMID:28400918

Improving compliance to colorectal cancer screening using blood and stool based tests in patients refusing screening colonoscopy in Germany.

PubMed

Adler, Andreas; Geiger, Sebastian; Keil, Anne; Bias, Harald; Schatz, Philipp; deVos, Theo; Dhein, Jens; Zimmermann, Mathias; Tauber, Rudolf; Wiedenmann, Bertram

2014-10-17

Despite strong recommendations for colorectal cancer (CRC) screening, participation rates are low. Understanding factors that affect screening choices is essential to developing future screening strategies. Therefore, this study assessed patient willingness to use non-invasive stool or blood based screening tests after refusing colonoscopy. Participants were recruited during regular consultations. Demographic, health, psychological and socioeconomic factors were recorded. All subjects were advised to undergo screening by colonoscopy. Subjects who refused colonoscopy were offered a choice of non-invasive tests. Subjects who selected stool testing received a collection kit and instructions; subjects who selected plasma testing had a blood draw during the office visit. Stool samples were tested with the Hb/Hp Complex Elisa test, and blood samples were tested with the Epi proColon® 2.0 test. Patients who were positive for either were advised to have a diagnostic colonoscopy. 63 of 172 subjects were compliant to screening colonoscopy (37%). 106 of the 109 subjects who refused colonoscopy accepted an alternative non-invasive method (97%). 90 selected the Septin9 blood test (83%), 16 selected a stool test (15%) and 3 refused any test (3%). Reasons for blood test preference included convenience of an office draw, overall convenience and less time consuming procedure. 97% of subjects refusing colonoscopy accepted a non-invasive screening test of which 83% chose the Septin9 blood test. The observation that participation can be increased by offering non-invasive tests, and that a blood test is the preferred option should be validated in a prospective trial in the screening setting.

Recruiting for values in healthcare: a preliminary review of the evidence.

PubMed

Patterson, Fiona; Prescott-Clements, Linda; Zibarras, Lara; Edwards, Helena; Kerrin, Maire; Cousans, Fran

2016-10-01

Displaying compassion, benevolence and respect, and preserving the dignity of patients are important for any healthcare professional to ensure the provision of high quality care and patient outcomes. This paper presents a structured search and thematic review of the research evidence relating to values-based recruitment within healthcare. Several different databases, journals and government reports were searched to retrieve studies relating to values-based recruitment published between 1998 and 2013, both in healthcare settings and other occupational contexts. There is limited published research related to values-based recruitment directly, so the available theoretical context of values is explored alongside an analysis of the impact of value congruence. The implications for the design of selection methods to measure values is explored beyond the scope of the initial literature search. Research suggests some selection methods may be appropriate for values-based recruitment, such as situational judgment tests (SJTs), structured interviews and multiple-mini interviews (MMIs). Personality tests were also identified as having the potential to compliment other methods (e.g. structured interviews), as part of a values-based recruitment agenda. Methods including personal statements, references and unstructured/'traditional' interviews were identified as inappropriate for values-based recruitment. Practical implications are discussed in the context of values-based recruitment in the healthcare context. Theoretical implications of our findings imply that prosocial implicit trait policies, which could be measured by selection tools such as SJTs and MMIs, may be linked to individuals' values via the behaviours individuals consider to be effective in given situations. Further research is required to state this conclusively however, and methods for values-based recruitment represent an exciting and relatively unchartered territory for further research.

What Is the Value of Value-Based Purchasing?

PubMed

Tanenbaum, Sandra J

2016-10-01

Value-based purchasing (VBP) is a widely favored strategy for improving the US health care system. The meaning of value that predominates in VBP schemes is (1) conformance to selected process and/or outcome metrics, and sometimes (2) such conformance at the lowest possible cost. In other words, VBP schemes choose some number of "quality indicators" and financially incent providers to meet them (and not others). Process measures are usually based on clinical science that cannot determine the effects of a process on individual patients or patients with comorbidities, and do not necessarily measure effects that patients value; additionally, there is no provision for different patients valuing different things. Proximate outcome measures may or may not predict distal ones, and the more distal the outcome, the less reliably it can be attributed to health care. Outcome measures may be quite rudimentary, such as mortality rates, or highly contestable: survival or function after prostate surgery? When cost is an element of value-based purchasing, it is the cost to the value-based payer and not to other payers or patients' families. The greatest value of value-based purchasing may not be to patients or even payers, but to policy makers seeking a morally justifiable alternative to politically contested regulatory policies. Copyright © 2016 by Duke University Press.

Epithelial–mesenchymal transition biomarkers and support vector machine guided model in preoperatively predicting regional lymph node metastasis for rectal cancer

PubMed Central

Fan, X-J; Wan, X-B; Huang, Y; Cai, H-M; Fu, X-H; Yang, Z-L; Chen, D-K; Song, S-X; Wu, P-H; Liu, Q; Wang, L; Wang, J-P

2012-01-01

Background: Current imaging modalities are inadequate in preoperatively predicting regional lymph node metastasis (RLNM) status in rectal cancer (RC). Here, we designed support vector machine (SVM) model to address this issue by integrating epithelial–mesenchymal-transition (EMT)-related biomarkers along with clinicopathological variables. Methods: Using tissue microarrays and immunohistochemistry, the EMT-related biomarkers expression was measured in 193 RC patients. Of which, 74 patients were assigned to the training set to select the robust variables for designing SVM model. The SVM model predictive value was validated in the testing set (119 patients). Results: In training set, eight variables, including six EMT-related biomarkers and two clinicopathological variables, were selected to devise SVM model. In testing set, we identified 63 patients with high risk to RLNM and 56 patients with low risk. The sensitivity, specificity and overall accuracy of SVM in predicting RLNM were 68.3%, 81.1% and 72.3%, respectively. Importantly, multivariate logistic regression analysis showed that SVM model was indeed an independent predictor of RLNM status (odds ratio, 11.536; 95% confidence interval, 4.113–32.361; P<0.0001). Conclusion: Our SVM-based model displayed moderately strong predictive power in defining the RLNM status in RC patients, providing an important approach to select RLNM high-risk subgroup for neoadjuvant chemoradiotherapy. PMID:22538975

A comparative study of machine learning methods for time-to-event survival data for radiomics risk modelling.

PubMed

Leger, Stefan; Zwanenburg, Alex; Pilz, Karoline; Lohaus, Fabian; Linge, Annett; Zöphel, Klaus; Kotzerke, Jörg; Schreiber, Andreas; Tinhofer, Inge; Budach, Volker; Sak, Ali; Stuschke, Martin; Balermpas, Panagiotis; Rödel, Claus; Ganswindt, Ute; Belka, Claus; Pigorsch, Steffi; Combs, Stephanie E; Mönnich, David; Zips, Daniel; Krause, Mechthild; Baumann, Michael; Troost, Esther G C; Löck, Steffen; Richter, Christian

2017-10-16

Radiomics applies machine learning algorithms to quantitative imaging data to characterise the tumour phenotype and predict clinical outcome. For the development of radiomics risk models, a variety of different algorithms is available and it is not clear which one gives optimal results. Therefore, we assessed the performance of 11 machine learning algorithms combined with 12 feature selection methods by the concordance index (C-Index), to predict loco-regional tumour control (LRC) and overall survival for patients with head and neck squamous cell carcinoma. The considered algorithms are able to deal with continuous time-to-event survival data. Feature selection and model building were performed on a multicentre cohort (213 patients) and validated using an independent cohort (80 patients). We found several combinations of machine learning algorithms and feature selection methods which achieve similar results, e.g. C-Index = 0.71 and BT-COX: C-Index = 0.70 in combination with Spearman feature selection. Using the best performing models, patients were stratified into groups of low and high risk of recurrence. Significant differences in LRC were obtained between both groups on the validation cohort. Based on the presented analysis, we identified a subset of algorithms which should be considered in future radiomics studies to develop stable and clinically relevant predictive models for time-to-event endpoints.

Otologic manifestations of Larsen syndrome.

PubMed

Marques, Letícia Helena de Sousa; Martins, Daniela Vieira; Juares, Gabriel Liria; Lorenzetti, Fábio Tadeu Moura; Monsanto, Rafael da Costa

2017-10-01

To describe and discuss otologic manifestations of Larsen syndrome, based on a case report and a systematic review of the literature. We performed a PubMED database search, and we selected studies reporting otolaryngologic manifestations secondary to Larsen syndrome. The selected articles were read in full, and three researchers independently extracted data from the studies. In parallel, we report the case of a 14-year-old patient who had hearing loss secondary to Larsen syndrome. Fifteen studies met our selection criteria. Seven studies reported hearing loss in patients with Larsen syndrome (4 had conductive hearing loss and 3 had mixed hearing loss). The conductive hearing loss may be secondary to ossicular malformations and/or middle ear effusions. Other causes for conductive hearing loss are mesenchymal remnants in the middle ear, Eustachian tube dysfunction, and cleft palate. Surgical management of the hearing loss is possible in selected cases, although the surgical and anesthetic risks should be considered. Hearing aids seem to be safe and effective treatment options for the hearing loss secondary to Larsen syndrome. Although rare, patients with Larsen syndrome may have hearing loss. The most frequent type of deficit is conductive, either secondary to malformation of the ossicles or middle ear effusion. Possible surgical correction of these abnormalities should be weighed against the anesthetic risks of these patients. Copyright © 2017 Elsevier B.V. All rights reserved.

Office Operative Hysteroscopy: An Update.

PubMed

Salazar, Christina Alicia; Isaacson, Keith B

2018-02-01

Hysteroscopy is considered the gold standard for the evaluation of intracavitary pathology in both premenopausal and postmenopausal patients associated with abnormal uterine bleeding, as well as for the evaluation of infertile patients with suspected cavity abnormalities. Office-based operative hysteroscopy allows patients to resume activities immediately and successfully integrates clinical practice into a "see and treat" modality, avoiding the added risks of anesthesia and the inconvenience of the operating room. For 2017, the Centers for Medicare and Medicaid Services has provided a substantial increase in reimbursement for a select number of office-based hysteroscopic procedures. This review provides an update on the indications, equipment, and procedures for office hysteroscopy, as well as the management of complications that may arise within an office-based practice. Copyright © 2018. Published by Elsevier Inc.

What affects response rates in primary healthcare-based programmes? An analysis of individual and unit-related factors associated with increased odds of non-response based on HCV screening in the general population in Poland

PubMed Central

Parda, Natalia; Stępień, Małgorzata; Zakrzewska, Karolina; Madaliński, Kazimierz; Kołakowska, Agnieszka; Godzik, Paulina; Rosińska, Magdalena

2016-01-01

Objectives Response rate in public health programmes may be a limiting factor. It is important to first consider their delivery and acceptability for the target. This study aimed at determining individual and unit-related factors associated with increased odds of non-response based on hepatitis C virus screening in primary healthcare. Design Primary healthcare units (PHCUs) were extracted from the Register of Health Care Centres. Each of the PHCUs was to enrol adult patients selected on a random basis. Data on the recruitment of PHCUs and patients were analysed. Multilevel modelling was applied to investigate individual and unit-related factors associated with non-response. Multilevel logistic model was developed with fixed effects and only a random intercept for the unit. Preliminary analysis included a random effect for unit and each of the individual or PHCU covariates separately. For each of the PHCU covariates, we applied a two-level model with individual covariates, unit random effect and a single fixed effect of this unit covariate. Setting This study was conducted in primary care units in selected provinces in Poland. Participants A total of 242 PHCUs and 24 480 adults were invited. Of them, 44 PHCUs and 20 939 patients agreed to participate. Both PHCUs and patients were randomly selected. Results Data on 44 PHCUs and 24 480 patients were analysed. PHCU-level factors and recruitment strategies were important predictors of non-response. Unit random effect was significant in all models. Larger and private units reported higher non-response rates, while for those with a history of running public health programmes the odds of non-response was lower. Proactive recruitment, more working hours devoted to the project and patient resulted in higher acceptance of the project. Higher number of personnel had no such effect. Conclusions Prior to the implementation of public health programme, several factors that could hinder its execution should be addressed. PMID:27927665

What affects response rates in primary healthcare-based programmes? An analysis of individual and unit-related factors associated with increased odds of non-response based on HCV screening in the general population in Poland.

PubMed

Parda, Natalia; Stępień, Małgorzata; Zakrzewska, Karolina; Madaliński, Kazimierz; Kołakowska, Agnieszka; Godzik, Paulina; Rosińska, Magdalena

2016-12-07

Response rate in public health programmes may be a limiting factor. It is important to first consider their delivery and acceptability for the target. This study aimed at determining individual and unit-related factors associated with increased odds of non-response based on hepatitis C virus screening in primary healthcare. Primary healthcare units (PHCUs) were extracted from the Register of Health Care Centres. Each of the PHCUs was to enrol adult patients selected on a random basis. Data on the recruitment of PHCUs and patients were analysed. Multilevel modelling was applied to investigate individual and unit-related factors associated with non-response. Multilevel logistic model was developed with fixed effects and only a random intercept for the unit. Preliminary analysis included a random effect for unit and each of the individual or PHCU covariates separately. For each of the PHCU covariates, we applied a two-level model with individual covariates, unit random effect and a single fixed effect of this unit covariate. This study was conducted in primary care units in selected provinces in Poland. A total of 242 PHCUs and 24 480 adults were invited. Of them, 44 PHCUs and 20 939 patients agreed to participate. Both PHCUs and patients were randomly selected. Data on 44 PHCUs and 24 480 patients were analysed. PHCU-level factors and recruitment strategies were important predictors of non-response. Unit random effect was significant in all models. Larger and private units reported higher non-response rates, while for those with a history of running public health programmes the odds of non-response was lower. Proactive recruitment, more working hours devoted to the project and patient resulted in higher acceptance of the project. Higher number of personnel had no such effect. Prior to the implementation of public health programme, several factors that could hinder its execution should be addressed. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

A Fuzzy-Based Decision Support Model for Selecting the Best Dialyser Flux in Haemodialysis.

PubMed

Oztürk, Necla; Tozan, Hakan

2015-01-01

Decision making is an important procedure for every organization. The procedure is particularly challenging for complicated multi-criteria problems. Selection of dialyser flux is one of the decisions routinely made for haemodialysis treatment provided for chronic kidney failure patients. This study provides a decision support model for selecting the best dialyser flux between high-flux and low-flux dialyser alternatives. The preferences of decision makers were collected via a questionnaire. A total of 45 questionnaires filled by dialysis physicians and nephrologists were assessed. A hybrid fuzzy-based decision support software that enables the use of Analytic Hierarchy Process (AHP), Fuzzy Analytic Hierarchy Process (FAHP), Analytic Network Process (ANP), and Fuzzy Analytic Network Process (FANP) was used to evaluate the flux selection model. In conclusion, the results showed that a high-flux dialyser is the best. option for haemodialysis treatment.

Paying for Primary Care: The Factors Associated with Physician Self-selection into Payment Models.

PubMed

Rudoler, David; Deber, Raisa; Barnsley, Janet; Glazier, Richard H; Dass, Adrian Rohit; Laporte, Audrey

2015-09-01

To determine the factors associated with primary care physician self-selection into different payment models, we used a panel of eight waves of administrative data for all primary care physicians who practiced in Ontario between 2003/2004 and 2010/2011. We used a mixed effects logistic regression model to estimate physicians' choice of three alternative payment models: fee for service, enhanced fee for service, and blended capitation. We found that primary care physicians self-selected into payment models based on existing practice characteristics. Physicians with more complex patient populations were less likely to switch into capitation-based payment models where higher levels of effort were not financially rewarded. These findings suggested that investigations aimed at assessing the impact of different primary care reimbursement models on outcomes, including costs and access, should first account for potential selection effects. Copyright © 2015 John Wiley & Sons, Ltd.

Validation of persuasive messages for the promotion of physical activity among people with coronary heart disease.

PubMed

Mendez, Roberto Della Rosa; Rodrigues, Roberta Cunha Matheus; Spana, Thaís Moreira; Cornélio, Marília Estevam; Gallani, Maria Cecília Bueno Jayme; Pérez-Nebra, Amalia Raquel

2012-01-01

to validate the content of persuasive messages for promoting walking among patients with coronary heart disease (CHD). The messages were constructed to strengthen or change patients' attitudes to walking. the selection of persuasive arguments was based on behavioral beliefs (determinants of attitude) related to walking. The messages were constructed based in the Elaboration Likelihood Model and were submitted to content validation. the data was analyzed with the content validity index and by the importance which the patients attributed to the messages' persuasive arguments. Positive behavioral beliefs (i.e. positive and negative reinforcement) and self-efficacy were the appeals which the patients considered important. The messages with validation evidence will be tested in an intervention study for the promotion of the practice of physical activity among patients with CHD.

Selecting Statistical Procedures for Quality Control Planning Based on Risk Management.

PubMed

Yago, Martín; Alcover, Silvia

2016-07-01

According to the traditional approach to statistical QC planning, the performance of QC procedures is assessed in terms of its probability of rejecting an analytical run that contains critical size errors (PEDC). Recently, the maximum expected increase in the number of unacceptable patient results reported during the presence of an undetected out-of-control error condition [Max E(NUF)], has been proposed as an alternative QC performance measure because it is more related to the current introduction of risk management concepts for QC planning in the clinical laboratory. We used a statistical model to investigate the relationship between PEDC and Max E(NUF) for simple QC procedures widely used in clinical laboratories and to construct charts relating Max E(NUF) with the capability of the analytical process that allow for QC planning based on the risk of harm to a patient due to the report of erroneous results. A QC procedure shows nearly the same Max E(NUF) value when used for controlling analytical processes with the same capability, and there is a close relationship between PEDC and Max E(NUF) for simple QC procedures; therefore, the value of PEDC can be estimated from the value of Max E(NUF) and vice versa. QC procedures selected by their high PEDC value are also characterized by a low value for Max E(NUF). The PEDC value can be used for estimating the probability of patient harm, allowing for the selection of appropriate QC procedures in QC planning based on risk management. © 2016 American Association for Clinical Chemistry.

Major publications in the critical care pharmacotherapy literature: January-December 2014.

PubMed

Day, Sarah A; Cucci, Michaelia; Droege, Molly E; Holzhausen, Jenna M; Kram, Bridgette; Kram, Shawn; Pajoumand, Mehrnaz; Parker, Christine R; Patel, Mona K; Peitz, Gregory J; Poore, Alia; Turck, Charles J; Van Berkel, Megan A; Wong, Adrian; Zomp, Amanda; Rech, Megan A

2015-11-15

Nine recently published articles and one guideline with important implications for critical care pharmacy practice are summarized. The Critical Care Pharmacotherapy Literature Update (CCPLU) group includes more than 40 experienced critical care pharmacists across the United States. Group members monitor 29 peer-reviewed journals on an ongoing basis to identify literature relevant to pharmacy practice in the critical care setting. After evaluation by CCPLU group members, selected articles are chosen for summarization and distribution to group members nationwide based on applicability to practice, relevance, and study design and strength. Hundreds of relevant articles were evaluated by the group in 2014, of which 114 were summarized and disseminated to CCPLU group members. From among those 114 publications, 10 deemed to be of particularly high utility to the critical care practitioner were selected for inclusion in this review for their potential to change practice or reinforce current evidence-based practice. One of the selected articles presents updated recommendations on the management of patients with atrial fibrillation (AF); the other 9 address topics such as albumin replacement in patients with severe sepsis, use of enteral statins for acute respiratory distress syndrome, fibrinolysis for patients with intermediate-risk pulmonary embolism, the use of unfractionated heparin versus bivalirudin for primary percutaneous coronary intervention, and early protocol-based care for septic shock. There were many important additions to the critical care pharmacotherapy literature in 2014, including a joint guideline for the management of AF and reports of clinical trials. Copyright © 2015 by the American Society of Health-System Pharmacists, Inc. All rights reserved.

Using technology to improve and support communication and workflow processes.

PubMed

Bahlman, Deborah Tuke; Johnson, Fay C

2005-07-01

In conjunction with a large expansion project, a team of perioperative staff members reviewed their workflow processes and designed their ideal patient tracking and communication system. Technologies selected and deployed included a passive infrared tracking system, an enhanced nurse call system, wireless telephones, and a web-based electronic grease board. The new system provides staff members with an easy way to obtain critical pieces of patient information, as well as track the progress of patients and locate equipment.

3D conformal radiation therapy for palliative treatment of canine nasal tumors.

PubMed

Buchholz, Julia; Hagen, Regine; Leo, Chiara; Ebling, Alessia; Roos, Malgorzata; Kaser-Hotz, Barbara; Bley, Carla Rohrer

2009-01-01

We evaluated the response of 38 dogs treated with a coarsely fractionated, palliative radiation protocol based on CT-based 3D treatment planning. Dogs with histologically confirmed malignant nasal tumors were studied. Treatment prescriptions consisted of 3-4 x 8 Gy, 4-5 x 6 Gy, or 10 x 3 Gy fractions. Selected patient and tumor factors were evaluated for an effect on outcome. Resolution of clinical signs was reported after irradiation in all dogs. Acute toxicities were mild and short lived. Thirty-seven of 38 dogs died or were euthanized due to tumor-related disease. Overall median progression-free interval (PFI) was 10 months. Tumor stage affected response, with modified stage 1 patients having a median PFI 21.3 months vs. a median PFI of 8.5 months for modified stage 2 patients (P = 0.0006). Modified stage was the only factor significantly related to outcome. Based on these findings, a palliative radiation prescription based on computerized treatment planning may be justified in some canine nasal tumor patients.

[Prevalence of chronic fatigue syndrome in 4 family practices in Leiden].

PubMed

Versluis, R G; de Waal, M W; Opmeer, C; Petri, H; Springer, M P

1997-08-02

To determine the prevalence of chronic fatigue syndrome (CFS) in general practice. Descriptive. General practice and primary health care centres in Leyden region, the Netherlands. RNUH-LEO is a computerized database which contains the anonymous patient information of one general practice (with two practitioners) and four primary health care centres. The fourteen participating general practitioners were asked what International Classification of Primary Care (ICPC) code they used to indicate a patient with chronic fatigue or with CFS. With these codes and with the code for depression patients were selected from the database. It then was determined whether these patients met the criteria of CFS by Holmes et al. The general practitioners used 10 codes. Including the code for depression a total of 601 patients were preselected from a total of 23,000 patients in the database. Based on the information from the patients' records in the database, 42 of the preselected patients were selected who might fulfill the Holmes' criteria of CFS. According to the patients' own general practitioner, 25 of the 42 patients would fulfil the Holmes' criteria. The men:women ratio was 1:5. The prevalence of CFS in the population surveyed was estimated to be at least 1.1 per 1,000 patients.

The Selection of the Appropriate Computer Interface Device for Patients With High Cervical Cord Injury

PubMed Central

Kim, Dong-Goo; Lim, Sung Eun; Kim, Dong-A; Hwang, Sung Il; Yim, You-lim; Park, Jeong Mi

2013-01-01

In order to determine the most suitable computer interfaces for patients with high cervical cord injury, we report three cases of applications of special input devices. The first was a 49-year-old patient with neurological level of injury (NLI) C4, American Spinal Injury Association Impairment Scale (ASIA)-A. He could move the cursor by using a webcam-based Camera Mouse. Moreover, clicking the mouse could only be performed by pronation of the forearm on the modified Micro Light Switch. The second case was a 41-year-old patient with NLI C3, ASIA-A. The SmartNav 4AT which responds according to head movements could provide stable performance in clicking and dragging. The third was a 13-year-old patient with NLI C1, ASIA-B. The IntegraMouse enabling clicking and dragging with fine movements of the lips. Selecting the appropriate interface device for patients with high cervical cord injury could be considered an important part of rehabilitation. We expect the standard proposed in this study will be helpful. PMID:23869346

Are validated outcome measures used in distal radial fractures truly valid?

PubMed Central

Nienhuis, R. W.; Bhandari, M.; Goslings, J. C.; Poolman, R. W.; Scholtes, V. A. B.

2016-01-01

Objectives Patient-reported outcome measures (PROMs) are often used to evaluate the outcome of treatment in patients with distal radial fractures. Which PROM to select is often based on assessment of measurement properties, such as validity and reliability. Measurement properties are assessed in clinimetric studies, and results are often reviewed without considering the methodological quality of these studies. Our aim was to systematically review the methodological quality of clinimetric studies that evaluated measurement properties of PROMs used in patients with distal radial fractures, and to make recommendations for the selection of PROMs based on the level of evidence of each individual measurement property. Methods A systematic literature search was performed in PubMed, EMbase, CINAHL and PsycINFO databases to identify relevant clinimetric studies. Two reviewers independently assessed the methodological quality of the studies on measurement properties, using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Level of evidence (strong / moderate / limited / lacking) for each measurement property per PROM was determined by combining the methodological quality and the results of the different clinimetric studies. Results In all, 19 out of 1508 identified unique studies were included, in which 12 PROMs were rated. The Patient-rated wrist evaluation (PRWE) and the Disabilities of Arm, Shoulder and Hand questionnaire (DASH) were evaluated on most measurement properties. The evidence for the PRWE is moderate that its reliability, validity (content and hypothesis testing), and responsiveness are good. The evidence is limited that its internal consistency and cross-cultural validity are good, and its measurement error is acceptable. There is no evidence for its structural and criterion validity. The evidence for the DASH is moderate that its responsiveness is good. The evidence is limited that its reliability and the validity on hypothesis testing are good. There is no evidence for the other measurement properties. Conclusion According to this systematic review, there is, at best, moderate evidence that the responsiveness of the PRWE and DASH are good, as are the reliability and validity of the PRWE. We recommend these PROMs in clinical studies in patients with distal radial fractures; however, more clinimetric studies of higher methodological quality are needed to adequately determine the other measurement properties. Cite this article: Dr Y. V. Kleinlugtenbelt. Are validated outcome measures used in distal radial fractures truly valid?: A critical assessment using the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklist. Bone Joint Res 2016;5:153–161. DOI: 10.1302/2046-3758.54.2000462. PMID:27132246

Group cognitive behavioral therapy to improve the quality of care to opioid-treated patients with chronic noncancer pain: a practice improvement project.

PubMed

Whitten, Stacey K; Stanik-Hutt, Julie

2013-07-01

To enhance outcomes of patients with chronic noncancer pain (CNCP) treated with opioids in a primary care setting by implementing an evidence-based quality improvement project. The project consisted of the implementation of a 6-week cognitive behavioral therapy (CBT) program. Twenty-two patients with CNCP completed the program. Impact of the project was evaluated by comparing pre- and postintervention participant self-reports of mood on the Beck Depression Inventory and functional status on the Brief Pain Inventory and Short Form-36. Patient perception of treatment benefit was also measured using the Patient Global Impression of Change. Qualitative provider perceptions of the program were also collected. Paired t-test statistics were used to analyze the data. Mood (including negative attitude, performance difficulty, and physical complaints), and patient impression of treatment benefit improved significantly after CBT was added. Primary care providers reported that the CBT supported their overall management of these complex patients. The addition of a CBT program improved selected outcomes in this self-selected sample of patients with CNCP treated with opioids. ©2012 The Author(s) ©2012 American Association of Nurse Practitioners.

Thyroid Lobectomy Is Associated with Excellent Clinical Outcomes in Properly Selected Differentiated Thyroid Cancer Patients with Primary Tumors Greater Than 1 cm

PubMed Central

Vaisman, Fernanda; Momesso, Denise; Bulzico, Daniel A.; Pessoa, Cencita H. C. N.; da Cruz, Manuel Domingos Gonçalves; Dias, Fernando; Corbo, Rossana; Vaisman, Mario; Tuttle, R. Michael

2013-01-01

Background and Objective. An individualized risk-based approach to the treatment of thyroid cancer is being extensively discussed in the recent literature. However, controversies about the ideal surgical approach remain an important issue with regard to the impact on prognosis and follow-up strategies. This study was designed to describe clinical outcomes in a cohort of low and intermediate risk thyroid cancer patients treated with thyroid lobectomy. Methods. Retrospective review of 70 patients who underwent lobectomy. Results. After a median follow-up of 11 years, 5 patients (5/70, 7.1%) recurred and 5 had a completion for benign lesions, while 60 patients (86%) continued to be observed without evidence for disease recurrence. Suspicious ultrasound findings were significantly more common in patients that had structural disease recurrence (100% versus 4.3%, P < 0.001). Furthermore, a rising suppressed Tg value over time was also associated with structural disease recurrence (80% versus 21.5%, P = 0.01). After additional therapy, 99% of the patients had no evidence of disease. Conclusions. Properly selected thyroid cancer patients can be treated with lobectomy with excellent clinical outcomes. PMID:24455413

Dose reduction for abdominal and pelvic MDCT after change to graduated weight-based protocol for selecting quality reference tube current, peak kilovoltage, and slice collimation.

PubMed

Herts, Brian R; Baker, Mark E; Obuchowski, Nancy; Primak, Andrew; Schneider, Erika; Rhana, Harpreet; Dong, Frank

2013-06-01

The purpose of this article is to determine the decrease in volume CT dose index (CTDI(vol)) and dose-length product (DLP) achieved by switching from fixed quality reference tube current protocols with automatic tube current modulation to protocols adjusting the quality reference tube current, slice collimation, and peak kilovoltage according to patient weight. All adult patients who underwent CT examinations of the abdomen or abdomen and pelvis during 2010 using weight-based protocols who also underwent a CT examination in 2008 or 2009 using fixed quality reference tube current protocols were identified from the radiology information system. Protocol pages were electronically retrieved, and the CT model, examination date, scan protocol, CTDI(vol), and DLP were extracted from the DICOM header or by optical character recognition. There were 15,779 scans with dose records for 2700 patients. Changes in CTDI(vol) and DLP were compared only between examinations of the same patient and same CT system model for examinations performed in 2008 or 2009 and those performed in 2010. The final analysis consisted of 1117 comparisons in 1057 patients, and 1209 comparisons in 988 patients for CTDI(vol) and DLP, respectively. The change to a weight-based protocol resulted in a statistically significant reduction in CTDI(vol) and DLP on three MDCT system models (p < 0.001). The largest average CTDI(vol) decrease was 13.9%, and the largest average DLP decrease was 16.1% on a 64-MDCT system. Both the CTDI(vol) and DLP decreased the most for patients who weighed less than 250 lb (112.5 kg). Adjusting the CT protocol by selecting parameters according to patient weight is a viable method for reducing CT radiation dose. The largest reductions occurred in the patients weighing less than 250 lb.

The development of a personalized patient education tool for decision making for postmenopausal women with osteoporosis.

PubMed

Hiligsmann, M; Ronda, G; van der Weijden, T; Boonen, A

2016-08-01

A personalized patient education tool for decision making (PET) for postmenopausal women with osteoporosis was developed by means of a systematic development approach. A prototype was constructed and refined by involving various professionals and patients. Professionals and patients expressed a positive attitude towards the use of the PET. The purpose was to systematically develop a paper-based personalized PET to assist postmenopausal women with osteoporosis in selecting a treatment in line with their personal values and preferences. The development of the PET was based on a systematic process including scope, design, development of a prototype, and alpha testing among professionals and patients by semi-structured interviews. The design and development resulted in a four-page PET prototype together with a one-page fact sheet of the different drug options. The prototype PET provided the personal risk factors, the estimated individualized risk for a future major osteoporotic fracture and potential reduction with drugs, and a summary of advantages and disadvantages whether or not to start drugs. The drug fact sheet presents five attributes of seven drugs in a tabular format. The alpha testing with professionals resulted in some adaptations, e.g., inclusion of the possibility to calculate fracture risk based on various individual risk scoring methods. Important results from the alpha testing with patients were differences in the fracture risk percentage which was seen as worthwhile to start drugs, the importance of an overview of side effects, and of the timing of the PET into the patient pathway. All women indicated that the PET could be helpful for their decision to select a treatment. Physicians and patients expressed a positive attitude towards the use of the proposed PET. Further research would be needed to test the effects of the PET on feasibility in clinical workflow and on patient outcomes.

Strategic Review Process for an Accountable Care Organization and Emerging Accountable Care Best Practices.

PubMed

Conway, Sarah J; Himmelrich, Sarah; Feeser, Scott A; Flynn, John A; Kravet, Steven J; Bailey, Jennifer; Hebert, Lindsay C; Donovan, Susan H; Kachur, Sarah G; Brown, Patricia M C; Baumgartner, William A; Berkowitz, Scott A

2018-02-02

Accountable Care Organizations (ACOs), like other care entities, must be strategic about which initiatives they support in the quest for higher value. This article reviews the current strategic planning process for the Johns Hopkins Medicine Alliance for Patients (JMAP), a Medicare Shared Savings Program Track 1 ACO. It reviews the 3 focus areas for the 2017 strategic review process - (1) optimizing care coordination for complex, at-risk patients, (2) post-acute care, and (3) specialty care integration - reviewing cost savings and quality improvement opportunities, associated best practices from the literature, and opportunities to leverage and advance existing ACO and health system efforts in each area. It then reviews the ultimate selection of priorities for the coming year and early thoughts on implementation. After the robust review process, key stakeholders voted to select interventions targeted at care coordination, post-acute care, and specialty integration including Part B drug and imaging costs. The interventions selected incorporate a mixture of enhancing current ACO initiatives, working collaboratively and synergistically on other health system initiatives, and taking on new projects deemed targeted, cost-effective, and manageable in scope. The annual strategic review has been an essential and iterative process based on performance data and informed by the collective experience of other organizations. The process allows for an evidence-based strategic plan for the ACO in pursuit of the best care for patients.

Prescription patterns and appropriateness of NSAID therapy according to gastrointestinal risk and cardiovascular history in patients with diagnoses of osteoarthritis.

PubMed

Lanas, Angel; Garcia-Tell, Guillermo; Armada, Beatriz; Oteo-Alvaro, Angel

2011-04-14

Prescription of non-steroidal anti-inflammatory drugs (NSAIDs) should be based on the assessment of both gastrointestinal (GI) and cardiovascular (CV) risk for the individual patient. We aimed to assess the GI/CV risk profile and the pharmacological management of patients with osteoarthritis (OA) in clinical practice. We conducted a cross-sectional, multicentre, observational study of consecutive OA patients that visited 1,760 doctors throughout the Spanish National Health System (NHS) in a single day. The presence of GI risk factors, CV histories, hypertension and current pharmacological treatments was recorded. Of the 60,868 patients, 17,105 had a diagnosis of OA and were evaluable. The majority (93.4%) had more than one GI risk factor and 60.3% were defined to be at high-GI risk. Thirty-two percent had a history of CV events, 57.6% were treated with anti-hypertensive therapy and 22.6% had uncontrolled hypertension. One-fifth of patients were treated with non-NSAID therapies, whereas the remaining patients received NSAIDs. Non-selective NSAIDs (nsNSAID) plus proton pump inhibitor (PPI) or cyclooxigenase-2 (COX-2)-selective NSAIDs alone were more frequently prescribed in patients at increased GI risk. Patients with a positive CV history received nsNSAIDs or COX-2-selective NSAIDs in 41.3% and 31.7% of cases, respectively. When both the GI and CV histories were combined, 51% of the overall population was being prescribed drugs that were either not recommended or contraindicated. Over 90% of patients with OA are at increased GI and/or CV risk. In over half of these patients, the prescription of NSAIDs was not in accordance with current guidelines or recommendations made by regulatory agencies.

Treatment Outcomes in Stage I Lung Cancer: A Comparison of Surgery and Stereotactic Body Radiation Therapy (SBRT)

PubMed Central

Puri, Varun; Crabtree, Traves D.; Bell, Jennifer M.; Broderick, Stephen R; Morgensztern, Daniel; Colditz, Graham A.; Kreisel, Daniel; Krupnick, A. Sasha; Patterson, G. Alexander; Meyers, Bryan F.; Patel, Aalok; Robinson, Clifford G.

2015-01-01

Introduction The relative roles of surgery and stereotactic body radiation therapy in stage I non-small cell lung cancer (NSCLC) are evolving particularly for marginally operable patients. Since there is limited prospective comparative data for these treatment modalities, we evaluated their relative use and outcomes at the population level using a national database. Methods Patient variables and treatment-related outcomes were abstracted for patients with clinical stage I NSCLC from the National Cancer Database. Patients receiving surgery were compared to those undergoing SBRT in exploratory unmatched and subsequent propensity matched analyses. Results Between 1998 and 2010, 117618 patients underwent surgery or SBRT for clinical stage I NSCLC. Of these, 111731 (95%) received surgery while 5887 (5%) underwent SBRT. Patients in the surgery group were younger, more likely to be males, and had higher Charlson comorbidity scores. SBRT patients were more likely to have T1 (vs.T2) tumors and receive treatment at academic centers. Thirty-day surgical mortality was 2596/109485 (2.4%). Median overall survival favored the surgery group in both unmatched (68.4 months vs. 33.3 months, p<.001) and matched analysis based on patient characteristics (62.3 months vs. 33.1months, p<.001). Disease specific survival was unavailable from the dataset. Conclusion In a propensity matched comparison, patients selected for surgery have improved survival compared with SBRT. In the absence of information on cause of death and with limited variables to characterize comorbidity, it is not possible to assess the relative contribution of patient selection or better cancer control towards the improved survival. Rigorous prospective studies are needed to optimize patient selection for SBRT in the high-risk surgical population. PMID:26334753

Patient-Customized Drug Combination Prediction and Testing for T-cell Prolymphocytic Leukemia Patients.

PubMed

He, Liye; Tang, Jing; Andersson, Emma I; Timonen, Sanna; Koschmieder, Steffen; Wennerberg, Krister; Mustjoki, Satu; Aittokallio, Tero

2018-05-01

The molecular pathways that drive cancer progression and treatment resistance are highly redundant and variable between individual patients with the same cancer type. To tackle this complex rewiring of pathway cross-talk, personalized combination treatments targeting multiple cancer growth and survival pathways are required. Here we implemented a computational-experimental drug combination prediction and testing (DCPT) platform for efficient in silico prioritization and ex vivo testing in patient-derived samples to identify customized synergistic combinations for individual cancer patients. DCPT used drug-target interaction networks to traverse the massive combinatorial search spaces among 218 compounds (a total of 23,653 pairwise combinations) and identified cancer-selective synergies by using differential single-compound sensitivity profiles between patient cells and healthy controls, hence reducing the likelihood of toxic combination effects. A polypharmacology-based machine learning modeling and network visualization made use of baseline genomic and molecular profiles to guide patient-specific combination testing and clinical translation phases. Using T-cell prolymphocytic leukemia (T-PLL) as a first case study, we show how the DCPT platform successfully predicted distinct synergistic combinations for each of the three T-PLL patients, each presenting with different resistance patterns and synergy mechanisms. In total, 10 of 24 (42%) of selective combination predictions were experimentally confirmed to show synergy in patient-derived samples ex vivo The identified selective synergies among approved drugs, including tacrolimus and temsirolimus combined with BCL-2 inhibitor venetoclax, may offer novel drug repurposing opportunities for treating T-PLL. Significance: An integrated use of functional drug screening combined with genomic and molecular profiling enables patient-customized prediction and testing of drug combination synergies for T-PLL patients. Cancer Res; 78(9); 2407-18. ©2018 AACR . ©2018 American Association for Cancer Research.

Mechanical Thrombectomy in Wake-Up Strokes: A Case Series Using Alberta Stroke Program Early CT Score (ASPECTS) for Patient Selection.

PubMed

Konstas, Angelos Aristeidis; Minaeian, Artin; Ross, Ian B

2017-07-01

There is lack of published studies on mechanical thrombectomy with stent retrievers for wake-up stroke (WUS). To report the outcomes of WUS patients with large vessel occlusions, selected for intervention based on Alberta Stroke Program Early CT Score (ASPECTS) and treated with stent retrievers or primary aspiration thrombectomy. Data were collected retrospectively for each consecutive WUS patient undergoing mechanical thrombectomy with a stent retriever or primary aspiration catheter between February 2015 and September 2016. ASPECTS ≥ 6 was used as the primary imaging criterion for offering thrombectomy in these WUS patients. Main outcomes were the in-hospital improvement in the National Institutes of Health Stroke Scale (NIHSS) and the occurrence of symptomatic hemorrhage. Twelve patients were included in this study; 11 were treated with stent retrievers and 1 was treated with primary aspiration thrombectomy alone. Successful recanalization was achieved in 100% of the patients (33% thrombolysis in cerebral infarction [TICI] 2B and 67% TICI 3). Every patient experienced a reduction in the NIHSS during hospitalization, with a mean NIHSS decrease of 11.1 ± 5.1 points. There was a trend for a larger reduction in the NIHSS in patients with TICI 3 compared to TICI 2B recanalization. There was no symptomatic intracranial hemorrhage in our cohort. For patients with WUS, careful selection of patients using ASPECTS may allow for safe interventions, with low risk of clinical deterioration, and no-periprocedural mortality. All our patients demonstrated a reduction in their NIHSS after the thrombectomy and clinical improvement. Copyright © 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Feasibility of Cisplatin-Based Neoadjuvant Chemotherapy in Muscle-Invasive Bladder Cancer Patients With Diminished Renal Function.

PubMed

Koshkin, Vadim S; Barata, Pedro C; Rybicki, Lisa A; Zahoor, Haris; Almassi, Nima; Redden, Alicia M; Fergany, Amr F; Kaouk, Jihad; Haber, Georges-Pascal; Stephenson, Andrew J; Ornstein, Moshe C; Gilligan, Timothy; Garcia, Jorge A; Rini, Brian I; Grivas, Petros

2018-02-22

Cisplatin-based neoadjuvant chemotherapy (NAC) before radical cystectomy is the standard of care in muscle-invasive bladder cancer. There are limited data regarding chemotherapy tolerability and outcomes for patients with low glomerular filtration rate (GFR) who receive cisplatin-based NAC. A retrospective analysis of patients who received cisplatin-based NAC at Cleveland Clinic (2005-2016) was undertaken. Patients with pre-NAC GFR < 60 mL/min by either Cockcroft-Gault (CG) or Modification of Diet in Renal Disease (MDRD) formula were compared to patients with GFR ≥ 60 mL/min for NAC tolerability, pathologic complete and partial response (pPR), and the ability to undergo radical cystectomy. Thirty patients with low GFR (34-59 mL/min) and 94 patients with normal GFR (≥ 60 mL/min) were identified. Low GFR patients were older (median, 71 vs. 65 years), but other demographic and transurethral resection of bladder tumor characteristics were comparable. Low GFR patients more frequently had early NAC discontinuation (30% vs. 13%), NAC modifications (delays, dose reduction, or discontinuation, 66% vs. 40%), and cisplatin-based NAC administered in split doses (37% vs. 16%). No differences in NAC tolerability or outcomes were noted among low GFR patients receiving split-dose versus standard regimens. No differences were noted between low and normal GFR patients in NAC cycles (median, 3 for each), cystectomy rates (93% for each), time to cystectomy, and GFR change from baseline to after NAC. Pathologic complete response was higher among normal GFR patients (24% vs. 14%). Patients with low GFR had more NAC discontinuations and modifications, but most completed planned NAC cycles. For carefully selected patients with GFR < 60 mL/min, cisplatin-based NAC remains a treatment option. Copyright © 2018 Elsevier Inc. All rights reserved.

Influence knowledge and behavior of TB medical personnels’ concordance principle based communications skill at primary healthcare, Medan, Indonesia

NASA Astrophysics Data System (ADS)

Wahyuni, A. S.; Soeroso, N. N.; Alona, I.; Yunanda, Y.; Siregar, I.

2018-03-01

Concordance behavior of TB management is a form of collaboration among doctors, personnel, and patients in treating TB. Approvalamong them could be achieved if credibility and policy occur. This study is aimed to analyze the influence of TB medical personnel’s concordance behaviour principle to patient obedience at primary health care in Medan.The design of this study was quasi experimental, focusing on interventional primary health care, which is those who applied concordance behaviour principle to non-interventionalprimary health care. The population is TB patients, starting from 18 years old, TB category I with positive Acid Fast Bacilli Smear Test (AFBST), and taking TB regimens at Medan. Seventy- four patients were selected to be samples. They had undergone interview based on validated concordance principle, knowledge, behavior, and treatment. Data were analyzed using chi- square. The percentage of knowledge, behavior of TB patient to the treatment is higher on interventional primary health care than noninterventional ones. Treatment awareness based on concordance principle is expected to planish DOTS-based TB programs.

The indications and timing for operative management of spinal epidural abscess: literature review and treatment algorithm.

PubMed

Tuchman, Alexander; Pham, Martin; Hsieh, Patrick C

2014-08-01

Delayed or inappropriate treatment of spinal epidural abscess (SEA) can lead to serious morbidity or death. It is a rare event with significant variation in its causes, anatomical locations, and rate of progression. Traditionally the treatment of choice has involved emergency surgical evacuation and a prolonged course of antibiotics tailored to the offending pathogen. Recent publications have advocated antibiotic treatment without surgical decompression in select patient populations. Clearly defining those patients who can be safely treated in this manner remains in evolution. The authors review the current literature concerning the treatment and outcome of SEA to make recommendations concerning what population can be safely triaged to nonoperative management and the optimal timing of surgery. A PubMed database search was performed using a combination of search terms and Medical Subject Headings, to identify clinical studies reporting on the treatment and outcome of SEA. The literature review revealed 28 original case series containing at least 30 patients and reporting on treatment and outcome. All cohorts were deemed Class III evidence, and in all but two the data were obtained retrospectively. Based on the conclusions of these studies along with selected smaller studies and review articles, the authors present an evidence-based algorithm for selecting patients who may be safe candidates for nonoperative management. Patients who are unable to undergo an operation, have a complete spinal cord injury more than 48 hours with low clinical or radiographic concern for an ascending lesion, or who are neurologically stable and lack risk factors for failure of medical management may be initially treated with antibiotics alone and close clinical monitoring. If initial medical management is to be undertaken the patient should be made aware that delayed neurological deterioration may not fully resolve even after prompt surgical treatment. Patients deemed good surgical candidates should receive their operation as soon as possible because the rate of clinical deterioration with SEA is notoriously unpredictable. Although patients tend to recover from neurological deficits after treatment of SEA, the time point when a neurological injury becomes irreversible is unknown, supporting emergency surgery in those patients with acute findings.

Under Pressure: Applying Practice-Based Learning and Improvement to the Treatment of Chronic Neuropathic Pain in Patients with Burns.

PubMed

Rapolti, Mihaela; Wu, Cindy; Schuth, Olga A; Hultman, Charles Scott

2017-10-01

Chronic neuropathic pain after burn injury may have multiple causes, such as direct nerve injury, nerve compression, or neuroma formation, and can significantly impair quality of life and limit functional recovery. Management includes a team-based approach that involves close collaboration between occupational and physical therapists, plastic surgeons, and experts in chronic pain, from neurology, anesthesia, psychiatry, and physiatry. Carefully selected patients with an anatomic cause of chronic neuropathic pain unequivocally benefit from surgical intervention. Self-reflection and analysis yield improvement in both efficiency and effectiveness when managing patients with burns with chronic neuropathic pain. Copyright © 2017 Elsevier Inc. All rights reserved.

Pedophiles and stalkers as transplant candidates: one program's experience.

PubMed

Paris, Wayne; Miller, Rachel; Hille, Cheryl; Nour, Bakr; Griggs, Johnny

2005-12-01

Transplant assessment of pedophiles and stalkers presents a challenge for clinicians and requires the ability to separate the science from the hysteria. Although rarely seen in organ transplant clinics, the presence of psychosexual disorders can result in both criminal charges and harsh societal reactions. Clinicians must be able to assess and make informed recommendations about the suitability of the candidate and any potential risks for staff, other patients, and society at large. Six patients (5 pedophiles and 1 stalker) were assessed at our major regional multiorgan transplant program; each patient presented with unique and challenging assessment, treatment, and selection issues for the transplant team. The objectives of this article are to raise awareness of the issues associated with pedophiles and stalkers, and to provide the basis for better-informed discussions based on one program's struggles with its candidate selection and follow-up.

Migraine preventive therapy: selection of appropriate patients and general principles of management.

PubMed

D'Amico, Domenico; Lanteri-Minet, Michel

2006-08-01

The goal of this review is to communicate the rationale and the possible benefits of migraine preventive treatments to clinicians and patients, and to address the many problematic issues created by missed diagnosis or misdiagnoses and inadequate migraine management. Successful implementation of migraine preventive treatment requires appropriate patient selection based on several factors, including the frequency of migraine attacks (> or =2-3 attacks/month), the level of disability incurred and the frequency of acute medication usage. Unfortunately, several epidemiologic surveys indicate that preventive therapies are significantly underutilized, which supports the need for greater dialog concerning migraine prevention between consumers and physicians. Effective migraine preventive therapy should reduce the frequency, duration, and severity of migraine, and also improve function, reduce disability, and possibly reduce the risk of worsening the headache syndrome, through acute medication overuse.

National variation in use of Immunosuppression for kidney transplantation: A call for evidence-based regimen selection

PubMed Central

Axelrod, David; Naik, Abhijit S.; Schnitzler, Mark A.; Segev, Dorry L.; Dharnidharka, Vikas R.; Brennan, Daniel C.; Bae, Sunjae; Chen, Jiajing; Massie, Allan; Lentine, Krista L.

2017-01-01

Immunosuppression management in kidney transplantation has evolved to include an increasingly diverse choice of medications. While informed by patient and donor characteristics, choice of immunosuppression regimen varies widely across transplant programs. Using a novel database integrating national transplant registry and pharmacy fill records, immunosuppression use 6–12 and 12–24 months post-transplant was evaluated for 22,453 patients transplanted at 249 U.S. programs in 2005–2010. Use of triple immunosuppression comprising tacrolimus, mycophenolic acid or azathioprine, and steroids varied widely (0–100% of patients per program), as did use of steroid-sparing regimens (0–77%), in sirolimus-based regimens (0–100%) and cyclosporine-based regimens (0–78%). Use of triple therapy was more common in highly sensitized patients, women, and recipients with dialysis duration > 5 years. Sirolimus use appeared to diminish over the study period. Overall, patient and donor characteristics explained only a limited amount of the observed variation in regimen use, while center choice explained 30–46% of the use of non-triple therapy immunosuppression. The majority of patients who received triple therapy (79%), cyclosporine-based (87.6%) and sirolimus-based regimens (84.3%) continued these regimens in the second year post-transplant. This population-based study of immunosuppression practice demonstrates substantial variation in center practice beyond that is explained by differences in patient and donor characteristics. PMID:26901466

Comparing narrative and multiple-choice formats in online communication skill assessment.

PubMed

Kim, Sara; Spielberg, Freya; Mauksch, Larry; Farber, Stu; Duong, Cuong; Fitch, Wes; Greer, Tom

2009-06-01

We compared multiple-choice and open-ended responses collected from a web-based tool designated 'Case for Change', which had been developed for assessing and teaching medical students in the skills involved in integrating sexual risk assessment and behaviour change discussions into patient-centred primary care visits. A total of 111 Year 3 students completed the web-based tool. A series of videos from one patient encounter illustrated how a clinician uses patient-centred communication and health behaviour change skills while caring for a patient presenting with a urinary tract infection. Each video clip was followed by a request for students to respond in two ways to the question: 'What would you do next?' Firstly, students typed their statements of what they would say to the patient. Secondly, students selected from a multiple-choice list the statements that most closely resembled their free text entries. These two modes of students' answers were analysed and compared. When articulating what they would say to the patient in a narrative format, students frequently used doctor-centred approaches that focused on premature diagnostic questioning or neglected to elicit patient perspectives. Despite the instruction to select a matching statement from the multiple-choice list, students tended to choose the most exemplary patient-centred statement, which was contrary to the doctor-centred approaches reflected in their narrative responses. Open-ended questions facilitate in-depth understanding of students' educational needs, although the scoring of narrative responses is time-consuming. Multiple-choice questions allow efficient scoring and individualised feedback associated with question items but do not fully elicit students' thought processes.

Building a Navigation System to Reduce Cancer Disparities in Urban Black Older Adults

PubMed Central

Bone, Lee; Edington, Kristen; Rosenberg, Jessica; Wenzel, Jennifer; Garza, Mary A.; Klein, Catherine; Schmitt, Lisa; Ford, Jean G.

2014-01-01

Background Although cancer outcomes have improved in recent decades, substantial disparities by race, ethnicity, income and education persist. Increasingly, patient navigation services are demonstrating success in improving cancer detection, treatment and care and in reducing cancer health disparities. To advance progress in developing patient navigation programs, extensive descriptions of each component of the program must be made available to researchers and health service providers. Objective To describe the components of a patient navigation program designed to improve cancer screening based on informed decision-making on cancer screening and cancer treatment services among predominantly Black older adults in Baltimore City. Methods A community-academic participatory approach was used to develop a patient navigation program in Baltimore, Maryland. The components of the patient navigation system included the development of a community academic (advisory) committee (CAC); recruitment and selection of community health workers (CHWs)/navigators and supervisory staff; initial training and continuing education of the CHWs/navigators; and evaluation of CHWs/navigators. The study was approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board. Conclusions The incorporation of community-based participatory research (CPBR) principles into each facet of this patient navigation program facilitated the attainment of the intervention’s objectives. This patient navigation program successfully delivered cancer navigation services to 1302 urban Black older adults. Appropriately recruited, selected and trained CHWs monitored by an experienced supervisor and investigators are the key elements in a patient navigation program. This model has the potential to be adapted by research and health service providers. PMID:23793252

Arrested Hydrocephalus in Childhood: Case Series and Review of the Literature.

PubMed

Hurni, Yannick; Poretti, Andrea; Schneider, Jacques; Guzman, Raphael; Ramelli, Gian Paolo

2018-06-22

 Hydrocephalus can be progressive or spontaneously arrested. In arrested hydrocephalus, the balance between production and absorption of the cerebrospinal fluid is restored. Patients are mostly asymptomatic, and no surgical treatment is necessary for them.  We performed a two-center consecutive case series study, aimed at investigating the safety of nonsurgical management of hydrocephalus in selected pediatric patients. We retrospectively selected all consecutive patients, suspected to suffer from arrested hydrocephalus and referred to our two institutions between January 2011 and December 2013. Data on clinical and radiological follow-up were collected until June 2017.  Five children diagnosed with arrested hydrocephalus were included in the study. All patients presented macrocephaly as the main presenting sign. Associated mild-to-moderate stable motor disorders were assessed in four out of five cases. Typical symptoms and signs associated with acute raised intracranial pressure were absent in all patients. Magnetic resonance imaging studies showed ventriculomegaly in all patients. A diagnosis of arrested hydrocephalus was made in all five cases based on stable clinical and radiological findings during the initial observation. Conservative management based on active surveillance was, therefore, proposed. During the follow-up period, we observed stable or improved conditions in four out of five patients, while the remaining patient presented progressive hydrocephalus.  Making a distinction between arrested and progressive hydrocephalus is fundamental, because of the opposed appropriate management. Any newly discovered case of hydrocephalus, not characterized by clear signs of progressive hydrocephalus, should benefit from active surveillance before any definitive decision is taken. Georg Thieme Verlag KG Stuttgart · New York.

[Proteome analysis for identification of tumor-associated biomarkers in breast cancer].

PubMed

Wang, Xi; Liang, Wei-Jiang; Zhu, Zhen-Yu; Yang, Ming-Tian; Zeng, Yi-Xin

2004-11-01

Pre-symptomatic screening of early-stage breast cancer may greatly reduce tumor-related mortality. Some tumor markers, such as CA15-3 and CA27-29, are recommended only for monitoring therapy of advanced or relapsed breast cancer. This study was to find new biomarkers that could be used individually or in combination with an existing modality for cost-effective screening of breast cancer by proteome analysis. Protein expression differences among 128 serum samples of 64 breast cancer patients (19 of stage I, 24 of stage II, and 21 of stage III), 52 patients with benign breast diseases, and 12 healthy women were analyzed with IMAC3 and WCX2 Ciphergen ProteinChip Arrays. On WCX2 chip, a panel of 5 proteins (9 116, 8 905, 8 749, 9 470, and 9 692 Da) was selected based on their collective contribution to the optimal separation between breast cancer patients and both non-cancer patients and healthy women, and expression of another 2 proteins (9 405 and 6 424 Da) was different between patients with breast cancer of stage I and stage III. On IMAC3 chip, a panel of 9 proteins (5 236, 7 823, 7 464, 5 213, 5 334, 5 064, 5 374, 7 756, and 7 623 Da) was selected based on their collective contribution to the optimal separation between breast cancer patients and both non-cancer patients and healthy women, and expression of another 3 proteins (7 922, 4 641, and 5 910 Da) was different between patients with breast cancer of stage I and stage III. Protein expression in breast cancer patients is different from that in both non-cancer patients and healthy women, and those proteins with different expression may be used as new biomarkers in breast cancer.

Intention-to-treat survival benefit of liver transplantation in patients with hepatocellular cancer.

PubMed

Lai, Quirino; Vitale, Alessandro; Iesari, Samuele; Finkenstedt, Armin; Mennini, Gianluca; Spoletini, Gabriele; Hoppe-Lotichius, Maria; Vennarecci, Giovanni; Manzia, Tommaso M; Nicolini, Daniele; Avolio, Alfonso W; Frigo, Anna Chiara; Graziadei, Ivo; Rossi, Massimo; Tsochatzis, Emmanouil; Otto, Gerd; Ettorre, Giuseppe M; Tisone, Giuseppe; Vivarelli, Marco; Agnes, Salvatore; Cillo, Umberto; Lerut, Jan

2017-12-01

The debate about the best approach to select patients with hepatocellular cancer (HCC) waiting for liver transplantation (LT) is still ongoing. This study aims to identify the best variables allowing to discriminate between "high-" and "low-benefit" patients. To do so, the concept of intention-to-treat (ITT) survival benefit of LT has been created. Data of 2,103 adult HCC patients consecutively enlisted during the period 1987-2015 were analyzed. Three rigorous statistical steps were used in order to create the ITT survival benefit of LT: the development of an ITT LT and a non-LT survival model, and the individual prediction of the ITT survival benefit of LT defined as the difference between the median ITT survival with (based on the first model) and without LT (based on the second model) calculated for each enrolled patient. Four variables (Model for End-Stage Liver Disease, alpha-fetoprotein, Milan-Criteria status, and radiological response) displayed a high effect in terms of delta benefit. According to these risk factors, four benefit groups were identified. Patients with three to four factors ("no-benefit group"; n = 405 of 2,103; 19.2%) had no benefit of LT compared to alternative treatments. Conversely, patients without any risk factor ("large-benefit group"; n = 108; 5.1%) yielded the highest benefit from LT reaching 60 months. The ITT transplant survival benefit presented here allows physicians to better select HCC patients waiting for LT. The obtained stratification may lead to an improved and more equitable method of organ allocation. Patients without benefit should be de-listed, whereas patients with large benefit ratio should be prioritized for LT. (Hepatology 2017;66:1910-1919). © 2017 by the American Association for the Study of Liver Diseases.

Survival analysis of multiple peptide vaccination for the selection of correlated peptides in urological cancers.

PubMed

Noguchi, Masanori; Koga, Noriko; Moriya, Fukuko; Suekane, Shigetaka; Yutani, Shigeru; Yamada, Akira; Shichijo, Shigeki; Kakuma, Tatuyuki; Itoh, Kyogo

2018-06-25

Peptide-based cancer vaccines are able to induce strong immune responses, but their clinical results are unsatisfactory. To determine clinically correlated peptides, we analyzed survival data from urological cancer patients treated by personalized peptide vaccination (PPV), in which different multiple peptides were used for individual patients based on human leukocyte antigen (HLA) type and pre-existing immunity. Survival data were obtained from a database of 265 urological cancer patients treated in 5 clinical PPV trials comprising 154 patients with castration-resistant prostate cancer (CRPC) and 111 patients with advanced urothelial cancer (UC). The expression of tumor-associated antigens (TAAs) was evaluated in 10 prostate cancer tissues, 4 metastatic lymph nodes from prostate cancer and 10 UC tissues using immunohistochemical staining. The clinical efficacy of individual peptides for overall survival was evaluated by the Cox proportional hazards regression model. All TAAs coding candidate peptides used in PPV treatment were expressed in tumor cells from prostate cancer and UC samples except for p56Lck in both, and PSA, PAP and PSMA in the UC samples. Patients with the following peptides had a significantly longer survival than patients without the peptides (Hazard ratio < 1.0, 95% confidence intervals < 1.0 and P < 0.05): SART3-109, PTHrP-102, HNPRL-140, SART3-302 and Lck-90 in CRPC patients, and EGF-R-800, Lck-486, PSMA-624, CypB-129 and SART3-734 in advanced UC patients, respectively. Correlated peptides selected using both survival data and pre-existing immunity for PPV treatment may enhance the clinical benefits for urological cancer patients. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Are emergency medical technician-basics able to use a selective immobilization of the cervical spine protocol?: a preliminary report.

PubMed

Dunn, Thomas M; Dalton, Alice; Dorfman, Todd; Dunn, William W

2004-01-01

To be a first step in determining whether emergency medicine technician (EMT)-Basics are capable of using a protocol that allows for selective immobilization of the cervical spine. Such protocols are coming into use at an advanced life support level and could be beneficial when used by basic life support providers. A convenience sample of participants (n=95) from 11 emergency medical services agencies and one college class participated in the study. All participants evaluated six patients in written scenarios and decided which should be placed into spinal precautions according to a selective spinal immobilization protocol. Systems without an existing selective spinal immobilization protocol received a one-hour continuing education lecture regarding the topic. College students received a similar lecture written so laypersons could understand the protocol. All participants showed proficiency when applying a selective immobilization protocol to patients in paper-based scenarios. Furthermore, EMT-Basics performed at the same level as paramedics when following the protocol. Statistical analysis revealed no significant differences between EMT-Basics and paramedics. A follow-up group of college students (added to have a non-EMS comparison group) also performed as well as paramedics when making decisions to use spinal precautions. Differences between college students and paramedics were also statistically insignificant. The results suggest that EMT-Basics are as accurate as paramedics when making decisions regarding selective immobilization of the cervical spine during paper-based scenarios. That laypersons are also proficient when using the protocol could indicate that it is extremely simple to follow. This study is a first step toward the necessary additional studies evaluating the efficacy of EMT-Basics using selective immobilization as a regular practice.

Rehabilitation therapy services for stroke patients living at home: systematic review of randomised trials.

PubMed

Legg, L; Langhorne, P

2004-01-31

Stroke-unit care can be valuable for stroke patients in hospital, but effectiveness of outpatient care is less certain. We aimed to assess the effects of therapy-based rehabilitation services targeted at stroke patients resident in the community within 1 year of stroke onset or discharge from hospital. We did a systematic review of randomised trials of outpatient services, including physiotherapy, occupational therapy, and multidisciplinary teams. We used Cochrane collaboration methodology. We identified a heterogeneous group of 14 trials (1617 patients). Therapy-based rehabilitation services for stroke patients living at home reduced the odds of deteriorating in personal activities of daily living (odds ratio 0.72 [95% CI 0.57-0.92], p=0.009) and increased ability of patients to do personal activities of daily living (standardised mean difference 0.14 [95% CI 0.02-0.25], p=0.02). For every 100 stroke patients resident in the community receiving therapy-based rehabilitation services, seven (95% CI 2-11) would not deteriorate. Therapy-based rehabilitation services targeted at selected patients resident in the community after stroke improve ability to undertake personal activities of daily living and reduce risk of deterioration in ability. These findings should be considered in future service planning.

Evaluation of selected recurrence measures in discriminating pre-ictal and inter-ictal periods from epileptic EEG data

NASA Astrophysics Data System (ADS)

Ngamga, Eulalie Joelle; Bialonski, Stephan; Marwan, Norbert; Kurths, Jürgen; Geier, Christian; Lehnertz, Klaus

2016-04-01

We investigate the suitability of selected measures of complexity based on recurrence quantification analysis and recurrence networks for an identification of pre-seizure states in multi-day, multi-channel, invasive electroencephalographic recordings from five epilepsy patients. We employ several statistical techniques to avoid spurious findings due to various influencing factors and due to multiple comparisons and observe precursory structures in three patients. Our findings indicate a high congruence among measures in identifying seizure precursors and emphasize the current notion of seizure generation in large-scale epileptic networks. A final judgment of the suitability for field studies, however, requires evaluation on a larger database.

Abnormal externally guided movement preparation in recent-onset schizophrenia is associated with impaired selective attention to external input.

PubMed

Smid, Henderikus G O M; Westenbroek, Joanna M; Bruggeman, Richard; Knegtering, Henderikus; Van den Bosch, Robert J

2009-11-30

Several theories propose that the primary cognitive impairment in schizophrenia concerns a deficit in the processing of external input information. There is also evidence, however, for impaired motor preparation in schizophrenia. This provokes the question whether the impaired motor preparation in schizophrenia is a secondary consequence of disturbed (selective) processing of the input needed for that preparation, or an independent primary deficit. The aim of the present study was to discriminate between these hypotheses, by investigating externally guided movement preparation in relation to selective stimulus processing. The sample comprised 16 recent-onset schizophrenia patients and 16 controls who performed a movement-precuing task. In this task, a precue delivered information about one, two or no parameters of a movement summoned by a subsequent stimulus. Performance measures and measures derived from the electroencephalogram showed that patients yielded smaller benefits from the precues and showed less cue-based preparatory activity in advance of the imperative stimulus than the controls, suggesting a response preparation deficit. However, patients also showed less activity reflecting selective attention to the precue. We therefore conclude that the existing evidence for an impairment of externally guided motor preparation in schizophrenia is most likely due to a deficit in selective attention to the external input, which lends support to theories proposing that the primary cognitive deficit in schizophrenia concerns the processing of input information.

Celecoxib versus a non-selective NSAID plus proton-pump inhibitor: what are the considerations?.

PubMed

Chen, Judy T; Pucino, Frank; Resman-Targoff, Beth H

2006-01-01

Nonsteroidal anti-inflammatory drugs (NSAIDs) are extensively used worldwide. However, associated adverse gastrointestinal effects (NSAID gastropathy) such as bleeding, perforation and obstruction result in considerable morbidity, mortality, and expense. Although it is essential to employ gastroprotective strategies to minimize these complications in patients at risk, controversy remains on whether celecoxib alone or a non-selective NSAID in conjunction with a proton-pump inhibitor (PPI) is a superior choice. Recent concerns regarding potential cardiovascular toxicities associated with cox-2 selective inhibitors may favor non-selective NSAID/PPI co-therapy as the preferred choice. Concomitant use of low-dose aspirin with any NSAID increases the risk of gastrointestinal complications and diminishes the improved gastrointestinal safety profile of celecoxib; whereas use of ibuprofen plus PPI regimens may negate aspirin's antiplatelet benefits. Evidence shows that concurrent use of a non-selective NSAID (such as naproxen) plus a PPI is as effective in preventing NSAID gastropathy as celecoxib, and may be more cost-effective. Patients failing or intolerant to this therapy would be candidates for celecoxib at the lowest effective dose for the shortest duration of time. Potential benefits from using low-dose celecoxib with a PPI in patients previously experiencing bleeding ulcers while taking NSAIDs remains to be proven. An evidence-based debate is presented to assist clinicians with the difficult decision-making process of preventing NSAID gastropathy while minimizing other complications.

The symptom cluster-based approach to individualize patient-centered treatment for major depression.

PubMed

Lin, Steven Y; Stevens, Michael B

2014-01-01

Unipolar major depressive disorder is a common, disabling, and costly disease that is the leading cause of ill health, early death, and suicide in the United States. Primary care doctors, in particular family physicians, are the first responders in this silent epidemic. Although more than a dozen different antidepressants in 7 distinct classes are widely used to treat depression in primary care, there is no evidence that one drug is superior to another. Comparative effectiveness studies have produced mixed results, and no specialty organization has published recommendations on how to choose antidepressants in a rational, evidence-based manner. In this article we present the theory and evidence for an individualized, patient-centered treatment model for major depression designed around a targeted symptom cluster-based approach to antidepressant selection. When using this model for healthy adults with major depressive disorder, the choice of antidepressants should be guided by the presence of 1 of 4 common symptom clusters: anxiety, fatigue, insomnia, and pain. This model was built to foster future research, provide a logical framework for teaching residents how to select antidepressants, and equip primary care doctors with a structured treatment strategy to deliver optimal patient-centered care in the management of a debilitating disease: major depressive disorder.

Availability of essential medicines in Ethiopia: an efficiency-equity trade-off?

PubMed

Carasso, Barbara S; Lagarde, Mylene; Tesfaye, Addis; Palmer, Natasha

2009-11-01

To investigate the availability and cost of essential medicines in health centres in rural Ethiopia, and to explore if the fee waiver system protects patients from having to pay for medicines. The study took place in five health centres in rural Ethiopia. Availability and price of selected key essential medicines was established in the budget and special pharmacy of the health centre, as well as private outlets. Information on availability and cost of prescribed drugs was obtained through patient exit-interviews. Availability based of essential drugs at facility level was 91% based on a list of selected drugs vs. 84% based on prescriptions filled. However, less than half the prescribed drugs were obtained from the budget pharmacy, and one in six patients was forced to purchase drugs in the private sector, where drugs are roughly twice as expensive. The waiver system did not safeguard against having to pay for medicines. A revolving drug fund system in Ethiopia seems to improve availability of medicines, and can improve affordability by protecting people from purchasing drugs in the private sector. However, it may result in a parallel system, whereby the poor cannot access drugs if these are not available in the budget pharmacy. Equity is a concern in the absence of an adequate mechanism to protect the poor from catastrophic health expenditure.

Discovery of Selective and Noncovalent Diaminopyrimidine-Based Inhibitors of Epidermal Growth Factor Receptor Containing the T790M Resistance Mutation

PubMed Central

2015-01-01

Activating mutations within the epidermal growth factor receptor (EGFR) kinase domain, commonly L858R or deletions within exon 19, increase EGFR-driven cell proliferation and survival and are correlated with impressive responses to the EGFR inhibitors erlotinib and gefitinib in nonsmall cell lung cancer patients. Approximately 60% of acquired resistance to these agents is driven by a single secondary mutation within the EGFR kinase domain, specifically substitution of the gatekeeper residue threonine-790 with methionine (T790M). Due to dose-limiting toxicities associated with inhibition of wild-type EGFR (wtEGFR), we sought inhibitors of T790M-containing EGFR mutants with selectivity over wtEGFR. We describe the evolution of HTS hits derived from Jak2/Tyk2 inhibitors into selective EGFR inhibitors. X-ray crystal structures revealed two distinct binding modes and enabled the design of a selective series of novel diaminopyrimidine-based inhibitors with good potency against T790M-containing mutants of EGFR, high selectivity over wtEGFR, broad kinase selectivity, and desirable physicochemical properties. PMID:25383627

Selection and application of familiar and novel tools in patients with left and right hemispheric stroke: Psychometrics and normative data.

PubMed

Buchmann, Ilka; Randerath, Jennifer

2017-09-01

Frequently left brain damage (LBD) leads to limb apraxia, a disorder that can affect tool-use. Despite its impact on daily life, classical tests examining the pantomime of tool-use and imitation of gestures are seldom applied in clinical practice. The study's aim was to present a diagnostic approach which appears more strongly related to actions in daily life in order to sensitize applicants and patients about the relevance of the disorder before patients are discharged. Two tests were introduced that evaluate actual tool selection and tool-object-application: the Novel Tools (NTT) and the Familiar Tools (FTT) Test (parts of the DILA-S: Diagnostic Instrument for Limb Apraxia - Short Version). Normative data in healthy subjects (N = 82) was collected. Then the tests were applied in stroke patients with unilateral left brain damage (LBD: N = 33), a control right brain damage group (RBD: N = 20) as well as healthy age and gender matched controls (CL: N = 28, and CR, N = 18). The tests showed appropriate interrater-reliability and internal consistency as well as concurrent and divergent validity. To examine criterion validity based on the well-known left lateralization of limb apraxia, group comparisons were run. As expected, the LBD group demonstrated a high prevalence of tool-use apraxia (NTT: 36.4%, FTT: 48.5%) ranging from mild to severe impairment and scored worse than their control group (CL). A few RBD patients did demonstrate impairments in tool-use (NTT: 15%, FTT: 15%). On a group level they did not differ from their healthy controls (CR). Further, it was demonstrated that the selection and application of familiar and novel tools can be impaired selectively. Our study results suggest that real tool-use tests evaluating tool selection and tool application should be considered for standard diagnosis of limb apraxia in left as well as right brain damaged patients. Copyright © 2017 The Authors. Published by Elsevier Ltd.. All rights reserved.

The sirolimus-eluting Cypher Select coronary stent for the treatment of bare-metal and drug-eluting stent restenosis: insights from the e-SELECT (Multicenter Post-Market Surveillance) registry.

PubMed

Abizaid, Alexandre; Costa, J Ribamar; Banning, Adrian; Bartorelli, Antonio L; Dzavik, Vladimir; Ellis, Stephen; Gao, Runlin; Holmes, David R; Jeong, Muyng Ho; Legrand, Victor; Neumann, Franz-Josef; Nyakern, Maria; Orlick, Amy; Spaulding, Christian; Worthley, Stephen; Urban, Philip M

2012-01-01

This study sought to compare the 1-year safety and efficacy of Cypher Select or Cypher Select Plus (Cordis Corporation, Bridgewater, New Jersey) sirolimus-eluting stents (SES) with the treatment of bare-metal stents (BMS) and drug-eluting stent (DES) in-stent restenosis (ISR) in nonselected, real-world patients. There is paucity of consistent data on DES for the treatment of ISR, especially, DES ISR. The e-SELECT (Multicenter Post-Market Surveillance) registry is a Web-based, multicenter and international registry encompassing virtually all subsets of patients and lesions treated with at least 1 SES during the period from 2006 to 2008. We enrolled in this pre-specified subanalysis all patients with at least 1 clinically relevant BMS or DES ISR treated with SES. Primary endpoint was major adverse cardiac events and stent thrombosis rate at 1 year. Of 15,147 patients enrolled, 1,590 (10.5%) presented at least 1 ISR (BMS group, n = 1,235, DES group, n = 355). Patients with DES ISR had higher incidence of diabetes (39.4% vs. 26.9%, p < 0.001), renal insufficiency (5.8% vs. 2.3%, p = 0.003), and prior coronary artery bypass graft (20.5% vs. 11.8%, p < 0.001). At 1 year, death (1.4% for BMS vs. 2.1% for DES, p = 0.3) and myocardial infarction (2.4% for BMS and 3.3% for DES, p = 0.3) rates were similar, whereas ischemia-driven target lesion revascularization and definite/probable late stent thrombosis were higher in patients with DES ISR (6.9% vs. 3.1%, p = 0.003, and 1.8% vs. 0.5%, p = 0.04, respectively). Use of SES for either BMS or DES ISR treatment is safe and associated with low target lesion revascularization recurrence and no apparent safety concern. Copyright © 2012 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Dysfunctional visual word form processing in progressive alexia

PubMed Central

Rising, Kindle; Stib, Matthew T.; Rapcsak, Steven Z.; Beeson, Pélagie M.

2013-01-01

Progressive alexia is an acquired reading deficit caused by degeneration of brain regions that are essential for written word processing. Functional imaging studies have shown that early processing of the visual word form depends on a hierarchical posterior-to-anterior processing stream in occipito-temporal cortex, whereby successive areas code increasingly larger and more complex perceptual attributes of the letter string. A region located in the left lateral occipito-temporal sulcus and adjacent fusiform gyrus shows maximal selectivity for words and has been dubbed the ‘visual word form area’. We studied two patients with progressive alexia in order to determine whether their reading deficits were associated with structural and/or functional abnormalities in this visual word form system. Voxel-based morphometry showed left-lateralized occipito-temporal atrophy in both patients, very mild in one, but moderate to severe in the other. The two patients, along with 10 control subjects, were scanned with functional magnetic resonance imaging as they viewed rapidly presented words, false font strings, or a fixation crosshair. This paradigm was optimized to reliably map brain regions involved in orthographic processing in individual subjects. All 10 control subjects showed a posterior-to-anterior gradient of selectivity for words, and all 10 showed a functionally defined visual word form area in the left hemisphere that was activated for words relative to false font strings. In contrast, neither of the two patients with progressive alexia showed any evidence for a selectivity gradient or for word-specific activation of the visual word form area. The patient with mild atrophy showed normal responses to both words and false font strings in the posterior part of the visual word form system, but a failure to develop selectivity for words in the more anterior part of the system. In contrast, the patient with moderate to severe atrophy showed minimal activation of any part of the visual word form system for either words or false font strings. Our results suggest that progressive alexia is associated with a dysfunctional visual word form system, with or without substantial cortical atrophy. Furthermore, these findings demonstrate that functional MRI has the potential to reveal the neural bases of cognitive deficits in neurodegenerative patients at very early stages, in some cases before the development of extensive atrophy. PMID:23471694

Dysfunctional visual word form processing in progressive alexia.

PubMed

Wilson, Stephen M; Rising, Kindle; Stib, Matthew T; Rapcsak, Steven Z; Beeson, Pélagie M

2013-04-01

Progressive alexia is an acquired reading deficit caused by degeneration of brain regions that are essential for written word processing. Functional imaging studies have shown that early processing of the visual word form depends on a hierarchical posterior-to-anterior processing stream in occipito-temporal cortex, whereby successive areas code increasingly larger and more complex perceptual attributes of the letter string. A region located in the left lateral occipito-temporal sulcus and adjacent fusiform gyrus shows maximal selectivity for words and has been dubbed the 'visual word form area'. We studied two patients with progressive alexia in order to determine whether their reading deficits were associated with structural and/or functional abnormalities in this visual word form system. Voxel-based morphometry showed left-lateralized occipito-temporal atrophy in both patients, very mild in one, but moderate to severe in the other. The two patients, along with 10 control subjects, were scanned with functional magnetic resonance imaging as they viewed rapidly presented words, false font strings, or a fixation crosshair. This paradigm was optimized to reliably map brain regions involved in orthographic processing in individual subjects. All 10 control subjects showed a posterior-to-anterior gradient of selectivity for words, and all 10 showed a functionally defined visual word form area in the left hemisphere that was activated for words relative to false font strings. In contrast, neither of the two patients with progressive alexia showed any evidence for a selectivity gradient or for word-specific activation of the visual word form area. The patient with mild atrophy showed normal responses to both words and false font strings in the posterior part of the visual word form system, but a failure to develop selectivity for words in the more anterior part of the system. In contrast, the patient with moderate to severe atrophy showed minimal activation of any part of the visual word form system for either words or false font strings. Our results suggest that progressive alexia is associated with a dysfunctional visual word form system, with or without substantial cortical atrophy. Furthermore, these findings demonstrate that functional MRI has the potential to reveal the neural bases of cognitive deficits in neurodegenerative patients at very early stages, in some cases before the development of extensive atrophy.

Home treatment of COPD exacerbation selected by DECAF score: a non-inferiority, randomised controlled trial and economic evaluation.

PubMed

Echevarria, Carlos; Gray, Joanne; Hartley, Tom; Steer, John; Miller, Jonathan; Simpson, A John; Gibson, G John; Bourke, Stephen C

2018-04-21

Previous models of Hospital at Home (HAH) for COPD exacerbation (ECOPD) were limited by the lack of a reliable prognostic score to guide patient selection. Approximately 50% of hospitalised patients have a low mortality risk by DECAF, thus are potentially suitable. In a non-inferiority randomised controlled trial, 118 patients admitted with a low-risk ECOPD (DECAF 0 or 1) were recruited to HAH or usual care (UC). The primary outcome was health and social costs at 90 days. Mean 90-day costs were £1016 lower in HAH, but the one-sided 95% CI crossed the non-inferiority limit of £150 (CI -2343 to 312). Savings were primarily due to reduced hospital bed days: HAH=1 (IQR 1-7), UC=5 (IQR 2-12) (P=0.001). Length of stay during the index admission in UC was only 3 days, which was 2 days shorter than expected. Based on quality-adjusted life years, the probability of HAH being cost-effective was 90%. There was one death within 90 days in each arm, readmission rates were similar and 90% of patients preferred HAH for subsequent ECOPD. HAH selected by low-risk DECAF score was safe, clinically effective, cost-effective, and preferred by most patients. Compared with earlier models, selection is simpler and approximately twice as many patients are eligible. The introduction of DECAF was associated with a fall in UC length of stay without adverse outcome, supporting use of DECAF to direct early discharge. Registered prospectively ISRCTN 29082260. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Measurement properties of patient-reported outcome measures (PROMs) used in adult patients with chronic kidney disease: a systematic review protocol.

PubMed

Aiyegbusi, Olalekan Lee; Kyte, Derek; Cockwell, Paul; Marshall, Tom; Keeley, Thomas; Gheorghe, Adrian; Calvert, Melanie

2016-10-12

Chronic kidney disease (CKD) is associated with symptoms that can significantly reduce the quality of life (QoL) of patients. Patient-reported outcome measures (PROMs) may facilitate the assessment of the impact of disease and treatment on the QoL, from a patient perspective. PROMs can be used in research and routine clinical practice. A systematic review of studies evaluating the measurement properties of PROMs in adults with CKD will be conducted. MEDLINE, EMBASE, PsycINFO and CINAHL Plus will be systematically searched from inception. Hand searching of reference lists and citations of included studies will be carried out. 2 reviewers will independently screen the titles and abstracts of all the studies retrieved during the systematic search to determine their eligibility. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) checklist will be used to appraise the methodological quality of the selected studies following the full-text review. Data on the study population, questionnaire characteristics and measurement properties will be extracted from the selected papers. Finally, a narrative synthesis of extracted data will be undertaken. Ethical permissions are not required for this study as data from published research articles will be used. Findings will be disseminated through publication in a peer-reviewed journal and presented at conferences. This systematic review will provide a comprehensive assessment of the measurement properties of PROMs currently available for use in adult patients with CKD and present evidence which may inform the selection of measures for use in research and clinical practice. CRD42016035554. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/.

Automatic Detection of Seizures with Applications

NASA Technical Reports Server (NTRS)

Olsen, Dale E.; Harris, John C.; Cutchis, Protagoras N.; Cristion, John A.; Lesser, Ronald P.; Webber, W. Robert S.

1993-01-01

There are an estimated two million people with epilepsy in the United States. Many of these people do not respond to anti-epileptic drug therapy. Two devices can be developed to assist in the treatment of epilepsy. The first is a microcomputer-based system designed to process massive amounts of electroencephalogram (EEG) data collected during long-term monitoring of patients for the purpose of diagnosing seizures, assessing the effectiveness of medical therapy, or selecting patients for epilepsy surgery. Such a device would select and display important EEG events. Currently many such events are missed. A second device could be implanted and would detect seizures and initiate therapy. Both of these devices require a reliable seizure detection algorithm. A new algorithm is described. It is believed to represent an improvement over existing seizure detection algorithms because better signal features were selected and better standardization methods were used.

Palatoglossus coupling in selective upper airway stimulation.

PubMed

Heiser, Clemens; Edenharter, Günther; Bas, Murat; Wirth, Markus; Hofauer, Benedikt

2017-10-01

Selective upper airway stimulation (sUAS) of the hypoglossal nerve is a useful therapy to treat patients with obstructive sleep apnea. Is it known that multiple obstructions can be solved by this stimulation technique, even at the retropalatal region. The aim of this study was to verify the palatoglossus coupling at the soft palate during stimulation. Single-center, prospective clinical trail. Twenty patients who received an sUAS implant from April 2015 to April 2016 were included. A drug-induced sedated endoscopy (DISE) was performed before surgery. Six to 12 months after activation of the system, patients' tongue motions were recorded, an awake transnasal endoscopy was performed with stimulation turned on, and a DISE with stimulation off and on was done. Patients with a bilateral protrusion of the tongue base showed a significantly increased opening at the retropalatal level compared to ipsilateral protrusions. Furthermore, patients with a clear activation of the geniohyoid muscle showed a better reduction in apnea-hypopnea index. A bilateral protrusion of the tongue base during sUAS seems to be accompanied with a better opening of the soft palate. This effect can be explained by the palatoglossal coupling, due to its linkage of the muscles within the soft palate to those of the lateral tongue body. 4 Laryngoscope, 127:E378-E383, 2017. © 2017 The American Laryngological, Rhinological and Otological Society, Inc.

Which kind of psychometrics is adequate for patient satisfaction questionnaires?

PubMed

Konerding, Uwe

2016-01-01

The construction and psychometric analysis of patient satisfaction questionnaires are discussed. The discussion is based upon the classification of multi-item questionnaires into scales or indices. Scales consist of items that describe the effects of the latent psychological variable to be measured, and indices consist of items that describe the causes of this variable. Whether patient satisfaction questionnaires should be constructed and analyzed as scales or as indices depends upon the purpose for which these questionnaires are required. If the final aim is improving care with regard to patients' preferences, then these questionnaires should be constructed and analyzed as indices. This implies two requirements: 1) items for patient satisfaction questionnaires should be selected in such a way that the universe of possible causes of patient satisfaction is covered optimally and 2) Cronbach's alpha, principal component analysis, exploratory factor analysis, confirmatory factor analysis, and analyses with models from item response theory, such as the Rasch Model, should not be applied for psychometric analyses. Instead, multivariate regression analyses with a direct rating of patient satisfaction as the dependent variable and the individual questionnaire items as independent variables should be performed. The coefficients produced by such an analysis can be applied for selecting the best items and for weighting the selected items when a sum score is determined. The lower boundaries of the validity of the unweighted and the weighted sum scores can be estimated by their correlations with the direct satisfaction rating. While the first requirement is fulfilled in the majority of the previous patient satisfaction questionnaires, the second one deviates from previous practice. Hence, if patient satisfaction is actually measured with the final aim of improving care with regard to patients' preferences, then future practice should be changed so that the second requirement is also fulfilled.

Evaluation of rational drug use based on World Health Organization core drug use indicators in selected public hospitals of eastern Ethiopia: a cross sectional study.

PubMed

Sisay, Mekonnen; Mengistu, Getnet; Molla, Bereket; Amare, Firehiwot; Gabriel, Tesfaye

2017-02-23

Despite the complexity of drug use, a number of indicators have been developed, standardized and evaluated by the World Health Organization (WHO). These indicators are grouped in to three categories namely: prescribing indicators, patient care indicators and facility indicators. The study was aimed to evaluate rational drug use based on WHO-core drug use indicators in Dilchora referral hospital, Dire Dawa; Hiwot Fana specialized university hospital, Harar and Karamara general hospital, Jigjiga, eastern Ethiopia. Hospital based quantitative cross sectional study design was employed to evaluate rational drug use based on WHO core drug use indicators in selected hospitals. Systematic random sampling for prescribing indicators and convenient sampling for patient care indicators was employed. Taking WHO recommendations in to account, a total of 1,500 prescription papers (500 from each hospitals) were investigated. In each hospital, 200 outpatient attendants and 30 key essential drugs were also selected using the WHO recommendation. Data were collected using retrospective and prospective structured observational check list. Data were entered to EPI Data Version 3.1, exported and analyzed using SPSS version 16.0. Besides, the data were evaluated as per the WHO guidelines. Statistical significance was determined by one way analysis of variance (ANOVA) for some variables. P-value of less than 0.05 was considered statistically significant. Finally, tabular presentation was used to present the data. Mean, 2.34 (±1.08) drugs were prescribed in the selected hospitals. Prescriptions containing antibiotics and that of injectables were 57.87 and 10.9% respectively. The average consultation and dispensing time were 276.5 s and 61.12 s respectively. Besides, 75.77% of the prescribed drugs were actually dispensed. Only 3.3% of prescriptions were adequately labeled and 75.7% patients know about the dosage of the prescription. Not more than, 20(66.7%) key drugs were available in stock while only 19(63.3%) of key drugs had adequate labeling. On average, selected key drugs were out of stock for 30 days per year. All of the hospitals included in the study used the national drug list, formulary and standard treatment guidelines but none of them had their own drug list or guideline. Majority of WHO stated core drug use indicators were not met by the three hospitals included in the study.

Feature selection and classification model construction on type 2 diabetic patients' data.

PubMed

Huang, Yue; McCullagh, Paul; Black, Norman; Harper, Roy

2007-11-01

Diabetes affects between 2% and 4% of the global population (up to 10% in the over 65 age group), and its avoidance and effective treatment are undoubtedly crucial public health and health economics issues in the 21st century. The aim of this research was to identify significant factors influencing diabetes control, by applying feature selection to a working patient management system to assist with ranking, classification and knowledge discovery. The classification models can be used to determine individuals in the population with poor diabetes control status based on physiological and examination factors. The diabetic patients' information was collected by Ulster Community and Hospitals Trust (UCHT) from year 2000 to 2004 as part of clinical management. In order to discover key predictors and latent knowledge, data mining techniques were applied. To improve computational efficiency, a feature selection technique, feature selection via supervised model construction (FSSMC), an optimisation of ReliefF, was used to rank the important attributes affecting diabetic control. After selecting suitable features, three complementary classification techniques (Naïve Bayes, IB1 and C4.5) were applied to the data to predict how well the patients' condition was controlled. FSSMC identified patients' 'age', 'diagnosis duration', the need for 'insulin treatment', 'random blood glucose' measurement and 'diet treatment' as the most important factors influencing blood glucose control. Using the reduced features, a best predictive accuracy of 95% and sensitivity of 98% was achieved. The influence of factors, such as 'type of care' delivered, the use of 'home monitoring', and the importance of 'smoking' on outcome can contribute to domain knowledge in diabetes control. In the care of patients with diabetes, the more important factors identified: patients' 'age', 'diagnosis duration' and 'family history', are beyond the control of physicians. Treatment methods such as 'insulin', 'diet' and 'tablets' (a variety of oral medicines) may be controlled. However lifestyle indicators such as 'body mass index' and 'smoking status' are also important and may be controlled by the patient. This further underlines the need for public health education to aid awareness and prevention. More subtle data interactions need to be better understood and data mining can contribute to the clinical evidence base. The research confirms and to a lesser extent challenges current thinking. Whilst fully appreciating the requirement for clinical verification and interpretation, this work supports the use of data mining as an exploratory tool, particularly as the domain is suffering from a data explosion due to enhanced monitoring and the (potential) storage of this data in the electronic health record. FSSMC has proved a useful feature estimator for large data sets, where processing efficiency is an important factor.

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

Nasehi Tehrani, J; Wang, J; McEwan, A

Purpose: In this study, we developed and evaluated a method for predicting lung surface deformation vector fields (SDVFs) based on surrogate signals such as chest and abdomen motion at selected locations and spirometry measurements. Methods: A Patient-specific 3D triangular surface mesh of the lung region at end-expiration (EE) phase was obtained by threshold-based segmentation method. For each patient, a spirometer recorded the flow volume changes of the lungs; and 192 selected points at a regular spacing of 2cm X 2cm matrix points over a total area of 34cm X 24cm on the surface of chest and abdomen was used tomore » detect chest wall motions. Preprocessing techniques such as QR factorization with column pivoting (QRCP) were employed to remove redundant observations of the chest and abdominal area. To create a statistical model between the lung surface and the corresponding surrogate signals, we developed a predictive model based on canonical ridge regression (CRR). Two unique weighting vectors were selected for each vertex on the surface of the lung, and they were optimized during the training process using the all other phases of 4D-CT except the end-inspiration (EI) phase. These parameters were employed to predict the vertices locations of a testing data set, which was the EI phase of 4D-CT. Results: For ten lung cancer patients, the deformation vector field of each vertex of lung surface mesh was estimated from the external motion at selected positions on the chest wall surface plus spirometry measurements. The average estimation of 98th percentile of error was less than 1 mm (AP= 0.85, RL= 0.61, and SI= 0.82). Conclusion: The developed predictive model provides a non-invasive approach to derive lung boundary condition. Together with personalized biomechanical respiration modelling, the proposed model can be used to derive the lung tumor motion during radiation therapy accurately from non-invasive measurements.« less

Purposeful Variable Selection and Stratification to Impute Missing FAST Data in Trauma Research

PubMed Central

Fuchs, Paul A.; del Junco, Deborah J.; Fox, Erin E.; Holcomb, John B.; Rahbar, Mohammad H.; Wade, Charles A.; Alarcon, Louis H.; Brasel, Karen J.; Bulger, Eileen M.; Cohen, Mitchell J.; Myers, John G.; Muskat, Peter; Phelan, Herb A.; Schreiber, Martin A.; Cotton, Bryan A.

2013-01-01

Background The Focused Assessment with Sonography for Trauma (FAST) exam is an important variable in many retrospective trauma studies. The purpose of this study was to devise an imputation method to overcome missing data for the FAST exam. Due to variability in patients’ injuries and trauma care, these data are unlikely to be missing completely at random (MCAR), raising concern for validity when analyses exclude patients with missing values. Methods Imputation was conducted under a less restrictive, more plausible missing at random (MAR) assumption. Patients with missing FAST exams had available data on alternate, clinically relevant elements that were strongly associated with FAST results in complete cases, especially when considered jointly. Subjects with missing data (32.7%) were divided into eight mutually exclusive groups based on selected variables that both described the injury and were associated with missing FAST values. Additional variables were selected within each group to classify missing FAST values as positive or negative, and correct FAST exam classification based on these variables was determined for patients with non-missing FAST values. Results Severe head/neck injury (odds ratio, OR=2.04), severe extremity injury (OR=4.03), severe abdominal injury (OR=1.94), no injury (OR=1.94), other abdominal injury (OR=0.47), other head/neck injury (OR=0.57) and other extremity injury (OR=0.45) groups had significant ORs for missing data; the other group odds ratio was not significant (OR=0.84). All 407 missing FAST values were imputed, with 109 classified as positive. Correct classification of non-missing FAST results using the alternate variables was 87.2%. Conclusions Purposeful imputation for missing FAST exams based on interactions among selected variables assessed by simple stratification may be a useful adjunct to sensitivity analysis in the evaluation of imputation strategies under different missing data mechanisms. This approach has the potential for widespread application in clinical and translational research and validation is warranted. Level of Evidence Level II Prognostic or Epidemiological PMID:23778515

Coronary Computed Tomographic Angiography-Derived Fractional Flow Reserve for Therapeutic Decision Making.

PubMed

Tesche, Christian; Vliegenthart, Rozemarijn; Duguay, Taylor M; De Cecco, Carlo N; Albrecht, Moritz H; De Santis, Domenico; Langenbach, Marcel C; Varga-Szemes, Akos; Jacobs, Brian E; Jochheim, David; Baquet, Moritz; Bayer, Richard R; Litwin, Sheldon E; Hoffmann, Ellen; Steinberg, Daniel H; Schoepf, U Joseph

2017-12-15

This study investigated the performance of coronary computed tomography angiography (cCTA) with cCTA-derived fractional flow reserve (CT-FFR) compared with invasive coronary angiography (ICA) with fractional flow reserve (FFR) for therapeutic decision making in patients with suspected coronary artery disease (CAD). Seventy-four patients (62 ± 11 years, 62% men) with at least 1 coronary stenosis of ≥50% on clinically indicated dual-source cCTA, who had subsequently undergone ICA with FFR measurement, were retrospectively evaluated. CT-FFR values were computed using an on-site machine-learning algorithm to assess the functional significance of CAD. The therapeutic strategy (optimal medical therapy alone vs revascularization) and the appropriate revascularization procedure (percutaneous coronary intervention vs coronary artery bypass grafting) were selected using cCTA-CT-FFR. Thirty-six patients (49%) had a functionally significant CAD based on ICA-FFR. cCTA-CT-FFR correctly identified a functionally significant CAD and the need of revascularization in 35 of 36 patients (97%). When revascularization was deemed indicated, the same revascularization procedure (32 percutaneous coronary interventions and 3 coronary artery bypass grafting) was chosen in 35 of 35 patients (100%). Overall, identical management strategies were selected in 73 of the 74 patients (99%). cCTA-CT-FFR shows excellent performance to identify patients with and without the need for revascularization and to select the appropriate revascularization strategy. cCTA-CT-FFR as a noninvasive "one-stop shop" has the potential to change diagnostic workflows and to directly inform therapeutic decision making in patients with suspected CAD. Copyright © 2017 Elsevier Inc. All rights reserved.

[Blood pressure lowering therapy for mild hypertensive patients with a history of stroke].

PubMed

Ishikawa, Eiichi; Ibayashi, Setsuro

2008-08-01

Hypertension is the primary and one of the major risk factors for stroke. Many hypertensive patients with a history of stroke might have mild to moderate hypertension at the same time. In order to prevent recurrence of cardiovascular diseases including stroke, we should lower their blood pressure levels, carefully and slowly below less than 140/90 mmHg or much lower. Additionally, the patients having any occlusion or stenoses in their carotid and/or intracranial arteries, or even in old-old patients with atherosclerosis, might need further consideration for the cerebral blood flow insufficiency in the course of blood pressure lowering therapy. Although the advantages of inhibitors of renin-angiotensin system are lionized these days (advertisement based medicine: ABM), we should never forget to select more favorable antihypertensive drugs for each patient in case by case (individual based medicine: IBM), to get the definite blood pressure lowering effects without worsening any complications. We also need further gathering of many evidences in a net-work-meta-analysis way, on blood pressure lowering therapy in those hypertensive patients with a history of stroke (evidence based medicine: EBM).

Early Metabolome Profiling and Prognostic Value in Paraquat-Poisoned Patients: Based on Ultraperformance Liquid Chromatography Coupled To Quadrupole Time-of-Flight Mass Spectrometry.

PubMed

Hu, Lufeng; Hong, Guangliang; Tang, Yahui; Wang, Xianqin; Wen, Congcong; Lin, Feiyan; Lu, Zhongqiu

2017-12-18

Paraquat (PQ) has caused countless deaths throughout the world. There remains no effective treatment for PQ poisoning. Here we study the blood metabolome of PQ-poisoned patients using ultraperformance liquid chromatography coupled to quadrupole time-of-flight mass spectrometry (UPLC/Q-TOF MS). Patients were divided into groups according to blood PQ concentration. Healthy subjects served as controls. Metabolic features were statistically analyzed using multivariate pattern-recognition techniques to identify the most important metabolites. Selected metabolites were further compared with a series of clinical indexes to assess the prognostic value. PQ-poisoned patients showed substantial differences compared with healthy subjects. Based on variable of importance in the project (VIP) values and statistical analysis, 17 metabolites were selected and identified. These metabolites well-classified low PQ-poisoned patients, high PQ-poisoned patients, and healthy subjects, which was better than that of a complete blood count (CBC). Among the 17 metabolites, 20:3/18:1-PC (PC), LPA (0:0/16:0) (LPA), 19-oxo-deoxycorticosterone (19-oxo-DOC), and eicosapentaenoic acid (EPA) had prognostic value. In particular, EPA was the most sensitive one. Besides, the levels of EPA was correlated with LPA and 19-oxo-DOC. If EPA was excessively consumed, then prognosis was poor. In conclusion, the serum metabolome is substantially perturbed by PQ poisoning. EPA is the most important biomarker in early PQ poisoning.

Risk Factors for Treatment Default among Re-Treatment Tuberculosis Patients in India, 2006

PubMed Central

Jha, Ugra Mohan; Satyanarayana, Srinath; Dewan, Puneet K.; Chadha, Sarabjit; Wares, Fraser; Sahu, Suvanand; Gupta, Devesh; Chauhan, L. S.

2010-01-01

Setting Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment. Objective To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients. Methodology For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters. Results 1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%–75% interquartile range 44–117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2–1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1–1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0–1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1–1.6). Conclusions Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pre-treatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening. PMID:20111727

Cognitive Decline in Patients with Chronic Hydrocephalus and Normal Aging: ‘Growing into Deficits’

PubMed Central

de Beer, Marlijn H.; Scheltens, Philip

2016-01-01

Background/Aim To explore the theory of ‘growing into deficits’, a concept known from developmental neurology, in a series of cases with chronic hydrocephalus (CH). Methods Patients were selected from the Amsterdam Dementia Cohort and underwent extensive dementia screening. Results Twelve patients with CH were selected, in whom Alzheimer's disease was considered unlikely, based on biomarker information and follow-up. Mean Mini-Mental State Examination score was 24 (range 7-30). Most patients were functioning on a level of mild dementia [Clinical Dementia Rating score of 0.5 in 8/11 (66.7%) patients]. On neuropsychological examination, memory and executive functions, as well as processing speed were most frequently impaired. Conclusion In our opinion, the theory of ‘growing into deficits’ shows a parallel with the clinical course of CH and normal aging when Alzheimer's disease was considered very unlikely, because most of these patients were functioning well for a very large part of their lives. The altered cerebrospinal fluid dynamics might make the brain more vulnerable to aging-related changes, leading to a faster cognitive decline in CH patients compared to healthy subjects, especially in case of concomitant brain damage such as traumatic brain injury or meningitis. PMID:27920793

Long-Term Treatment with Paroxetine Increases Verbal Declarative Memory and Hippocampal Volume in Posttraumatic Stress Disorder

PubMed Central

Vermetten, Eric; Vythilingam, Meena; Southwick, Steven M.; Charney, Dennis S.; Bremner, J. Douglas

2011-01-01

Background Animal studies have shown that stress is associated with damage to the hippocampus, inhibition of neurogenesis, and deficits in hippocampal-based memory dysfunction. Studies in patients with posttraumatic stress disorder (PTSD) found deficits in hippocampal-based declarative verbal memory and smaller hippocampal volume, as measured with magnetic resonance imaging (MRI). Recent preclinical evidence has shown that selective serotonin reuptake inhibitors promote neurogenesis and reverse the effects of stress on hippocampal atrophy. This study assessed the effects of long-term treatment with paroxetine on hippocampal volume and declarative memory performance in PTSD. Methods Declarative memory was assessed with the Wechsler Memory Scale–Revised and Selective Reminding Test before and after 9–12 months of treatment with paroxetine in PTSD. Hippocampal volume was measured with MRI. Of the 28 patients who started the protocol, 23 completed the full course of treatment and neuropsychological testing. Twenty patients were able to complete MRI imaging. Results Patients with PTSD showed a significant improvement in PTSD symptoms with treatment. Treatment resulted in significant improvements in verbal declarative memory and a 4.6% increase in mean hippocampal volume. Conclusions These findings suggest that long-term treatment with paroxetine is associated with improvement of verbal declarative memory deficits and an increase in hippocampal volume in PTSD. PMID:14512209

Modelling the Costs and Effects of Selective and Universal Hospital Admission Screening for Methicillin-Resistant Staphylococcus aureus

PubMed Central

Hubben, Gijs; Bootsma, Martin; Luteijn, Michiel; Glynn, Diarmuid; Bishai, David

2011-01-01

Background Screening at hospital admission for carriage of methicillin-resistant Staphylococcus aureus (MRSA) has been proposed as a strategy to reduce nosocomial infections. The objective of this study was to determine the long-term costs and health benefits of selective and universal screening for MRSA at hospital admission, using both PCR-based and chromogenic media-based tests in various settings. Methodology/Principal Findings A simulation model of MRSA transmission was used to determine costs and effects over 15 years from a US healthcare perspective. We compared admission screening together with isolation of identified carriers against a baseline policy without screening or isolation. Strategies included selective screening of high risk patients or universal admission screening, with PCR-based or chromogenic media-based tests, in medium (5%) or high nosocomial prevalence (15%) settings. The costs of screening and isolation per averted MRSA infection were lowest using selective chromogenic-based screening in high and medium prevalence settings, at $4,100 and $10,300, respectively. Replacing the chromogenic-based test with a PCR-based test costs $13,000 and $36,200 per additional infection averted, and subsequent extension to universal screening with PCR would cost $131,000 and $232,700 per additional infection averted, in high and medium prevalence settings respectively. Assuming $17,645 benefit per infection averted, the most cost-saving strategies in high and medium prevalence settings were selective screening with PCR and selective screening with chromogenic, respectively. Conclusions/Significance Admission screening costs $4,100–$21,200 per infection averted, depending on strategy and setting. Including financial benefits from averted infections, screening could well be cost saving. PMID:21483492

Coronary intervention in thrombus-rich lesions: beyond stents and glycoprotein IIb/IIIa inhibitors.

PubMed

Halkin, Amir; Keren, Gad; Stone, Gregg W; Holmes, David R; Rosenschein, Uri

2003-11-01

Despite widespread use of stents and GP IIb/IIIa antagonists, complications following percutaneous treatment of thrombus-rich lesions continue to plague patients with ACS. In these patients the angiographically evident coronary thrombosis may represent a high degree of thrombus burden, which leads to a higher level of microembolization and its clinical sequelae. New catheter-based thrombus burden reduction systems and distal protection devices show promise for improving the prognosis of these high risk patients by decreasing distal microembolization, and thereby preventing myonecrosis. Careful procedural timing and patient selection are also likely to improve outcomes and resource utilization in the management of ACS patients.

An EEG-based functional connectivity measure for automatic detection of alcohol use disorder.

PubMed

Mumtaz, Wajid; Saad, Mohamad Naufal B Mohamad; Kamel, Nidal; Ali, Syed Saad Azhar; Malik, Aamir Saeed

2018-01-01

The abnormal alcohol consumption could cause toxicity and could alter the human brain's structure and function, termed as alcohol used disorder (AUD). Unfortunately, the conventional screening methods for AUD patients are subjective and manual. Hence, to perform automatic screening of AUD patients, objective methods are needed. The electroencephalographic (EEG) data have been utilized to study the differences of brain signals between alcoholics and healthy controls that could further developed as an automatic screening tool for alcoholics. In this work, resting-state EEG-derived features were utilized as input data to the proposed feature selection and classification method. The aim was to perform automatic classification of AUD patients and healthy controls. The validation of the proposed method involved real-EEG data acquired from 30 AUD patients and 30 age-matched healthy controls. The resting-state EEG-derived features such as synchronization likelihood (SL) were computed involving 19 scalp locations resulted into 513 features. Furthermore, the features were rank-ordered to select the most discriminant features involving a rank-based feature selection method according to a criterion, i.e., receiver operating characteristics (ROC). Consequently, a reduced set of most discriminant features was identified and utilized further during classification of AUD patients and healthy controls. In this study, three different classification models such as Support Vector Machine (SVM), Naïve Bayesian (NB), and Logistic Regression (LR) were used. The study resulted into SVM classification accuracy=98%, sensitivity=99.9%, specificity=95%, and f-measure=0.97; LR classification accuracy=91.7%, sensitivity=86.66%, specificity=96.6%, and f-measure=0.90; NB classification accuracy=93.6%, sensitivity=100%, specificity=87.9%, and f-measure=0.95. The SL features could be utilized as objective markers to screen the AUD patients and healthy controls. Copyright © 2017 Elsevier B.V. All rights reserved.

Targeting the interleukin-11 receptor α in metastatic prostate cancer: A first-in-man study.

PubMed

Pasqualini, Renata; Millikan, Randall E; Christianson, Dawn R; Cardó-Vila, Marina; Driessen, Wouter H P; Giordano, Ricardo J; Hajitou, Amin; Hoang, Anh G; Wen, Sijin; Barnhart, Kirstin F; Baze, Wallace B; Marcott, Valerie D; Hawke, David H; Do, Kim-Anh; Navone, Nora M; Efstathiou, Eleni; Troncoso, Patricia; Lobb, Roy R; Logothetis, Christopher J; Arap, Wadih

2015-07-15

Receptors in tumor blood vessels are attractive targets for ligand-directed drug discovery and development. The authors have worked systematically to map human endothelial receptors ("vascular zip codes") within tumors through direct peptide library selection in cancer patients. Previously, they selected a ligand-binding motif to the interleukin-11 receptor alpha (IL-11Rα) in the human vasculature. The authors generated a ligand-directed, peptidomimetic drug (bone metastasis-targeting peptidomimetic-11 [BMTP-11]) for IL-11Rα-based human tumor vascular targeting. Preclinical studies (efficacy/toxicity) included evaluating BMTP-11 in prostate cancer xenograft models, drug localization, targeted apoptotic effects, pharmacokinetic/pharmacodynamic analyses, and dose-range determination, including formal (good laboratory practice) toxicity across rodent and nonhuman primate species. The initial BMTP-11 clinical development also is reported based on a single-institution, open-label, first-in-class, first-in-man trial (National Clinical Trials number NCT00872157) in patients with metastatic, castrate-resistant prostate cancer. BMTP-11 was preclinically promising and, thus, was chosen for clinical development in patients. Limited numbers of patients who had castrate-resistant prostate cancer with osteoblastic bone metastases were enrolled into a phase 0 trial with biology-driven endpoints. The authors demonstrated biopsy-verified localization of BMTP-11 to tumors in the bone marrow and drug-induced apoptosis in all patients. Moreover, the maximum tolerated dose was identified on a weekly schedule (20-30 mg/m(2) ). Finally, a renal dose-limiting toxicity was determined, namely, dose-dependent, reversible nephrotoxicity with proteinuria and casts involving increased serum creatinine. These biologic endpoints establish BMTP-11 as a targeted drug candidate in metastatic, castrate-resistant prostate cancer. Within a larger discovery context, the current findings indicate that functional tumor vascular ligand-receptor targeting systems may be identified through direct combinatorial selection of peptide libraries in cancer patients. © 2015 American Cancer Society.

Building a business case for colorectal surgery quality improvement.

PubMed

Lee, Ken K H; Berenholtz, Sean M; Hobson, Deborah B; Demski, Renee J; Yang, Ting; Wick, Elizabeth C

2013-11-01

Improving surgical quality is a priority, but building a business case for the efforts could be challenging. Bridging the gap between the clinicians and hospital leaders is the first step to align quality and financial priorities within health care. The aim of this study was to evaluate the financial impact of the surgical comprehensive unit-based safety program on colorectal surgery procedures. This a retrospective cohort study. This study was conducted at a university-based tertiary care hospital. All patients undergoing colectomy or proctectomy between July 2010 and June 2012 were included. A comprehensive unit-based safety program focused on colorectal surgical site infection reduction was implemented. Three surgeons participated in the program in year 1, and 5 surgeons participated in year 2. Patients were categorized as participating or nonparticipating based on the surgeon who performed the procedure. Resource utilization and cost were the main outcome measures. During the 2 years, there were 626 patients who met the selection criteria. Participating surgeons operated on 444 patients (70.9%), and the nonparticipating surgeons operated on 182 patients (29.1%). After adjusting for covariates, the variable direct cost was significantly lower for the participating surgeons in laboratory work by $191 (p = 0.009), operating room utilization by $149 (p = 0.05), and supplies by $615 (p = 0.003). The surgical site infection rates, need for an intensive care unit stay, and length of stay were not significantly different between the 2 groups. The multiple biases related to surgeon self-selection for program participation and surgeon training and clinical skills were not addressed in this study owing to the limitations in sample size and data collection. A comprehensive unit-based safety program implementation, including dedicated frontline providers who focused on the standardization of protocols, was able to reduce the variation in resource utilization and costs in comparison with a control group.

Recent advances in cancer therapeutics.

PubMed

Chessum, Nicola; Jones, Keith; Pasqua, Elisa; Tucker, Michael

2015-01-01

In the past 20 years, cancer therapeutics has undergone a paradigm shift away from the traditional cytotoxic drugs towards the targeting of proteins intimately involved in driving the cancer phenotype. The poster child for this alternative approach to the treatment of cancer is imatinib, a small-molecule kinase inhibitor designed to target chronic myeloid leukaemia driven by the BCR-ABL translocation in a defined patient population. The improvement in survival achieved by treatment of this patient cohort with imatinib is impressive. Thus, the aim is to provide efficacy but with low toxicity. The role of the medicinal chemist in oncology drug discovery is now closely aligned with the role in most other therapeutic areas with high-throughput and/or fragment-based screening, structure-based design, selectivity, pharmacokinetic optimisation and pharmacodynamic biomarker modulation, all playing a familiar part in the process. In this chapter, we selected four areas in which compounds are either approved drugs or in clinical trials. These are chaperone inhibitors, kinase inhibitors, histone deacetylase inhibitors and inhibitors of protein-protein interactions. Even within these areas, we have been selective, particularly for kinase inhibitors, and our aim has been to exemplify newer approaches and novel aspects of medicinal chemistry. © 2015 Elsevier B.V. All rights reserved.

Prediction and Informative Risk Factor Selection of Bone Diseases.

PubMed

Li, Hui; Li, Xiaoyi; Ramanathan, Murali; Zhang, Aidong

2015-01-01

With the booming of healthcare industry and the overwhelming amount of electronic health records (EHRs) shared by healthcare institutions and practitioners, we take advantage of EHR data to develop an effective disease risk management model that not only models the progression of the disease, but also predicts the risk of the disease for early disease control or prevention. Existing models for answering these questions usually fall into two categories: the expert knowledge based model or the handcrafted feature set based model. To fully utilize the whole EHR data, we will build a framework to construct an integrated representation of features from all available risk factors in the EHR data and use these integrated features to effectively predict osteoporosis and bone fractures. We will also develop a framework for informative risk factor selection of bone diseases. A pair of models for two contrast cohorts (e.g., diseased patients versus non-diseased patients) will be established to discriminate their characteristics and find the most informative risk factors. Several empirical results on a real bone disease data set show that the proposed framework can successfully predict bone diseases and select informative risk factors that are beneficial and useful to guide clinical decisions.

Selecting relevant and feasible measurement instruments for the revised Dutch clinical practice guideline for physical therapy in patients after stroke.

PubMed

Otterman, Nicoline; Veerbeek, Janne; Schiemanck, Sven; van der Wees, Philip; Nollet, Frans; Kwakkel, Gert

2017-07-01

To select relevant and feasible instruments for the revision of the Dutch clinical practice guideline for physical therapy in patients with stroke. In this implementation study a comprehensive proposal for ICF categories and matching instruments was developed, based on reliability and validity. Relevant instruments were then selected in a consensus round by 11 knowledge brokers who were responsible for the implementation of the selected instruments. The feasibility of the selected instruments was tested by 36 physical therapists at different work settings within stroke services. Finally, instruments that were deemed relevant and feasible were included in the revised guideline. A total of 28 instruments were recommended for inclusion in the revised guideline. Nineteen instruments were retained from the previous guideline. Ten new instruments were tested in clinical practice, seven of which were found feasible. Two more instruments were added after critical appraisal of the set of the measurement instruments. The revised guideline contains 28 relevant and feasible instrument selected and tested in clinical practice by physical therapists. Further education and implementation is needed to integrate instruments in clinical practice. Further research is proposed for developing and implementing a core set of measurement instruments to be used at fixed time points to establish data registries that allow for continuous improvement of rehabilitation for stroke patients. Implications for Rehabilitation The revised Dutch Stroke Physical Therapy Guideline recommends a total of 28 instruments, that are relevant and feasible for clinical practice of physical therapist in the different settings of stroke rehabilitation. The selection of instrument in daily practice should be part of the clinical reasoning process of PTs and be tailored to individual patients' needs and the degree of priority of the affected ICF category. Suggested education strategies for further integration of instruments in of the daily practice of PTs in Stroke Rehabilitation are: 'Training on the job' and 'peer assessment in clinical situations'.

Evaluating Patient Reported Outcome Measures (PROMs) for bladder cancer: a systematic review using the COSMIN checklist.

PubMed

Mason, Samantha J; Catto, James Wf; Downing, Amy; Bottomley, Sarah E; Glaser, Adam W; Wright, Penny

2018-05-03

Patient Reported Outcome Measures (PROMs) are important tools used to understand patient focused outcomes from care. Various PROMs have been developed for patients with Bladder Cancer (BC), although the disease's heterogeneity makes selection difficult. Accurate measurement of Health Related Quality of Life (HRQL) can only be achieved if the PROM chosen is 'fit for purpose' (i.e. psychometrically sound). Systematic reviews of psychometric properties are useful for selecting the best PROM for a specific purpose. The COnsensus-based Standards for the selection of health Measurement Instruments (COSMIN) developed a checklist to improve the selection of health measurement instruments as part of a review process. Our aims were to undertake a systematic review, using the COSMIN criteria, to assess the quality of studies that report the psychometric properties of PROMs used with people with BC and determine the psychometric quality of these PROMs. An electronic search of seven databases including PubMed, MEDLINE and EMBASE (PROSPERO reference CRD42016051974) was undertaken to identify English language publications, published between January 1990 and September 2017 that evaluated psychometric properties of PROMs used in BC research. Two researchers independently screened abstracts and selected full text papers. Studies were rated on methodological quality using the COSMIN checklist. Overall, 4,663 records were screened and 23 studies, reporting outcomes in 3,568 patients, were evaluated using the COSMIN checklist. Most PROMs had limited information reported about their psychometric properties. Studies reporting on the Bladder Cancer Index (BCI) and Functional Assessment of Cancer Therapy Vanderbilt Cystectomy Index (FACT-VCI) provided the most detail and these PROMs could be evaluated on the most COSMIN properties. Based on the available evidence, no existing PROM stands out as the most appropriate to measure HRQL in BC populations. This is due to two factors; (i) the heterogeneity of BC and its treatments (ii) no PROM was evaluated on all COSMIN measurement properties due to a lack of validation studies. We suggest future evaluation of generic, cancer generic and BC specific PROMs to better understand their application with BC populations and propose strategies to help clinicians and researchers. This article is protected by copyright. All rights reserved. This article is protected by copyright. All rights reserved.

Targeting the interleukin-11 receptor α in metastatic prostate cancer: A first-in-man study

PubMed Central

Pasqualini, Renata; Millikan, Randall E; Christianson, Dawn R; Cardó-Vila, Marina; Driessen, Wouter H P; Giordano, Ricardo J; Hajitou, Amin; Hoang, Anh G; Wen, Sijin; Barnhart, Kirstin F; Baze, Wallace B; Marcott, Valerie D; Hawke, David H; Do, Kim-Anh; Navone, Nora M; Efstathiou, Eleni; Troncoso, Patricia; Lobb, Roy R; Logothetis, Christopher J; Arap, Wadih

2015-01-01

BACKGROUND Receptors in tumor blood vessels are attractive targets for ligand-directed drug discovery and development. The authors have worked systematically to map human endothelial receptors (“vascular zip codes”) within tumors through direct peptide library selection in cancer patients. Previously, they selected a ligand-binding motif to the interleukin-11 receptor alpha (IL-11Rα) in the human vasculature. METHODS The authors generated a ligand-directed, peptidomimetic drug (bone metastasis-targeting peptidomimetic-11 [BMTP-11]) for IL-11Rα–based human tumor vascular targeting. Preclinical studies (efficacy/toxicity) included evaluating BMTP-11 in prostate cancer xenograft models, drug localization, targeted apoptotic effects, pharmacokinetic/pharmacodynamic analyses, and dose-range determination, including formal (good laboratory practice) toxicity across rodent and nonhuman primate species. The initial BMTP-11 clinical development also is reported based on a single-institution, open-label, first-in-class, first-in-man trial (National Clinical Trials number NCT00872157) in patients with metastatic, castrate-resistant prostate cancer. RESULTS BMTP-11 was preclinically promising and, thus, was chosen for clinical development in patients. Limited numbers of patients who had castrate-resistant prostate cancer with osteoblastic bone metastases were enrolled into a phase 0 trial with biology-driven endpoints. The authors demonstrated biopsy-verified localization of BMTP-11 to tumors in the bone marrow and drug-induced apoptosis in all patients. Moreover, the maximum tolerated dose was identified on a weekly schedule (20-30 mg/m2). Finally, a renal dose-limiting toxicity was determined, namely, dose-dependent, reversible nephrotoxicity with proteinuria and casts involving increased serum creatinine. CONCLUSIONS These biologic endpoints establish BMTP-11 as a targeted drug candidate in metastatic, castrate-resistant prostate cancer. Within a larger discovery context, the current findings indicate that functional tumor vascular ligand-receptor targeting systems may be identified through direct combinatorial selection of peptide libraries in cancer patients. Cancer 2015;121:2411–2421. © 2015 The Authors. Cancer published by Wiley Periodicals, Inc. on behalf of American Cancer Society. The authors report on the development of a new ligand-directed peptidomimetic (termed bone metastasis-targeting peptidomimetic-11) for interleukin-11 receptor-based human vascular targeting, including the translation from preclinical studies to a first-in-class, first-in-man clinical trial in patients with metastatic, castrate-resistant prostate cancer. PMID:25832466

Discriminant analysis of resting-state functional connectivity patterns on the Grassmann manifold

NASA Astrophysics Data System (ADS)

Fan, Yong; Liu, Yong; Jiang, Tianzi; Liu, Zhening; Hao, Yihui; Liu, Haihong

2010-03-01

The functional networks, extracted from fMRI images using independent component analysis, have been demonstrated informative for distinguishing brain states of cognitive functions and neurological diseases. In this paper, we propose a novel algorithm for discriminant analysis of functional networks encoded by spatial independent components. The functional networks of each individual are used as bases for a linear subspace, referred to as a functional connectivity pattern, which facilitates a comprehensive characterization of temporal signals of fMRI data. The functional connectivity patterns of different individuals are analyzed on the Grassmann manifold by adopting a principal angle based subspace distance. In conjunction with a support vector machine classifier, a forward component selection technique is proposed to select independent components for constructing the most discriminative functional connectivity pattern. The discriminant analysis method has been applied to an fMRI based schizophrenia study with 31 schizophrenia patients and 31 healthy individuals. The experimental results demonstrate that the proposed method not only achieves a promising classification performance for distinguishing schizophrenia patients from healthy controls, but also identifies discriminative functional networks that are informative for schizophrenia diagnosis.

How do intake clinicians use patient characteristics to select treatment for patients with personality disorders?

PubMed

van Manen, Janine; Kamphuis, Jan Henk; Visbach, Geny; Ziegler, Uli; Gerritsen, Ad; Van Rossum, Bert; Rijnierse, Piet; Timman, Reinier; Verheul, Roel

2008-11-01

Treatment selection in clinical practice is a poorly understood, often largely implicit decision process, perhaps especially for patients with personality disorders. This study, therefore, investigated how intake clinicians use information about patient characteristics to select psychotherapeutic treatment for patients with personality disorder. A structured interview with a forced-choice format was administered to 27 experienced intake clinicians working in five specialist mental health care institutes in the Netherlands. Substantial consensus was evident among intake clinicians. The results revealed that none of the presented patient characteristics were deemed relevant for the selection of the suitable treatment setting. The appropriate duration and intensity are selected using severity or personal strength variables. The theoretical orientation is selected using personal strength variables.

EHR based Genetic Testing Knowledge Base (iGTKB) Development

PubMed Central

2015-01-01

Background The gap between a large growing number of genetic tests and a suboptimal clinical workflow of incorporating these tests into regular clinical practice poses barriers to effective reliance on advanced genetic technologies to improve quality of healthcare. A promising solution to fill this gap is to develop an intelligent genetic test recommendation system that not only can provide a comprehensive view of genetic tests as education resources, but also can recommend the most appropriate genetic tests to patients based on clinical evidence. In this study, we developed an EHR based Genetic Testing Knowledge Base for Individualized Medicine (iGTKB). Methods We extracted genetic testing information and patient medical records from EHR systems at Mayo Clinic. Clinical features have been semi-automatically annotated from the clinical notes by applying a Natural Language Processing (NLP) tool, MedTagger suite. To prioritize clinical features for each genetic test, we compared odds ratio across four population groups. Genetic tests, genetic disorders and clinical features with their odds ratios have been applied to establish iGTKB, which is to be integrated into the Genetic Testing Ontology (GTO). Results Overall, there are five genetic tests operated with sample size greater than 100 in 2013 at Mayo Clinic. A total of 1,450 patients who was tested by one of the five genetic tests have been selected. We assembled 243 clinical features from the Human Phenotype Ontology (HPO) for these five genetic tests. There are 60 clinical features with at least one mention in clinical notes of patients taking the test. Twenty-eight clinical features with high odds ratio (greater than 1) have been selected as dominant features and deposited into iGTKB with their associated information about genetic tests and genetic disorders. Conclusions In this study, we developed an EHR based genetic testing knowledge base, iGTKB. iGTKB will be integrated into the GTO by providing relevant clinical evidence, and ultimately to support development of genetic testing recommendation system, iGenetics. PMID:26606281

EHR based Genetic Testing Knowledge Base (iGTKB) Development.

PubMed

Zhu, Qian; Liu, Hongfang; Chute, Christopher G; Ferber, Matthew

2015-01-01

The gap between a large growing number of genetic tests and a suboptimal clinical workflow of incorporating these tests into regular clinical practice poses barriers to effective reliance on advanced genetic technologies to improve quality of healthcare. A promising solution to fill this gap is to develop an intelligent genetic test recommendation system that not only can provide a comprehensive view of genetic tests as education resources, but also can recommend the most appropriate genetic tests to patients based on clinical evidence. In this study, we developed an EHR based Genetic Testing Knowledge Base for Individualized Medicine (iGTKB). We extracted genetic testing information and patient medical records from EHR systems at Mayo Clinic. Clinical features have been semi-automatically annotated from the clinical notes by applying a Natural Language Processing (NLP) tool, MedTagger suite. To prioritize clinical features for each genetic test, we compared odds ratio across four population groups. Genetic tests, genetic disorders and clinical features with their odds ratios have been applied to establish iGTKB, which is to be integrated into the Genetic Testing Ontology (GTO). Overall, there are five genetic tests operated with sample size greater than 100 in 2013 at Mayo Clinic. A total of 1,450 patients who was tested by one of the five genetic tests have been selected. We assembled 243 clinical features from the Human Phenotype Ontology (HPO) for these five genetic tests. There are 60 clinical features with at least one mention in clinical notes of patients taking the test. Twenty-eight clinical features with high odds ratio (greater than 1) have been selected as dominant features and deposited into iGTKB with their associated information about genetic tests and genetic disorders. In this study, we developed an EHR based genetic testing knowledge base, iGTKB. iGTKB will be integrated into the GTO by providing relevant clinical evidence, and ultimately to support development of genetic testing recommendation system, iGenetics.

Advances and Challenges in Treatment of Locally Advanced Rectal Cancer

PubMed Central

Smith, J. Joshua; Garcia-Aguilar, Julio

2015-01-01

Dramatic improvements in the outcomes of patients with rectal cancer have occurred over the past 30 years. Advances in surgical pathology, refinements in surgical techniques and instrumentation, new imaging modalities, and the widespread use of neoadjuvant therapy have all contributed to these improvements. Several questions emerge as we learn of the benefits or lack thereof for components of the current multimodality treatment in subgroups of patients with nonmetastatic locally advanced rectal cancer (LARC). What is the optimal surgical technique for distal rectal cancers? Do all patients need postoperative chemotherapy? Do all patients need radiation? Do all patients need surgery, or is a nonoperative, organ-preserving approach warranted in selected patients? Answering these questions will lead to more precise treatment regimens, based on patient and tumor characteristics, that will improve outcomes while preserving quality of life. However, the idea of shifting the treatment paradigm (chemoradiotherapy, total mesorectal excision, and adjuvant therapy) currently applied to all patients with LARC to a more individually tailored approach is controversial. The paradigm shift toward organ preservation in highly selected patients whose tumors demonstrate clinical complete response to neoadjuvant treatment is also controversial. Herein, we highlight many of the advances and resultant controversies that are likely to dominate the research agenda for LARC in the modern era. PMID:25918296

Thromboembolism prevention in surgery of digestive cancer.

PubMed

Malafaia, Osvaldo; Montagnini, Andre Luís; Luchese, Angélica; Accetta, Antonio Carlos; Zilberstein, Bruno; Malheiros, Carlos Alberto; Jacob, Carlos Eduardo; Quireze-Junior, Claudemiro; Bresciani, Cláudio José Caldas; Kruel, Cleber Dario Pinto; Cecconello, Ivan; Sad, Eduardo Fonseca; Ohana, Jorge Alberto Langbeck; Aguilar-Nascimento, José Eduardo de; Manso, José Eduardo Ferreira; Ribas-Filho, Jurandir Marcondes; Santo, Marco Aurélio; Andreollo, Nelson Adami; Torres, Orlando Jorge Martins; Herman, Paulo; Cuenca, Ronaldo Mafia; Sallum, Rubens Antônio Aissar; Bernardo, Wanderley Marques

2012-01-01

The venous thromboembolism is a common complication after surgical treatment in general and, in particular, on the therapeutic management on cancer. Surgery of the digestive tract has been reported to induce this complication. Patients with digestive cancer have substantial increased risk of initial or recurrent thromboembolism. To provide to surgeons working in digestive surgery and general surgery guidance on how to make safe thromboprophylaxis for patients requiring operations in the treatment of their gastrointestinal malignancies. The guideline was based on 15 relevant clinical issues and related to the risk factors, treatment and prognosis of the patient undergoing surgical treatment of cancer on digestive tract. They focused thromboembolic events associated with operations and thromboprophylaxis. The questions were structured using the PICO (Patient, Intervention or Indicator, Comparison and Outcome), allowing strategies to generate evidence on the main primary bases of scientific information (Medline / Pubmed, Embase, Lilacs / Scielo, Cochrane Library, PreMedline via OVID). Evidence manual search was also conducted (BDTD and IBICT). The evidence was recovered from the selected critical evaluation using discriminatory instruments (scores) according to the category of the question: risk, prognosis and therapy (JADAD Randomized Clinical Trials and New Castle Ottawa Scale for studies not randomized). After defining potential studies to support the recommendations, they were selected by the strength of evidence and grade of recommendation according to the classification of Oxford, including the available evidence of greater strength. A total of 53,555 papers by title and / or abstract related to issue were found. Of this total were selected (1st selection) 478 studies that were evaluated as full-text. From them to support the recommendations were included in the consensus 132 papers. The 15 questions could be answered with evidence grade of articles with 31 A, 130 B, 1 C and 0 D. It was possible to prepare safe recommendations as guidance for thromboembolism prophylaxis in operations on the digestive tract malignancies, addressing the most frequent topics of everyday work of digestive and general surgeons.

Technical Aspects of Fecal Microbial Transplantation (FMT).

PubMed

Bhutiani, N; Schucht, J E; Miller, K R; McClave, Stephen A

2018-06-09

Fecal microbial transplantation (FMT) has become established as an effective therapeutic modality in the treatment of antibiotic-refractory recurrent Clostridium difficile colitis. A number of formulations and methods of delivery of FMT are currently available, each with distinct advantages. This review aims to review donor and patient selection for FMT as well as procedural aspects of FMT to help guide clinical practice. FMT can be obtained in fresh, frozen, lyophilized, and capsule-based formulations for delivery by oral ingestion, nasoenteric tube, colonoscopy, or enema (depending on the formulation used). Choosing the optimal method relies heavily on patient-related factors, including underlying pathology and severity of illness. As potential applications for FMT expand, careful donor screening and patient selection are critical to minimizing risk to patients and physicians. FMT represents an excellent therapeutic option for treatment of recurrent Clostridium difficile colitis and holds promise as a possible treatment modality in a variety of other conditions. The wide array of delivery methods allows for its application in various disease states in both the inpatient and outpatient setting.

External-beam radiotherapy for differentiated thyroid cancer locoregional control: A statement of the American Head and Neck Society

PubMed Central

Kiess, Ana P.; Agrawal, Nishant; Brierley, James D.; Duvvuri, Umamaheswar; Ferris, Robert L.; Genden, Eric; Wong, Richard J.; Tuttle, R. Michael; Lee, Nancy Y.; Randolph, Gregory W.

2016-01-01

The use of external-beam radiotherapy (EBRT) in differentiated thyroid cancer (DTC) is debated because of a lack of prospective clinical data, but recent retrospective studies have reported benefits in selected patients. The Endocrine Surgery Committee of the American Head and Neck Society provides 4 recommendations regarding EBRT for locoregional control in DTC, based on review of literature and expert opinion of the authors. (1) EBRT is recommended for patients with gross residual or unresectable locoregional disease, except for patients <45 years old with limited gross disease that is radioactive iodine (RAI)-avid. (2) EBRT should not be routinely used as adjuvant therapy after complete resection of gross disease. (3) After complete resection, EBRT may be considered in select patients >45 years old with high likelihood of microscopic residual disease and low likelihood of responding to RAI. (4) Cervical lymph node involvement alone should not be an indication for adjuvant EBRT. PMID:26716601

Alectinib: a selective, next-generation ALK inhibitor for treatment of ALK-rearranged non-small-cell lung cancer.

PubMed

Santarpia, Mariacarmela; Altavilla, Giuseppe; Rosell, Rafael

2015-06-01

Crizotinib was the first clinically available anaplastic lymphoma kinase (ALK) inhibitor, showing remarkable activity against ALK-rearranged non-small-cell lung cancer (NSCLC). Despite initial responses, acquired resistance to crizotinib inevitably develops, with the brain being a common site of relapse. Alectinib is a highly selective, next-generation ALK inhibitor with potent inhibitory activity also against ALK mutations conferring resistance to crizotinib, including the gatekeeper L1196M substitution. In a Phase I/II study from Japan, alectinib was found to be highly active and safe in crizotinib-naïve, ALK-rearranged NSCLC patients. Alectinib also demonstrated promising antitumor activity in crizotinib-resistant patients, including those with CNS metastases. Based on these data, the drug received Breakthrough Therapy Designation by the US FDA and has been recently approved in Japan for the treatment of ALK-positive, advanced NSCLC patients. However, patients may eventually develop resistance to alectinib, highlighting the need for novel therapeutic strategies to further improve the management of ALK-rearranged NSCLC.

Laparoscopic repair of perforated peptic duodenal ulcer.

PubMed

Busić, Zeljko; Servis, Draien; Slisurić, Ferdinand; Kristek, Jozo; Kolovrat, Marijan; Cavka, Vlatka; Cavka, Mislav; Cupurdija, Kristijan; Patrlj, Leonardo; Kvesić, Ante

2010-03-01

Although prevalence of peptic ulcer is decreasing, the number of peptic ulcer perforations appears to be unchanged. This complication of peptic ulcer is traditionally surgically treated. In recent years, a number of papers have been published where the authors managed perforated duodenal peptic ulcer in selected patients using laparoscopic approach. Laparoscopic treatment of perforated duodenal ulcer has been described as safe and advantageous compared to open technique but advantages are still not clear due to small number of cases in published studies. Based on these recommendations we decided to establish our own protocol for laparoscopic treatment of perforated peptic duodenal ulcer. In this prospective study we evaluated the first 10 patients in whom we performed laparoscopic repair of perforated duodenal ulcer. There were no conversions to open procedure and no early postoperative complications. The patients were contacted by phone a year after the operation, and all were satisfied with the operation and the appearance of postoperative scars. We regard laparoscopic repair of selected patients with perforated duodenal ulcer as a safe and preferable treatment.

Risk of Febrile Neutropenia Associated With Select Myelosuppressive Chemotherapy Regimens in a Large Community-Based Oncology Practice.

PubMed

Li, Yanli; Family, Leila; Yang, Su-Jau; Klippel, Zandra; Page, John H; Chao, Chun

2017-09-01

Background: NCCN has classified commonly used chemotherapy regimens into high (>20%), intermediate (10%-20%), or low (<10%) febrile neutropenia (FN) risk categories based primarily on clinical trial evidence. Many chemotherapy regimens, however, remain unclassified by NCCN or lack FN incidence data in real-world clinical practice. Patients and Methods: We evaluated incidence proportions of FN and grade 4 and 3/4 neutropenia during the first chemotherapy course among patients from Kaiser Permanente Southern California who received selected chemotherapy regimens without well-established FN risk. Patients given granulocyte colony-stimulating factor (G-CSF) prophylaxis were excluded. Sensitivity analyses were performed to account for FN misclassification and censoring. Results: From 2008 to 2013, 1,312 patients with breast cancer who received docetaxel and cyclophosphamide (TC; n=853) or docetaxel, carboplatin, and trastuzumab (TCH; n=459); 1,321 patients with colorectal cancer who received capecitabine and oxaliplatin (XELOX; n=401) or leucovorin, 5-fluorouracil, and oxaliplatin (FOLFOX6; n=920); 307 patients with non-Hodgkin's lymphoma who received bendamustine with or without rituximab; and 181 patients with multiple myeloma who received lenalidomide with or without dexamethasone were included. Crude FN risk was >20% for both breast cancer regimens (TC and TCH). Crude FN risks for XELOX, FOLFOX6, bendamustine, and lenalidomide were <10%; however, when potential FN misclassification and censoring were considered, FN risks were >10%. Conclusions: Our results support published literature highlighting the real-world, "high" FN risk of the TC and TCH regimens for breast cancer. There is strong suggestive evidence that FN risks for XELOX, FOLFOX6, bendamustine, and lenalidomide are >10%. Calculation of chemotherapy course-level FN incidence without controlling for differential censoring for patients who discontinued regimens early, or possible FN misclassification, might have resulted in bias toward an underestimation of the true FN risk. These findings help define FN risk of the selected regimens in the real-world setting and inform prophylactic G-CSF use. Copyright © 2017 by the National Comprehensive Cancer Network.

Toward Personalized Targeted Therapeutics: An Overview.

PubMed

Weathers, Shiao-Pei S; Gilbert, Mark R

2017-04-01

In neuro-oncology, there has been a movement towards personalized medicine, or tailoring treatment to the individual patient. Ideally, tumor and patient evaluations would lead to the selection of the best treatment (based on tumor characterization) and the right dosing schedule (based on patient characterization). The recent advances in the molecular analysis of glioblastoma have created optimism that personalized targeted therapy is within reach. Although our understanding of the molecular complexity of glioblastoma has increased over the years, the path to developing effective targeted therapeutic strategies is wrought with many challenges, as described in this review. These challenges include disease heterogeneity, clinical and genomic patient variability, limited number of effective treatments, clinical trial inefficiency, drug delivery, and clinical trial support and accrual. To confront these challenges, it will be imperative to devise innovative and adaptive clinical trials in order to accelerate our efforts in improving the outcomes for our patients who have been in desperate need.

[Development and Testing of a Mastery Learning Program of Nursing Skills for Undergraduate Nursing Students].

PubMed

Park, SoMi; Hur, Hea Kung; Kim, Ki Kyong; Song, Hee Young

2017-08-01

This study was undertaken to develop and test a mastery learning program of nursing skills for undergraduate nursing students. In this methodological study, first, the preliminary draft of a mastery learning program to provide training for nursing skills was developed based on Bloom's framework for mastery learning. Second, to test the developed program, a single-blinded, nonequivalent control group nonsynchronized study was conducted on 50 senior nursing students in a University selected by convenient sampling. Thirteen students were assigned to a control group; 13, 12, and 13 of them were assigned to intravenous therapy, transfusion, and patient transfer groups, respectively. The achievement levels and performance scores of the selected nursing skills were measured before and after the completion of the program in all the groups. Lastly, the final program was confirmed based on the results of the program testing. Intravenous therapy, transfusion, and patient transfer were selected as essential nursing skills for the program based on the priorities rated by clinical instructors and staff nurses. The achievement levels of selected nursing skills were determined by Angoff scores. After participating in the program, the proportion of passers and performance scores of the nursing skills in the experimental groups were significantly higher than those in the control group. The final program was confirmed which included a diagnostic test, enrichment activities for the passers and three repetitions of corrective activities and formative assessments for non-passers. The results suggest that a mastery learning program for undergraduate students can lead to better improvement and performance of essential nursing skills. © 2017 Korean Society of Nursing Science

Inadequate Diagnostic Evaluation in Young Patients Registered with a Diagnosis of Dementia: A Nationwide Register-Based Study

PubMed Central

Salem, Lise Cronberg; Andersen, Birgitte Bo; Nielsen, T. Rune; Stokholm, Jette; Jørgensen, Martin Balslev; Waldemar, Gunhild

2014-01-01

Background Establishing a diagnosis of dementia in young patients may be complex and have significant implications for the patient. The aim of this study was to evaluate the quality of the diagnostic work-up in young patients diagnosed with dementia in the clinical routine. Methods Two hundred patients were randomly selected from 891 patients aged ≤65 years registered with a diagnosis of dementia for the first time in 2008 in Danish hospitals, and 159 medical records were available for review. Three raters evaluated their medical records for the completeness of the diagnostic work-up on which the diagnosis of dementia had been based, using evidence-based guidelines for the diagnostic evaluation of dementia as reference standards. Results According to the rater review, only 111 (70%) patients met the clinical criteria for dementia. An acceptable diagnostic work-up including all items of recommended basic diagnostic evaluation was performed in only 24%, although more often (28%) in the subgroup of patients where dementia was confirmed by raters. Conclusion This first nationwide study of unselected young patients registered with a diagnosis of dementia indicated that the concept of dementia may be misinterpreted by clinicians and that a diagnosis of dementia in the young is only rarely based on a complete basic diagnostic work-up, calling for increased competency. PMID:24711812

Selected algorithms for measurement data processing in impulse-radar-based system for monitoring of human movements

NASA Astrophysics Data System (ADS)

Miękina, Andrzej; Wagner, Jakub; Mazurek, Paweł; Morawski, Roman Z.

2016-11-01

The importance of research on new technologies that could be employed in care services for elderly and disabled persons is highlighted. Advantages of impulse-radar sensors, when applied for non-intrusive monitoring of such persons in their home environment, are indicated. Selected algorithms for the measurement data preprocessing - viz. the algorithms for clutter suppression and echo parameter estimation, as well as for estimation of the twodimensional position of a monitored person - are proposed. The capability of an impulse-radar- based system to provide some application-specific parameters, viz. the parameters characterising the patient's health condition, is also demonstrated.

Evoked Potential in Panic Disorder Patients: A Systematic Review.

PubMed

Di Giorgio, Luiza Medeiros Wanick; Velasques, Bruna Brandao; Ribeiro, Pedro; Nardi, Antonio Egidio; de Carvalho, Marcele Regine

2015-01-01

Researchers have been using the electroencephalogram to better understand the cognitive and neurobiological bases of panic disorder (PD) through the P300 component; this is an electric potential of the cerebral cortex that is generated in response to external sensorial stimuli and which involves more complex neurophysiological processes related to stimulus interpretation; it is then used to investigate possible alterations in the information processing and attention of patients suffering from this disorder. Aiming to verify the results found by experimental articles already published about P300 in PD patients and the information processing differences between PD patients and healthy controls, a systematic review of the PubMed and Institute for Scientific Information databases was conducted. The selection criterion involved those articles, written in English, which referred to an experimental research that focused on the P300 component, with a sample composed of PD (or panic attacks) patients. Seven articles were found that fit the selected criteria. Most of the articles show that these patients suffer from: impaired information processing and attention, an inability to automatically respond to new stimuli, and impaired interpretation of internal and external stimuli related to the disorder. Such impairment may be related to an unspecified dysfunction in the limbic-reticular structures, which would affect: active, focused and short-term attention, working and short-term memory, recognition and decision making. Some limitations were highlighted, such as the use of small samples and possible comorbidity with other disorders, which did not allow clearer results. This research can contribute to understand the neurobiological differences of PD patients and develop treatments based on such evidence.

Free Web-based personal health records: an analysis of functionality.

PubMed

Fernández-Alemán, José Luis; Seva-Llor, Carlos Luis; Toval, Ambrosio; Ouhbi, Sofia; Fernández-Luque, Luis

2013-12-01

This paper analyzes and assesses the functionality of free Web-based PHRs as regards health information, user actions and connection with other tools. A systematic literature review in Medline, ACM Digital Library, IEEE Digital Library and ScienceDirect was used to select 19 free Web-based PHRs from the 47 PHRs identified. The results show that none of the PHRs selected met 100% of the 28 functions presented in this paper. Two free Web-based PHRs target a particular public. Around 90 % of the PHRs identified allow users throughout the world to create their own profiles without any geographical restrictions. Only half of the PHRs selected provide physicians with user actions. Few PHRs can connect with other tools. There was considerable variability in the types of data included in free Web-based PHRs. Functionality may have implications for PHR use and adoption, particularly as regards patients with chronic illnesses or disabilities. Support for standard medical document formats and protocols are required to enable data to be exchanged with other stakeholders in the health care domain. The results of our study may assist users in selecting the PHR that best fits their needs, since no significant connection exists between the number of functions of the PHRs identified and their popularity.

Patient Motivation and Long-Term Satisfaction with Treatment Choice in Vestibular Schwannoma.

PubMed

Carlson, Matthew L; Tveiten, Øystein Vesterli; Lund-Johansen, Morten; Tombers, Nicole M; Lohse, Christine M; Link, Michael J

2018-06-01

To ascertain primary motivation and long-term satisfaction with treatment selection in patients with vestibular schwannoma. A multicenter, cross-sectional survey was performed. Patients with small- to medium-sized sporadic vestibular schwannoma who underwent stereotactic radiosurgery (SRS; n = 247), microsurgery (n = 144), or observation (n = 148) between 1998 and 2008 were surveyed regarding their motivation behind treatment selection and hindsight satisfaction with their choice of management. "Physician recommendation" was the most commonly stated reason for modality selection in all 3 groups. The second and third most common reasons for selecting SRS included "less invasive option than surgery" in 80 patients (32%) and "less recovery time than surgery" in 16 patients (6%). The second and third most common reasons for selecting observation included "to avoid side-effects of treatment" in 25 patients (17%) and "symptoms not severe enough to warrant intervention" in 22 patients (15%). The second and third most common reasons for selecting microsurgery included "do not want tumor in head" in 35 patients (24%) and "most definitive treatment" in 15 patients (10%). Overall, 232 patients (96%) treated with SRS, 141 observed patients (97%), and 121 patients (85%) who underwent microsurgical treatment were satisfied with their original decision (P < 0.001). Motivation behind treatment selection varies between individuals. Those who select observation and SRS commonly reference less invasiveness and lower risk, whereas those who select microsurgery are commonly motivated by having their tumor physically removed and the more definitive nature of treatment. Posttreatment satisfaction is highest in patients who undergo SRS and observation, although all 3 groups report high levels of satisfaction. Copyright © 2018 Elsevier Inc. All rights reserved.

Influence of (11)C-choline PET/CT on radiotherapy planning in prostate cancer.

PubMed

López, Escarlata; Lazo, Antonio; Gutiérrez, Antonio; Arregui, Gregorio; Núñez, Isabel; Sacchetti, Antonio

2015-01-01

To evaluate the influence of (11)C-choline PET/CT on radiotherapy planning in prostate cancer patients. Precise information on the extension of prostate cancer is crucial for the choice of an appropriate therapeutic strategy. (11)C-choline positron emission tomography ((11)C-choline PET/CT) has two roles in radiation oncology (RT): (1) patient selection for treatment and (2) target volume selection and delineation. In conjunction with high-accuracy techniques, it might offer an opportunity of dose escalation and better tumour control while sparing healthy tissues. We carried out a retrospective study in order to analyse RT planning modification based on (11)C-choline PET/CT in 16 prostate cancer patients. Patients were treated with hypofractionated step-and-shoot Intensity Modulated Radiotherapy (IMRT), or Volumetric Modulated Arc Therapy (VMAT), and a daily cone-beam CT for Image Guided Radiation Therapy (IGRT). All patients underwent a (11)C-choline-PET/CT scan prior to radiotherapy. In 37.5% of cases, a re-delineation and new dose prescription occurred. Data show good preliminary clinical results in terms of biochemical control and toxicity. No gastrointestinal (GI)/genitourinary (GU) grade III toxicities were observed after a median follow-up of 9.5 months. In our experience, concerning the treatment of prostate cancer (PCa), (11)C-choline PET/CT may be helpful in radiotherapy planning, either for dose escalation or exclusion of selected sites.

FDG-PET in the selection of brain lesions for biopsy

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

Hanson, M.W.; Glantz, M.J.; Hoffman, J.M.

1991-09-01

The CT-guided stereotaxic needle biopsy has become a widely used procedure in the diagnostic evaluation of intracranial lesions including tumors. Conventional CT or MR frequently defines the anatomic regions of abnormality, which may be multiple lesions or a single lesion that is heterogeneous in cellular composition owing to the topographic variation of cellular constituency or the combination of active disease, nonspecific inflammation, necrosis, and/or edema. In these cases, selection of the most appropriate site for a successful diagnostic needle biopsy can be difficult. In three patients, we have used (18F)fluorodeoxyglucose (FDG) positron emission tomography (PET) to determine the site mostmore » likely to provide a diagnostic biopsy result. In the first patient, who presented with confusion, multiple biopsies from the temporal lobe, based on MR abnormalities, revealed only reactive gliosis and edema. Repeat biopsy directed by PET revealed an anaplastic astrocytoma. In a second patient, PET allowed us to differentiate radiation effect from active metastatic breast cancer. In the third patient, who presented with a grand mal seizure, biopsy of a CT-defined hypodense region demonstrated lymphocytosis. Metabolism of FDG was normal or increased in areas of Aspergillus encephalitis at autopsy. These preliminary studies suggest a complementary role for FDG-PET and CT or MR in selected patients for defining the intracranial site most likely to yield a positive biopsy result.« less

Enhancing clinical communication assessments using an audiovisual BCI for patients with disorders of consciousness

NASA Astrophysics Data System (ADS)

Wang, Fei; He, Yanbin; Qu, Jun; Xie, Qiuyou; Lin, Qing; Ni, Xiaoxiao; Chen, Yan; Pan, Jiahui; Laureys, Steven; Yu, Ronghao; Li, Yuanqing

2017-08-01

Objective. The JFK coma recovery scale-revised (JFK CRS-R), a behavioral observation scale, is widely used in the clinical diagnosis/assessment of patients with disorders of consciousness (DOC). However, the JFK CRS-R is associated with a high rate of misdiagnosis (approximately 40%) because DOC patients cannot provide sufficient behavioral responses. A brain-computer interface (BCI) that detects command/intention-specific changes in electroencephalography (EEG) signals without the need for behavioral expression may provide an alternative method. Approach. In this paper, we proposed an audiovisual BCI communication system based on audiovisual ‘yes’ and ‘no’ stimuli to supplement the JFK CRS-R for assessing the communication ability of DOC patients. Specifically, patients were given situation-orientation questions as in the JFK CRS-R and instructed to select the answers using the BCI. Main results. Thirteen patients (eight vegetative state (VS) and five minimally conscious state (MCS)) participated in our experiments involving both the BCI- and JFK CRS-R-based assessments. One MCS patient who received a score of 1 in the JFK CRS-R achieved an accuracy of 86.5% in the BCI-based assessment. Seven patients (four VS and three MCS) obtained unresponsive results in the JFK CRS-R-based assessment but responsive results in the BCI-based assessment, and 4 of those later improved scores in the JFK CRS-R-based assessment. Five patients (four VS and one MCS) obtained usresponsive results in both assessments. Significance. The experimental results indicated that the audiovisual BCI could provide more sensitive results than the JFK CRS-R and therefore supplement the JFK CRS-R.

Enhancing clinical communication assessments using an audiovisual BCI for patients with disorders of consciousness.

PubMed

Wang, Fei; He, Yanbin; Qu, Jun; Xie, Qiuyou; Lin, Qing; Ni, Xiaoxiao; Chen, Yan; Pan, Jiahui; Laureys, Steven; Yu, Ronghao; Li, Yuanqing

2017-08-01

The JFK coma recovery scale-revised (JFK CRS-R), a behavioral observation scale, is widely used in the clinical diagnosis/assessment of patients with disorders of consciousness (DOC). However, the JFK CRS-R is associated with a high rate of misdiagnosis (approximately 40%) because DOC patients cannot provide sufficient behavioral responses. A brain-computer interface (BCI) that detects command/intention-specific changes in electroencephalography (EEG) signals without the need for behavioral expression may provide an alternative method. In this paper, we proposed an audiovisual BCI communication system based on audiovisual 'yes' and 'no' stimuli to supplement the JFK CRS-R for assessing the communication ability of DOC patients. Specifically, patients were given situation-orientation questions as in the JFK CRS-R and instructed to select the answers using the BCI. Thirteen patients (eight vegetative state (VS) and five minimally conscious state (MCS)) participated in our experiments involving both the BCI- and JFK CRS-R-based assessments. One MCS patient who received a score of 1 in the JFK CRS-R achieved an accuracy of 86.5% in the BCI-based assessment. Seven patients (four VS and three MCS) obtained unresponsive results in the JFK CRS-R-based assessment but responsive results in the BCI-based assessment, and 4 of those later improved scores in the JFK CRS-R-based assessment. Five patients (four VS and one MCS) obtained usresponsive results in both assessments. The experimental results indicated that the audiovisual BCI could provide more sensitive results than the JFK CRS-R and therefore supplement the JFK CRS-R.

Prospective study of the impact of the Prosigna assay on adjuvant clinical decision-making in unselected patients with estrogen receptor positive, human epidermal growth factor receptor negative, node negative early-stage breast cancer.

PubMed

Martín, Miguel; González-Rivera, Milagros; Morales, Serafín; de la Haba-Rodriguez, Juan; González-Cortijo, Lucía; Manso, Luis; Albanell, Joan; González-Martín, Antonio; González, Sónia; Arcusa, Angels; de la Cruz-Merino, Luis; Rojo, Federico; Vidal, María; Galván, Patricia; Aguirre, Elena; Morales, Cristina; Ferree, Sean; Pompilio, Kristen; Casas, Maribel; Caballero, Rosalía; Goicoechea, Uxue; Carrasco, Eva; Michalopoulos, Steven; Hornberger, John; Prat, Aleix

2015-06-01

Improved understanding of risk of recurrence (ROR) is needed to reduce cases of recurrence and more effectively treat breast cancer patients. The purpose of this study was to examine how a gene-expression profile (GEP), identified by Prosigna, influences physician adjuvant treatment selection for early breast cancer (EBC) and the effects of this influence on optimizing adjuvant treatment recommendations in clinical practice. A prospective, observational, multicenter study was carried out in 15 hospitals across Spain. Participating medical oncologists completed pre-assessment, post-assessment, and follow-up questionnaires recording their treatment recommendations and confidence in these recommendations, before and after knowing the patient's ROR. Patients completed questionnaires on decision-making, anxiety, and health status. Between June 2013 and January 2014, 217 patients enrolled and a final 200 were included in the study. Patients were postmenopausal, estrogen receptor positive, human epidermal growth hormone factor negative, and node negative with either stage 1 or stage 2 tumors. After receiving the GEP results, treatment recommendations were changed for 40 patients (20%). The confidence of medical oncologists in their treatment recommendations increased in 41.6% and decreased in 6.5% of total cases. Patients reported lower anxiety after physicians made treatment recommendations based on the GEP results (p < 0.05). Though this study does not include evaluation of the impact of GEP on long-term outcomes, it was found that GEP results influenced the treatment decisions of medical oncologists and their confidence in adjuvant therapy selection. Patients' anxiety about the selected adjuvant therapy decreased with use of the GEP.

CorRECTreatment: A Web-based Decision Support Tool for Rectal Cancer Treatment that Uses the Analytic Hierarchy Process and Decision Tree

PubMed Central

Karakülah, G.; Dicle, O.; Sökmen, S.; Çelikoğlu, C.C.

2015-01-01

Summary Background The selection of appropriate rectal cancer treatment is a complex multi-criteria decision making process, in which clinical decision support systems might be used to assist and enrich physicians’ decision making. Objective The objective of the study was to develop a web-based clinical decision support tool for physicians in the selection of potentially beneficial treatment options for patients with rectal cancer. Methods The updated decision model contained 8 and 10 criteria in the first and second steps respectively. The decision support model, developed in our previous study by combining the Analytic Hierarchy Process (AHP) method which determines the priority of criteria and decision tree that formed using these priorities, was updated and applied to 388 patients data collected retrospectively. Later, a web-based decision support tool named corRECTreatment was developed. The compatibility of the treatment recommendations by the expert opinion and the decision support tool was examined for its consistency. Two surgeons were requested to recommend a treatment and an overall survival value for the treatment among 20 different cases that we selected and turned into a scenario among the most common and rare treatment options in the patient data set. Results In the AHP analyses of the criteria, it was found that the matrices, generated for both decision steps, were consistent (consistency ratio<0.1). Depending on the decisions of experts, the consistency value for the most frequent cases was found to be 80% for the first decision step and 100% for the second decision step. Similarly, for rare cases consistency was 50% for the first decision step and 80% for the second decision step. Conclusions The decision model and corRECTreatment, developed by applying these on real patient data, are expected to provide potential users with decision support in rectal cancer treatment processes and facilitate them in making projections about treatment options. PMID:25848413

CorRECTreatment: a web-based decision support tool for rectal cancer treatment that uses the analytic hierarchy process and decision tree.

PubMed

Suner, A; Karakülah, G; Dicle, O; Sökmen, S; Çelikoğlu, C C

2015-01-01

The selection of appropriate rectal cancer treatment is a complex multi-criteria decision making process, in which clinical decision support systems might be used to assist and enrich physicians' decision making. The objective of the study was to develop a web-based clinical decision support tool for physicians in the selection of potentially beneficial treatment options for patients with rectal cancer. The updated decision model contained 8 and 10 criteria in the first and second steps respectively. The decision support model, developed in our previous study by combining the Analytic Hierarchy Process (AHP) method which determines the priority of criteria and decision tree that formed using these priorities, was updated and applied to 388 patients data collected retrospectively. Later, a web-based decision support tool named corRECTreatment was developed. The compatibility of the treatment recommendations by the expert opinion and the decision support tool was examined for its consistency. Two surgeons were requested to recommend a treatment and an overall survival value for the treatment among 20 different cases that we selected and turned into a scenario among the most common and rare treatment options in the patient data set. In the AHP analyses of the criteria, it was found that the matrices, generated for both decision steps, were consistent (consistency ratio<0.1). Depending on the decisions of experts, the consistency value for the most frequent cases was found to be 80% for the first decision step and 100% for the second decision step. Similarly, for rare cases consistency was 50% for the first decision step and 80% for the second decision step. The decision model and corRECTreatment, developed by applying these on real patient data, are expected to provide potential users with decision support in rectal cancer treatment processes and facilitate them in making projections about treatment options.

Risk Factors for Opioid-Use Disorder and Overdose.

PubMed

Webster, Lynn R

2017-11-01

Opioid analgesics are recognized as a legitimate medical therapy for selected patients with severe chronic pain that does not respond to other therapies. However, opioids are associated with risks for patients and society that include misuse, abuse, diversion, addiction, and overdose deaths. Therapeutic success depends on proper candidate selection, assessment before administering opioid therapy, and close monitoring throughout the course of treatment. Risk assessment and prevention include knowledge of patient factors that may contribute to misuse, abuse, addiction, suicide, and respiratory depression. Risk factors for opioid misuse or addiction include past or current substance abuse, untreated psychiatric disorders, younger age, and social or family environments that encourage misuse. Opioid mortality prevalence is higher in people who are middle aged and have substance abuse and psychiatric comorbidities. Suicides are probably undercounted or frequently misclassified in reports of opioid-related poisoning deaths. Greater understanding and better assessment are needed of the risk associated with suicide risk in patients with pain. Clinical tools and an evolving evidence base are available to assist clinicians with identifying patients whose risk factors put them at risk for adverse outcomes with opioids.

Neural oscillatory deficits in schizophrenia predict behavioral and neurocognitive impairments

PubMed Central

Martínez, Antígona; Gaspar, Pablo A.; Hillyard, Steven A.; Bickel, Stephan; Lakatos, Peter; Dias, Elisa C.; Javitt, Daniel C.

2015-01-01

Paying attention to visual stimuli is typically accompanied by event-related desynchronizations (ERD) of ongoing alpha (7–14 Hz) activity in visual cortex. The present study used time-frequency based analyses to investigate the role of impaired alpha ERD in visual processing deficits in schizophrenia (Sz). Subjects viewed sinusoidal gratings of high (HSF) and low (LSF) spatial frequency (SF) designed to test functioning of the parvo- vs. magnocellular pathways, respectively. Patients with Sz and healthy controls paid attention selectively to either the LSF or HSF gratings which were presented in random order. Event-related brain potentials (ERPs) were recorded to all stimuli. As in our previous study, it was found that Sz patients were selectively impaired at detecting LSF target stimuli and that ERP amplitudes to LSF stimuli were diminished, both for the early sensory-evoked components and for the attend minus unattend difference component (the Selection Negativity), which is generally regarded as a specific index of feature-selective attention. In the time-frequency domain, the differential ERP deficits to LSF stimuli were echoed in a virtually absent theta-band phase locked response to both unattended and attended LSF stimuli (along with relatively intact theta-band activity for HSF stimuli). In contrast to the theta-band evoked responses which were tightly stimulus locked, stimulus-induced desynchronizations of ongoing alpha activity were not tightly stimulus locked and were apparent only in induced power analyses. Sz patients were significantly impaired in the attention-related modulation of ongoing alpha activity for both HSF and LSF stimuli. These deficits correlated with patients’ behavioral deficits in visual information processing as well as with visually based neurocognitive deficits. These findings suggest an additional, pathway-independent, mechanism by which deficits in early visual processing contribute to overall cognitive impairment in Sz. PMID:26190988

Detrended fluctuation analysis for major depressive disorder.

PubMed

Mumtaz, Wajid; Malik, Aamir Saeed; Ali, Syed Saad Azhar; Yasin, Mohd Azhar Mohd; Amin, Hafeezullah

2015-01-01

Clinical utility of Electroencephalography (EEG) based diagnostic studies is less clear for major depressive disorder (MDD). In this paper, a novel machine learning (ML) scheme was presented to discriminate the MDD patients and healthy controls. The proposed method inherently involved feature extraction, selection, classification and validation. The EEG data acquisition involved eyes closed (EC) and eyes open (EO) conditions. At feature extraction stage, the de-trended fluctuation analysis (DFA) was performed, based on the EEG data, to achieve scaling exponents. The DFA was performed to analyzes the presence or absence of long-range temporal correlations (LRTC) in the recorded EEG data. The scaling exponents were used as input features to our proposed system. At feature selection stage, 3 different techniques were used for comparison purposes. Logistic regression (LR) classifier was employed. The method was validated by a 10-fold cross-validation. As results, we have observed that the effect of 3 different reference montages on the computed features. The proposed method employed 3 different types of feature selection techniques for comparison purposes as well. The results show that the DFA analysis performed better in LE data compared with the IR and AR data. In addition, during Wilcoxon ranking, the AR performed better than LE and IR. Based on the results, it was concluded that the DFA provided useful information to discriminate the MDD patients and with further validation can be employed in clinics for diagnosis of MDD.

The selection of core International Classification of Functioning, Disability, and Health (ICF) categories for patient-reported outcome measurement in spine trauma patients-results of an international consensus process.

PubMed

Sadiqi, Said; Lehr, A Mechteld; Post, Marcel W; Jacobs, Wilco C H; Aarabi, Bizhan; Chapman, Jens R; Dunn, Robert N; Dvorak, Marcel F; Fehlings, Michael G; Rajasekaran, S; Vialle, Luiz R; Vaccaro, Alexander R; Oner, F Cumhur

2016-08-01

There is no outcome instrument specifically designed and validated for spine trauma patients without complete paralysis, which makes it difficult to compare outcomes of different treatments of the spinal column injury within and between studies. The paper aimed to report on the evidence-based consensus process that resulted in the selection of core International Classification of Functioning, Disability, and Health (ICF) categories, as well as the response scale for use in a universal patient-reported outcome measure for patients with traumatic spinal column injury. The study used a formal decision-making and consensus process. The sample includes patients with a primary diagnosis of traumatic spinal column injury, excluding completely paralyzed and polytrauma patients. The wide array of function and health status of patients with traumatic spinal column injury was explored through the identification of all potentially meaningful ICF categories. A formal decision-making and consensus process integrated evidence from four preparatory studies. Three studies aimed to identify relevant ICF categories from three different perspectives. The research perspective was covered by a systematic literature review identifying outcome measures focusing on the functioning and health of spine trauma patients. The expert perspective was explored through an international web-based survey among spine surgeons from the five AOSpine International world regions. The patient perspective was investigated in an international empirical study. A fourth study investigated various response scales for their potential use in the future universal outcome instrument. This work was supported by AOSpine. AOSpine is a clinical division of the AO Foundation, an independent medically guided non-profit organization. The AOSpine Knowledge Forums are pathology-focused working groups acting on behalf of AOSpine in their domain of scientific expertise. Combining the results of the preparatory studies, the list of ICF categories presented at the consensus conference included 159 different ICF categories. Based on voting and discussion, 11 experts from 6 countries selected a total of 25 ICF categories as core categories for patient-reported outcome measurement in adult traumatic spinal column injury patients (9 body functions, 14 activities and participation, and 2 environmental factors). The experts also agreed to use the Numeric Rating Scale 0-100 as response scale in the future universal outcome instrument. A formal consensus process integrating evidence and expert opinion led to a set of 25 core ICF categories for patient-reported outcome measurement in adult traumatic spinal column injury patients, as well as the response scale for use in the future universal disease-specific outcome instrument. The adopted core ICF categories could also serve as a benchmark for assessing the content validity of existing and future outcome instruments used in this specific patient population. Copyright © 2016 Elsevier Inc. All rights reserved.

Dual Kidney Transplantation: Evaluation of Recipient Selection Criteria at Niguarda Hospital.

PubMed

Mariani, A; Ferla, F; De Carlis, R; Rossetti, O; Covucci, E; Tripepi, M; Concone, G; Lauterio, A; Mangoni, I; De Carlis, L

2016-03-01

Dual kidney transplantation (DKT) is a largely accepted strategy to enlarge the donor pool. Niguarda Hospital started this program in December 2010, and 38 DKT have been performed. In our series, we included recipients older than those in the other series published in literature. The aim of this study was to know if our recipient selection criteria for DKT are safe. We reviewed our data base of DKT and analyzed recipients' medical history, surgical technique, post-operative complications, graft survival, morbidity, and mortality. We then compared our results with the literature. From December 2010 to April 2015, 38 DKT were performed in Niguarda Hospital. Delayed graft function was present in 21 recipients. Explantation of both kidneys was performed in 1 patient and explantation of 1 kidney in 6 patients. Post-operative complications were present in 8 patients. Five patients returned to hemodialysis after DKT. One recipient died of medical post-operative sepsis. The mean follow-up was 24 months. Graft survival and patient survival were 86.84% and 97.93%, respectively. Compared with the literature, our series had similar mortality and morbidity rates, even if recipients' age was higher than in other series. The strategy of DKT allocation in elderly recipients is safe. Further studies have to be performed to optimized selection of the recipients for DKT not to disadvantage younger patients in the transplant waiting list and to improve the technique of organ evaluation and preservation to refine graft allocation. Copyright © 2016 Elsevier Inc. All rights reserved.

Social reintegration of TBI patients: a solution to provide long-term support.

PubMed

Bulinski, Leszek

2010-01-01

This article evaluates the effectiveness of a workable long-term program to provide social support for TBI patients, based on the "Academy of Life" concept. Disability after TBI causes numerous disruptions of normal life, which affect the patient, the family, and society. The patient needs the particular kind of support the program was designed to provide. The study involved 200 married couples with a TBI spouse previously enrolled in the "Academy of Life." The methods included documentation analysis, clinical interviews, the Family Bonds Scale, the Social Isolation Scale, and the Social Functions subscale from a battery used to evaluate QOL after TBI. The subjects were examined before and after completing the program. In the first examination all types of family bonds were found to be severely weakened; there was deep social isolation, loneliness, sadness, a feeling of being surrounded by hostility, and no purposeful social activity. The most common form of support from significant others was pity and unwanted interference, accompanied by lack of understanding and social ostracism. In the second examination there was selective improvement of all parameters, significantly greater in patients without PTSD symptoms. The best effects were achieved in the reduction of social dysfunctions, the growth of purposeful social activity, and improvement in the type of support received, and a reduction of selected parameters of social isolation. The program here described is selectively effective for the social reintegration of TBI-patients, especially those without PTSD symptoms.

Management of advanced non-small-cell lung cancer in elderly populations.

PubMed

Lilenbaum, Rogerio

2003-11-01

Elderly patients, defined as those >or= 70 years of age, represent approximately 40% of all patients diagnosed with non-small-cell lung cancer in the United States. Nonetheless, elderly patients have been underrepresented in national cooperative group trials, and many do not receive appropriate treatment. Whereas the benefit of systemic chemotherapy in younger patients is accepted by most clinicians, there remains a great deal of skepticism with respect to older patients, who are often labeled unfit for chemotherapy. More recent studies with a special focus on elderly patients demonstrate that these patients indeed benefit from chemotherapy. The landmark Elderly Lung Cancer Vinorelbine Italian Study Group trial and the Multicentre Italian Lung Cancer in the Elderly Study clarified the role of vinorelbine in the treatment of elderly patients. Retrospective and prospective subgroup analyses from selected North American trials suggested that elderly patients also benefit from platinum-based combinations. Whether elderly patients should be treated with single-agent versus combination chemotherapy is discussed in this review. The available data suggest that patients should be evaluated for chemotherapy based on their performance status and comorbidities rather than age alone. For elderly patients judged fit to receive combination chemotherapy, carboplatin-based regimens are a reasonable option. In elderly patients with less than optimal performance status or significant comorbid conditions, single-agent therapy may be more appropriate.

Lifelong personal health data and application software via virtual machines in the cloud.

PubMed

Van Gorp, Pieter; Comuzzi, Marco

2014-01-01

Personal Health Records (PHRs) should remain the lifelong property of patients, who should be able to show them conveniently and securely to selected caregivers and institutions. In this paper, we present MyPHRMachines, a cloud-based PHR system taking a radically new architectural solution to health record portability. In MyPHRMachines, health-related data and the application software to view and/or analyze it are separately deployed in the PHR system. After uploading their medical data to MyPHRMachines, patients can access them again from remote virtual machines that contain the right software to visualize and analyze them without any need for conversion. Patients can share their remote virtual machine session with selected caregivers, who will need only a Web browser to access the pre-loaded fragments of their lifelong PHR. We discuss a prototype of MyPHRMachines applied to two use cases, i.e., radiology image sharing and personalized medicine.

Modern radiosurgical and endovascular classification schemes for brain arteriovenous malformations.

PubMed

Tayebi Meybodi, Ali; Lawton, Michael T

2018-05-04

Stereotactic radiosurgery (SRS) and endovascular techniques are commonly used for treating brain arteriovenous malformations (bAVMs). They are usually used as ancillary techniques to microsurgery but may also be used as solitary treatment options. Careful patient selection requires a clear estimate of the treatment efficacy and complication rates for the individual patient. As such, classification schemes are an essential part of patient selection paradigm for each treatment modality. While the Spetzler-Martin grading system and its subsequent modifications are commonly used for microsurgical outcome prediction for bAVMs, the same system(s) may not be easily applicable to SRS and endovascular therapy. Several radiosurgical- and endovascular-based grading scales have been proposed for bAVMs. However, a comprehensive review of these systems including a discussion on their relative advantages and disadvantages is missing. This paper is dedicated to modern classification schemes designed for SRS and endovascular techniques.

Wavenumber selection based analysis in Raman spectroscopy improves skin cancer diagnostic specificity at high sensitivity levels (Conference Presentation)

NASA Astrophysics Data System (ADS)

Zhao, Jianhua; Zeng, Haishan; Kalia, Sunil; Lui, Harvey

2017-02-01

Background: Raman spectroscopy is a non-invasive optical technique which can measure molecular vibrational modes within tissue. A large-scale clinical study (n = 518) has demonstrated that real-time Raman spectroscopy could distinguish malignant from benign skin lesions with good diagnostic accuracy; this was validated by a follow-up independent study (n = 127). Objective: Most of the previous diagnostic algorithms have typically been based on analyzing the full band of the Raman spectra, either in the fingerprint or high wavenumber regions. Our objective in this presentation is to explore wavenumber selection based analysis in Raman spectroscopy for skin cancer diagnosis. Methods: A wavenumber selection algorithm was implemented using variably-sized wavenumber windows, which were determined by the correlation coefficient between wavenumbers. Wavenumber windows were chosen based on accumulated frequency from leave-one-out cross-validated stepwise regression or least and shrinkage selection operator (LASSO). The diagnostic algorithms were then generated from the selected wavenumber windows using multivariate statistical analyses, including principal component and general discriminant analysis (PC-GDA) and partial least squares (PLS). A total cohort of 645 confirmed lesions from 573 patients encompassing skin cancers, precancers and benign skin lesions were included. Lesion measurements were divided into training cohort (n = 518) and testing cohort (n = 127) according to the measurement time. Result: The area under the receiver operating characteristic curve (ROC) improved from 0.861-0.891 to 0.891-0.911 and the diagnostic specificity for sensitivity levels of 0.99-0.90 increased respectively from 0.17-0.65 to 0.20-0.75 by selecting specific wavenumber windows for analysis. Conclusion: Wavenumber selection based analysis in Raman spectroscopy improves skin cancer diagnostic specificity at high sensitivity levels.

An ensemble-of-classifiers based approach for early diagnosis of Alzheimer's disease: classification using structural features of brain images.

PubMed

Farhan, Saima; Fahiem, Muhammad Abuzar; Tauseef, Huma

2014-01-01

Structural brain imaging is playing a vital role in identification of changes that occur in brain associated with Alzheimer's disease. This paper proposes an automated image processing based approach for the identification of AD from MRI of the brain. The proposed approach is novel in a sense that it has higher specificity/accuracy values despite the use of smaller feature set as compared to existing approaches. Moreover, the proposed approach is capable of identifying AD patients in early stages. The dataset selected consists of 85 age and gender matched individuals from OASIS database. The features selected are volume of GM, WM, and CSF and size of hippocampus. Three different classification models (SVM, MLP, and J48) are used for identification of patients and controls. In addition, an ensemble of classifiers, based on majority voting, is adopted to overcome the error caused by an independent base classifier. Ten-fold cross validation strategy is applied for the evaluation of our scheme. Moreover, to evaluate the performance of proposed approach, individual features and combination of features are fed to individual classifiers and ensemble based classifier. Using size of left hippocampus as feature, the accuracy achieved with ensemble of classifiers is 93.75%, with 100% specificity and 87.5% sensitivity.

The skin health and beauty pyramid: a clinically based guide to selecting topical skincare products.

PubMed

Mayoral, Flor A; Kenner, Julie R; Draelos, Zoe Diana

2014-04-01

The use of cosmeceuticals by patients is now commonplace. Without consultation and direction from an informed clinician, marketing pressures can lead consumers to make poor product choices that can result in wasted money and unsatisfactory outcomes. Skin professionals need a scientifically based, succinct tool to guide their patients toward best topical skincare practices. The Skin Health and Beauty Pyramid is an educational framework and product guide created from extensive scientific literature and study review on ingredients, formulations and technologies affecting skin biology. This clinical tool can simplify product choices for physicians and clinicians in the process of professionally guiding patients toward the optimal use of topical products to achieve best outcomes for skin health and beauty.

Leukocyte-reduced blood components: patient benefits and practical applications.

PubMed

Higgins, V L

1996-05-01

To review the various types of filters used for red blood cell and platelet transfusions and to explain the trend in the use of leukocyte removal filters, practical information about their use, considerations in the selection of a filtration method, and cost-effectiveness issues. Published articles, books, and the author's experience. Leukocyte removal filters are used to reduce complications associated with transfused white blood cells that are contained in units of red blood cells and platelets. These complications include nonhemolytic febrile transfusion reactions (NHFTRs), alloimmunization and refractoriness to platelet transfusion, transfusion-transmitted cytomegalovirus (CMV), and immunomodulation. Leukocyte removal filters may be used at the bedside, in a hospital blood bank, or in a blood collection center. Factors that affect the flow rate of these filters include the variations in the blood component, the equipment used, and filter priming. Studies on the cost-effectiveness of using leukocyte-reduced blood components demonstrate savings based on the reduction of NHFTRs, reduction in the number of blood components used, and the use of filtered blood components as the equivalent of CMV seronegative-screened products. The use of leukocyte-reduced blood components significantly diminishes or prevents many of the adverse transfusion reactions associated with donor white blood cells. Leukocyte removal filters are cost-effective, and filters should be selected based on their ability to consistently achieve low leukocyte residual levels as well as their ease of use. Physicians may order leukocyte-reduced blood components for specific patients, or the components may be used because of an established institutional transfusion policy. Nurses often participate in deciding on a filtration method, primarily based on ease of use. Understanding the considerations in selecting a filtration method will help nurses make appropriate decisions to ensure quality patient care.

Clinical Decision Support Tools for Selecting Interventions for Patients with Disabling Musculoskeletal Disorders: A Scoping Review.

PubMed

Gross, Douglas P; Armijo-Olivo, Susan; Shaw, William S; Williams-Whitt, Kelly; Shaw, Nicola T; Hartvigsen, Jan; Qin, Ziling; Ha, Christine; Woodhouse, Linda J; Steenstra, Ivan A

2016-09-01

Purpose We aimed to identify and inventory clinical decision support (CDS) tools for helping front-line staff select interventions for patients with musculoskeletal (MSK) disorders. Methods We used Arksey and O'Malley's scoping review framework which progresses through five stages: (1) identifying the research question; (2) identifying relevant studies; (3) selecting studies for analysis; (4) charting the data; and (5) collating, summarizing and reporting results. We considered computer-based, and other available tools, such as algorithms, care pathways, rules and models. Since this research crosses multiple disciplines, we searched health care, computing science and business databases. Results Our search resulted in 4605 manuscripts. Titles and abstracts were screened for relevance. The reliability of the screening process was high with an average percentage of agreement of 92.3 %. Of the located articles, 123 were considered relevant. Within this literature, there were 43 CDS tools located. These were classified into 3 main areas: computer-based tools/questionnaires (n = 8, 19 %), treatment algorithms/models (n = 14, 33 %), and clinical prediction rules/classification systems (n = 21, 49 %). Each of these areas and the associated evidence are described. The state of evidentiary support for CDS tools is still preliminary and lacks external validation, head-to-head comparisons, or evidence of generalizability across different populations and settings. Conclusions CDS tools, especially those employing rapidly advancing computer technologies, are under development and of potential interest to health care providers, case management organizations and funders of care. Based on the results of this scoping review, we conclude that these tools, models and systems should be subjected to further validation before they can be recommended for large-scale implementation for managing patients with MSK disorders.

Feasibility of the adaptive and automatic presentation of tasks (ADAPT) system for rehabilitation of upper extremity function post-stroke.

PubMed

Choi, Younggeun; Gordon, James; Park, Hyeshin; Schweighofer, Nicolas

2011-08-03

Current guidelines for rehabilitation of arm and hand function after stroke recommend that motor training focus on realistic tasks that require reaching and manipulation and engage the patient intensively, actively, and adaptively. Here, we investigated the feasibility of a novel robotic task-practice system, ADAPT, designed in accordance with such guidelines. At each trial, ADAPT selects a functional task according to a training schedule and with difficulty based on previous performance. Once the task is selected, the robot picks up and presents the corresponding tool, simulates the dynamics of the tasks, and the patient interacts with the tool to perform the task. Five participants with chronic stroke with mild to moderate impairments (> 9 months post-stroke; Fugl-Meyer arm score 49.2 ± 5.6) practiced four functional tasks (selected out of six in a pre-test) with ADAPT for about one and half hour and 144 trials in a pseudo-random schedule of 3-trial blocks per task. No adverse events occurred and ADAPT successfully presented the six functional tasks without human intervention for a total of 900 trials. Qualitative analysis of trajectories showed that ADAPT simulated the desired task dynamics adequately, and participants reported good, although not excellent, task fidelity. During training, the adaptive difficulty algorithm progressively increased task difficulty leading towards an optimal challenge point based on performance; difficulty was then continuously adjusted to keep performance around the challenge point. Furthermore, the time to complete all trained tasks decreased significantly from pretest to one-hour post-test. Finally, post-training questionnaires demonstrated positive patient acceptance of ADAPT. ADAPT successfully provided adaptive progressive training for multiple functional tasks based on participant's performance. Our encouraging results establish the feasibility of ADAPT; its efficacy will next be tested in a clinical trial.

Progressive addition lenses--measurements and ratings.

PubMed

Sheedy, Jim; Hardy, Raymond F; Hayes, John R

2006-01-01

This study is a followup to a previous study in which the optics of several progressive addition lens (PALs) designs were measured and analyzed. The objective was to provide information about various PAL designs to enable eye care practitioners to select designs based on the particular viewing requirements of the patient. The optical properties of 12 lenses of the same power for each of 23 different PAL designs were measured with a Rotlex Class Plus lens analyzer. Lenses were ordered through optical laboratories and specified to be plano with a +2.00 diopters add. Measurements were normalized to plano at the manufacturer-assigned location for the distance power to eliminate laboratory tolerance errors. The magnitude of unwanted astigmatism and the widths and areas of the distance, intermediate, and near viewing zones were calculated from the measured data according to the same criteria used in a previous study. The optical characteristics of the different PAL designs were significantly different from one another. The differences were significant in terms of the sizes and widths of the viewing zones, the amount of unwanted astigmatism, and the minimum fitting height. Ratings of the distance, intermediate, and near viewing areas were calculated for each PAL design based on the widths and sizes of those zones. Ratings for unwanted astigmatism and recommended minimum fitting heights were also determined. Ratings based on combinations of viewing zone ratings are also reported. The ratings are intended to be used to select a PAL design that matches the particular visual needs of the patient and to evaluate the success and performance of currently worn PALs. Reasoning and task analyses suggest that these differences can be used to select a PAL design to meet the individual visual needs of the patient; clinical trials studies are required to test this hypothesis.

Quality of life of community-based chronic schizophrenia patients in Penang, Malaysia.

PubMed

Mubarak, A R; Baba, Ismail; Chin, Low Heng; Hoe, Quah Soon

2003-10-01

This is a study of the quality of life (QOL) of 174 community-based chronic schizophrenia patients in Penang, Malaysia. The study samples were selected from the Out Patient Department, Department of Psychiatry, Penang General Hospital, Malaysia. The data was collected through personal interviews with the respondents. A questionnaire prepared by the research team was used to collect data on background characteristics. Lehman's (1988) Quality of Life Interview was used to collect data on patients' QOL. Equal number of males and females participated in the study. The interviews on QOL indicated problems in the areas of life in general, place of living, daily activities, social relations, finance, work and general health. The results also revealed that community-based schizophrenia patients had acute poverty and experienced social isolation, discrimination and exploitation in the workplace. Implications of these results on the implementation process of National Mental Health Policy in Malaysia are discussed. The research paper also discusses the negative impacts of limited rehabilitation facilities available in the community and its implications on the QOL of severely mentally ill patients. The need for immediate research attention on QOL of such patients in the South-east Asian region has been highlighted.

Osteoporosis in adult patients with atopic dermatitis: A nationwide population-based study

PubMed Central

Lu, Chun-Ching; Su, Yu-Feng; Tsai, Tai-Hsin; Wu, Chieh-Hsin

2017-01-01

The aim of this study was to investigate osteoporosis risk in atopic dermatitis (AD) patients. This study included patients in the Taiwan National Health Insurance Research dataset. The population-based study included all patients aged 20–49 years who had been diagnosed with AD during 1996–2010. In total, 35,229 age and gender-matched patients without AD in a 1:1 ratio were randomly selected as the non-AD group. Cox proportional-hazards regression and Kaplan–Meier analyses were used to measure the hazard ratios and the cumulative incidences of osteoporosis, respectively. During the follow-up period, 360(1.02%) AD patients and 127(0.36%) non-AD patients developed osteoporosis. The overall incidence of osteoporosis was4.72-fold greater in the AD patients compared to the non-AD patients (1.82 vs. 0.24 per 1,000 person-years, respectively) after adjusting for potential confounding factors. Osteoporosis risk factors included female gender, age, advanced Charlson Comorbidity Index, depression and use of corticosteroids. The dataset analysis showed that AD was significantly associated with subsequent risk of osteoporosis. PMID:28207767

Reference Pricing Changes The 'Choice Architecture' Of Health Care For Consumers.

PubMed

Robinson, James C; Brown, Timothy T; Whaley, Christopher

2017-03-01

Reference pricing in health insurance creates incentives for patients to select for nonemergency services providers that charge relatively low prices and still offer high quality of care. It changes the "choice architecture" by offering standard coverage if the patient chooses cost-effective providers but requires considerable consumer cost sharing if more expensive alternatives are selected. The short-term impact of reference pricing has been to shift patient volumes from hospital-based to freestanding surgical, diagnostic, imaging, and laboratory facilities. This article summarizes reference pricing's impacts to date on patient choice, provider prices, surgical complications, and employer spending and estimates its potential impacts if expanded to more services and a broader population. Reference pricing induces consumers to select lower-price alternatives for all of the forms of care studied, leading to significant reductions in prices paid and spending incurred by insurers and employers. The impact on consumer cost sharing is mixed, with some studies finding higher copayments and some lower. We conclude with a discussion of the incentives created for providers to redesign their clinical processes and for efficient providers to expand into price-sensitive markets. Over time, reference pricing may increase pressures for price competition and lead to further cost-reducing innovations in health care products and processes. Project HOPE—The People-to-People Health Foundation, Inc.

Treatment and Prognosis of Facial Palsy on Ramsay Hunt Syndrome: Results Based on a Review of the Literature

PubMed Central

Monsanto, Rafael da Costa; Bittencourt, Aline Gomes; Bobato Neto, Natal José; Beilke, Silvia Carolina Almeida; Lorenzetti, Fabio Tadeu Moura; Salomone, Raquel

2016-01-01

Introduction Ramsay Hunt syndrome is the second most common cause of facial palsy. Early and correct treatment should be performed to avoid complications, such as permanent facial nerve dysfunction. Objective The objective of this study is to review the prognosis of the facial palsy on Ramsay Hunt syndrome, considering the different treatments proposed in the literature. Data Synthesis We read the abstract of 78 studies; we selected 31 studies and read them in full. We selected 19 studies for appraisal. Among the 882 selected patients, 621 (70.4%) achieved a House-Brackmann score of I or II; 68% of the patients treated only with steroids achieved HB I or II, versus 70.5% when treated with steroids plus antiviral agents. Among patients with complete facial palsy (grades V or VI), 51.4% recovered to grades I or II. The rate of complete recovery varied considering the steroid associated with acyclovir: 81.3% for methylprednisolone, 69.2% for prednisone; 61.4% for prednisolone; and 76.3% for hydrocortisone. Conclusions Patients with Ramsay-hunt syndrome, when early diagnosed and treated, achieve high rates of complete recovery. The association of steroids and acyclovir is better than steroids used in monotherapy. PMID:27746846

Treatment and Prognosis of Facial Palsy on Ramsay Hunt Syndrome: Results Based on a Review of the Literature.

PubMed

Monsanto, Rafael da Costa; Bittencourt, Aline Gomes; Bobato Neto, Natal José; Beilke, Silvia Carolina Almeida; Lorenzetti, Fabio Tadeu Moura; Salomone, Raquel

2016-10-01

Introduction  Ramsay Hunt syndrome is the second most common cause of facial palsy. Early and correct treatment should be performed to avoid complications, such as permanent facial nerve dysfunction. Objective  The objective of this study is to review the prognosis of the facial palsy on Ramsay Hunt syndrome, considering the different treatments proposed in the literature. Data Synthesis  We read the abstract of 78 studies; we selected 31 studies and read them in full. We selected 19 studies for appraisal. Among the 882 selected patients, 621 (70.4%) achieved a House-Brackmann score of I or II; 68% of the patients treated only with steroids achieved HB I or II, versus 70.5% when treated with steroids plus antiviral agents. Among patients with complete facial palsy (grades V or VI), 51.4% recovered to grades I or II. The rate of complete recovery varied considering the steroid associated with acyclovir: 81.3% for methylprednisolone, 69.2% for prednisone; 61.4% for prednisolone; and 76.3% for hydrocortisone. Conclusions  Patients with Ramsay-hunt syndrome, when early diagnosed and treated, achieve high rates of complete recovery. The association of steroids and acyclovir is better than steroids used in monotherapy.